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Katie or to feel unwell (Hetz, S.P. et

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Katie
is a 25-year-old female that has been classified with fair cardiorespiratory
fitness. Her CRF classification was determined using her measured VO2 max of 38
ml.kg-1.min-1) (Cooper Institute of Aerobic Research, 2005). Fair cardiorespiratory fitness in young adults is associated
with the development of cardiovascular disease risk factors (Carnethon, M.R. et al, 2003), diabetes, colon and
breast cancer, and depression (Warburton, D.E. et al, 2006). There is indisputable
evidence that regular physical activity is effective in the primary and
secondary prevention of such chronic diseases (Warburton,
D.E. et al, 2006). An individual may present with a fair CRF classification due
to decreased physical activity; this is defined as any bodily movement produced
by skeletal muscle that requires energy expenditure (World Health Organisation,
2012). It is also likely to be due to unhealthy lifestyle behaviours that may
have been established during younger years (Nabi, T et al, 2015) as it has been
evidenced that children who are physically active go on to be healthier adults
(Boreham, C. and Riddoch, C.,
2001). Negative
experiences during school physical activity classes are the strongest factor
that discourage participation in physical activity in teenage girls and this
continued anxiety and lack of self-confidence are factors that continue in to
adulthood (Allender, S. et al, 2006). As
well as the numerous health benefits that have been associated with increased
cardiorespiratory fitness, patients with lower cardiorespiratory fitness may
have difficulty performing more strenuous activities of daily living. These
activities include; walking for long distances and climbing the stairs and may
cause Katie to experience shortness of breath or to feel unwell (Hetz, S.P. et al, 2009). It is essential that Katie improves
her cardiorespiratory fitness to help make it easier for her to do these
activities of daily living and also to allow her to get back to the leisure
activities that she enjoys.  Barriers
that may be currently preventing Katie from reaching the recommended physical
activity guidelines include; lack of time, lack of social
support, inclement weather and disruptions in routine (Dunn, A.L. et al, 1999). By prescribing a goal
orientated treatment plan that fits around Katie’s lifestyle the intention is
to help improve her VO2 max and therefore increase her cardiorespiratory
fitness.

The
American College of Sports Medicine (2013) recommends that to see improvements in
Katie’s health, she should be exercising at a moderate intensity on at least 5
days per week. Moderate intensity exercise includes; brisk walking, housework
and cycling (World Health Organisation, 2018). Katie’s CRF classification can
be used to recommend a more individualised exercise programme and it is
suggested that individuals with fair cardiorespiratory fitness levels should
exercise at a moderate to vigorous intensity a minimum of three times per week
to produce significant changes in aerobic endurance (ACSM, 2013). An
appropriate combination of exercise intensity and duration is required so that
the individual adequately stresses the cardiorespiratory system without
overexertion (Heyward, V. H and Gibson, A.L, 2014). Therefore, Katie should be
looking to complete a combination of moderate and vigorous intensity exercises,
such as walking, running and climbing the stairs) for 20-60 continuous minutes
in order to see improvements in her cardiorespiratory fitness (World Health
Organisation, 2012). The greatest conditioning effects will occur during the
first 6 to 8 weeks of the exercise programme. For Katie to continue to see
improvements in her cardiorespiratory fitness, the system must be overloaded
through adjustments in the intensity and duration of the exercise to the new
level of fitness (Heyward, V. H and Gibson, A.L, 2014).

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Cardiorespiratory
fitness classification is classified using the patient’s VO2max. The VO2 max reflects the
capacity of the heart, lungs, and blood to deliver oxygen to the working
muscles during dynamic exercise involving large muscle mass (Heyward, V. H and
Gibson, A.L, 2014). Katie’s CRF classification can be used to understand the
percentage of heart rate reserve, percentage heart rate max or percentage of
VO2 max that she should be working at in order to improve her cardiorespiratory
fitness.

VO2max can be used
as an outcome measure for cardiorespiratory fitness (Bennett, H. et al, 2016), the graded exercise tests
allow for the patient to reach voluntary exhaustion allowing a direct and therefore
more likely accurate measurement. However, VO2max can be more difficult to
measure than alternative outcome measures such as heart rate and in Katie’s
case I decided not to use VO2 max due to Katie’s fair cardiorespiratory fitness
and safety concerns that may come with allowing her to reach full exertion and
also due to the lack of equipment available.

Heart rate is an alternative
outcome measure that can be used that is easily measured using heart rate
monitors that can be worn around the patient’s chest (Machado, F.A. and Denadai, B.S., 2011). They are easy to use and
often more available than gas analysers that are required when directly measuring
VO2 max. Limitations to using heart rate however are that it be affected by
medication, emotional states and environmental factors such as; temperature,
humidity and air pollution (Heyward, V. H and Gibson, A.L, 2014). Two
alternatives of heart rate measurements can be used when prescribing an appropriate
exercise intensity; the percentage of heart rate max and the percentage of
heart rate reserve. Percentage of heart rate reserve is the preferred outcome
measure due to the inclusion of the patient’s specific resting heart rate, the
calculation is therefore more individualised to the patient. Exclusively using
heart rate to develop intensity recommendations however, may lead to large
errors in estimating relative exercise intensities for some individuals. This
is especially true when HRmax is predicted from age (220-age) instead of being
directly measured (Heyward, V. H and Gibson, A.L, 2014). It is therefore
recommended that when using heart rate as an outcome measure, it should be used
in combination with ratings of perceived exertion in order to accurately
prescribe an individualised exercise plan. A Borg scale is used so that the
patient can rate their perceived exertion. They are very easy to use and can be
used by patients during physiotherapy sessions and when completing the
treatment plan at home. They are cheap and subjective and can help patients who
are afraid of increasing their heart rate to understand the appropriate level
she should be working at.

