Frequently Asked Questions
Is access to a defibrillator required for long term exercise (Phase IV) sessions?
As outlined in the updated BACPR RCUK statement a defibrillator is now recommended best practice for all long term exercise (Phase IV) programmes and the BACPR are currently researching avenues for funding of defibrillators which will be published on the same page of the BACPR website as the RCUK statement in due course.
In the meantime we would recommend approaching the British Heart Foundation or Arrhythmia Alliance for further information on funding for defibrillators.
What temperature and humidity is safe to exercise patients with cardiovascular disease?
The guidelines are laid out to ensure the safety of participants and although not policy, they still set out best practice and are there for the protection of participants. The recommended guidelines from the Association of Chartered Physiotherapists in Cardiac Rehabilitation (ACPICR) are ‘All areas should provide a comfortable temperature of between 18-23C and humidity at 65%’.
You need to develop a local policy depending on your circumstances. In some areas sessions are cancelled where temperatures are above the guidelines; others have changed the nature of the class i.e. running a relaxation class. Fans, open windows and doors, plenty of water will help to make it more comfortable for your users.
What considerations should be taken when exercising individuals with diabetes?
Hypoglycaemic episodes are not uncommon in exercise classes. Hypoglycaemia is less likely to occur if:
- Blood glucose levels are checked twice before exercising; 30 minutes before exercising and once again immediately before exercising. Twenty to thirty grams of additional carbohydrate should be ingested if pre-exercise blood glucose is < 5.5 mmol L-1.
- If new to exercise or increasing the intensity or duration of the exercise session, levels should be checked every 30 minutes during exercise. Although dependent upon the size of the individual and the intensity of the exercise, 1 hour of moderate intensity exercise will generally require about 15 grams of extra carbohydrate before or during exercise.
- Insulin is not injected into an area over active muscle mass e.g. use the abdominal area rather than the thigh
- Exercise is avoided during peak action of insulin
- After exercise, blood glucose level is checked again at least twice to ensure that hypoglycaemia is not developing (see Chapter 11, Table 11.2).
Those on insulin medication can experience ‘exercise induced hyperglycaemia’ i.e. a rise in blood glucose levels when they commence exercise. This is because exercise triggers release of glycogen stored in the liver and so blood glucose levels rise. However, if the insulin levels are inadequate, the glucose cannot be made available to the muscles and so levels continue to rise. Exercise should not be commenced if pre-exercise blood glucose levels are > 13 mmol/l. If glucose levels pre-exercise are > 10 mmol/l, check again 10 minutes after starting exercise and only continue to exercise if the level has fallen.
Autonomic neuropathy may lead to abnormal heart rate and blood pressure responses.
Peripheral neuropathy highlights the need for good foot care. Clients should check their feet before and after exercise as their peripheral neuropathy can make them unaware of blisters. Lack of sensation in their hands means that some clients are unable to grip equipment properly, e.g. dumbbells.
The American College of Sports Medicine and the American Diabetes Association have released the joint position statement ‘Exercise and Type 2 Diabetes’. This position stand discusses the benefits of physical training, along with recommendations for varying activities, physical activity-associated blood glucose management, diabetes prevention, gestational diabetes, and safe and effective practices for physical activity with diabetes-related complications.
Can individuals who have had elective PCI be fast tracked to Long term exercise sessions (Phase IV)?
Referral of elective PCI straight onto a long term exercise (Phase IV) session for their exercise component of CR is at the discretion of the early CR team.
It must be noted that fast tracking to Phase IV for the exercise component only addresses one component of the BACPR standards and the other components must also be provided effectively by suitably skilled/trained professionals. View the BACPR Standards here.
In our experience, a high proportion of the elective PCIs have complex disease and therefore should undergo a thorough assessment and reassessment for exercise prescription and secondary prevention needs by the early CR team and the decision to refer directly to Phase IV should be done based on the assessment of needs (ideally a functional assessment).
A fast track service to a Phase IV exercise session is current practice in some services in the UK One example of current practice is that there is an agreement that should the patient encounter issues / symptoms within the Phase III timeframe i.e 8 weeks they can be re-referred back into the Phase III service. Elective PCI and Primary PCI patient are offered an assessment within 1 - 2 weeks of procedure so that their needs are assessed before they return to work.
Which risk stratification tool should be used to assess patients’ suitability for Cardiac Rehabilitation?
The recommended risk stratification tool has been developed by the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR). This can be accessed from the Association of Chartered Physiotherapists in Cardiac Rehabilitation website
How should heart failure patients with an improved ejection fraction be risk assessed?
Individuals with a diagnosis of heart failure who have an improvement in ejection fraction following medical management would still remain in the high risk category, as the diagnosis of heart failure would still put that individual at a higher risk for cardiac rhythm abnormalities.