Alison Lovkay

Initial Exercise Prescription:

When looking at risk stratification, it was clear that Patient A was a high risk patient. There are four main factors that put him in this category. His resting EKG shows ectopy, his ejection fraction is less than 40% (35%), he has been been diagnosed with CHF in the last 12 months and his functional capacity is less than 3 METS. We take all of this in account when making his exercise prescription so that we don't push him too hard. On the first day, he came in with his wife who was more nervous than him. He has a "whatever" type attitude and seemed to not have many opinions on the exercise. Patient A expresses that he is guilty for what happened and feels like a burden to his wife. Patient A's goals are to improve strength/endurance, reduce fatigue and regain an appetite. I started Patient A on three types of equipment. The recumbent bike at 20 watts for 8 minutes, the nustep at level 1 for 6 minutes and the arm cycle at 5 watts for 6 minutes. He offered no complaints besides calf pain, which he states never goes away. His HR, BP and RPE responses were all normal. When talking to the patient, I discovered his sleeping/eating patterns that he is struggling with. He says he sleeps for an hour at most at night and spends the rest of the night watching TV. He also does not have an appetite and says its a good day when he has breakfast. I mentioned talking to the behavioral therapist about these problems, which he is not interested in. He also does not want to attend the education classes, because he does not feel like they would benefit him in anyway. Week 2, we increased the time on the nustep and arm cycle to 8 minutes each and increased the wattage on the recumbant bike to 30 watts. 

 

Progressing the Ex Rx:

The arm cycle began to give Patient A a lot of arm pain. We took this into account and changed his exercise prescription. He is now doing 30 watts on the recumbant bike for 8 minutes, level 1 on the nustep and level 1 on the biostep. This eliminates his arm pain so that he is more comfortable during exercise. He is still not eating or sleeping and a visit to the behavioral therapist is still encouraged. On week 5, we progresed the Ex Rx even more. He is now doing the bike for 10 and biostep for 10 minutes at the same resistance, and the nustep for 12 minutes. He also started hand weights. He does bicep curls, upright row and lateral raise with 2 lbs for 1 set of 10 reps. BP, HR and RPE are all still normal. During this week, Patient A agreed to meet with the behavioral therapist. After looking at her notes, she believes he is clinically depressed. She wanted to meet with him a second time, which he didn't feel was necessary. He tells me he likes the program, but doesn't notice any changes at this time. During week 6, we made more changes to progress the prescription. We took him off the nustep and had him start using the treadmill. He was very nervous about the change and didn't believe he would be able to do more than 2 minutes, but was able to complete 10 minutes his first session. We now added the treadmill at 1.2 mph for 10 minutes. Patient A had an echo during week 7, which showed no changes since the last. He is still being prepped for a defibrillator. 

 

Progessing in the Program:

Patient A is starting to make significant changes in the program. He is describing a better appetite and says he is eating three times a day. He also stated that he listened to my advice on not to watch TV when he cannot sleep and describes that he has been sleeping through the night. He says he is proud of the work is he doing and that he is starting to feel accomplished. His RPE's are going from moderate to light, an indication for us to increase his prescription. He is also gaining some weight back that he had lost when he was not eating. 

 

Problems with CHF: 

In the beginning of week 8, Patient A stated he was not feeling that great. I also noticed that he had gained 5 pounds in just a few days. He had pitting on both legs, indicating that CHF was getting worse. Lung sounds had faint crackles in the bases bilaterally. His doctor was notified and his lasix dose was doubled. When he returned, the pitting disappeared and lung sounds were clear again. He is attending a weekly lecture on CHF and says he is getting a lot out of it. 

 

Home Stretch:

Week 8 was a big progression in his exercise prescription. He is now on the recumbant bike at 40 watts for 15 minutes, the biostep at level 2 for 15 minutes and the treadmill at 1.4mph for 10 minutes. He is also doing handweights at 2 lbs each. He says he is eating full meals three times a day and has been listening to the advice of our nutrition student. He brought recipes home for his wife to make. He also has been sleeping better and hasn't complained of fatigue. Week 9, his exercise prescription was progressed again, as he is doing 50 watts on the bike and 1.5mph on the treadmill. During week 10, he had his exit stress test. Patient "A" did 7 minutes on his motified bruce protocol, which is 4 minutes greater than his entrance stress test. He quit due to calf pain but said he could continue a little longer. 

 

Weeks 11 and 12 were great for Patient "A". He stated that he feels healthier and stronger, something he was very doubtful of from the beginning. He says he is going to continue exercising at home, whether it be walking outside with his wife or joining a gym at the senior center. He is thrilled with hs progress and says he is no longer skeptical of how exercise is beneficial for his health.