The treatment approach I decided to use was to focus on a Katie’s
individual health goals. This involves focusing on health goals within dimensions
such as; symptoms, physical functional status and social functions (Reuben, D.B. and Tinetti, M.E., 2012.). Katie’s main goal was to
get back to the leisure activities she previously enjoyed and to make
activities such as walking long distances easier. In a goal-orientated treatment
plan the goals set should be specific, measurable, attainable, realistic and
time-based (Bovend’Eerdt, T.J. et al,
2009.). I
therefore worked with Katie to create goals that could realistically be
achieved in the ten-week time frame, and that were individualised to her
lifestyle and that I could use an outcome measure to ensure achievement. In
order to increase Katie’s cardiorespiratory fitness, she needed to increase her
maximal oxygen consumption. Using Katie’s CRF classification I was able to
determine the percentage of heart rate reserve she should be working at and her
target heart rate range (125-144bpm). By using a Borg scale in conjunction with
the heart rate monitor, Katie is able to understand the intensity she should be
working at using a visual aid. I calculated Katie should be working an RPE of
12-13, which is categorised as fairly light-somewhat hard. I was then able to
use Katie’s rating of perceived exertion alongside the reading from the heart
rate monitor to either progress or regress her exercises to ensure she is
working at the appropriate intensity.

 

Katie’s
treatment plan involves exercises from the class, it also involves helping her
to understand other ways she can incorporate her 30 minutes of moderate
exercise on 5 days a week into her lifestyle. During the exercise class I was
able to use the heart rate monitor and Katie’s RPE to progress and regress the
exercises to the appropriate level. I recommended to Katie that at home she did
this set of exercises on three days a week for 30 minutes as in accordance with
the guidelines for someone of Katie’s age with her level of fitness. Using
Metabolic Equivalents, an alternative to VO2max, I was able to determine how
Katie would be able to get back to her leisure activities that she set out in
her goals.  One of Katie’s goals was to
get back to swimming on a regular basis, and using the calculation that
converts her intensity level to METS I was able to prescribe that Katie took
part in 30 minutes of moderate intensity swimming, such as breaststroke, once
or twice a week. Using a Borg scale, she is able to understand the appropriate level
she should be working at whist swimming, and I also suggested that she went
swimming with a friend so that she was be able to make sure she was still able
to talk during the exercise. Moderate intensity exercise involves the
individual getting hot and slightly sweaty, however they should still be able
to hold a conversation (Nhs.uk, 2018). Whilst talking to Katie
about other aspects of her daily life I was able to create an alternative goal
for another day of the week. I was able to calculate the walking speed that can
be classified as moderate intensity exercise and suggested to Katie that she
tried to walk the two-mile trip to the shop and back in 30 minutes on one day a
week, therefore allowing her to reach the 30-minute exercise goal, increasing
her cardio-respiratory fitness, whilst also allowing her to get back to
activities of daily-living.

There may be a
number of reasons as to why Katie’s adherence to the programme does not remain
high. For example, Katie may not continue to adhere to the plan is due to pain
she may experience after the first few sessions. Katie will be doing
unfamiliar, high-force muscular work that may result in delayed onset muscle soreness
(Cheung, K. et al, 2003.). Although the symptoms should
suppress within a few days, the pain may cause Katie not to want to continue
with her plan, this is one example of when physician communication is
significantly related to patient adherence (Zolnierek, K.B.H. and DiMatteo, M.R., 2009), as if Katie understands
why she is experiencing these symptoms she will hopefully continue to complete
the plan as recommended. It is essential to evaluate and measure patient
adherence reliably (Atreja,
A. et al, 2005).
To ensure that Katie is reaching her activity goals I have decided to provide
Katie with an accelerometer so that I am able to track her levels of physical activity.
Accelerometers are small, discrete devices that measure the magnitude of the
bodies accelerate that are able to provide information on duration, frequency
and duration of activity (Yang,
C.C. and Hsu, Y.L., 2010). Although they cannot detect a gradient and can be inaccurate at
measuring cycling and upper limb movements (Scheers, T. et al, 2012) I think that it will be a useful tool to provide me with
information on Katie’s activity patterns and establish her adherence to the
treatment plan. I intend to continue to have regular assessments of Katie’s
adherence to the programme using both this method and self-reports provided to
me by Katie throughout the programme.

Katie
was classified as having a CRF of fair using her measured VO2 max. There is a
great deal of evidence that shows cardiorespiratory fitness can be increased
and the health benefits that come with this are massive. Katie’s main goals for
the programme were to increase her fitness to allow her to get back to leisure
activities she enjoys, the added health benefits that will come with this
increase in physical activity are great. The key to setting appropriate goals
was to understand the reasons as to why Katie’s cardiorespiratory fitness has
reduced and the current barriers that are preventing her from reaching the
guidelines that are set for someone of her age. I was able to determine the
heart rate range and perceived exertion Katie should be working at during both
set exercises and when incorporating physical activity into her daily life. These
measures allowed me to set an achievable goal-orientated treatment plan that
will allow Katie to get back to the activities she enjoys whilst also
continuing to increase her cardiorespiratory fitness. 

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