Integrating The Use Of Heart Rate Rpe Mets And Observation

As discussed in the preceding sections, at times there are limitations to the reliability and validity of using either HR, RPE, observation and METs alone to control or monitor exercise intensity in the cardiac patient. Furthermore, the patient's psychological state may be an important factor that holds back or advances too quickly the patient from exercising at the physiologically beneficial intensity. Figure 3.8 summarises these four important facets to guiding the patient towards the appropriate intensity, eventually with them taking command. The RPE provides a channel through which the patient's psychological status influences the appropriate exercise intensity.

In the initial stages of rehabilitation, if an MET value and HR are known from an ETT, to show the intensity at which any critical cardiac events occur, these should be used to guide exercise intensity. RPE should be used immediately to link with these, but its reliability to represent these levels should be

Figure 3.8. Framework of the integrated components in monitoring exercise intensity in cardiac patient rehabilitation.

assessed. It has been reported that patients tend to inflate their RPE in an initial exercise ETT compared to subsequent exercise at the same intensity in the CR exercise class, with only a few days separating the two sessions (Buckley, et al., 2000). If the exercise sessions involve the use of exercise machines, then either HR or METs, relative to the peak measurements from the exercise test, can be used to set intensity. If the exercise is a class, circuit or home-based activity then HR will be the obvious choice initially, but giving patients advice about what activities they can or should do based on the MET value is an important adjunct. Models of good practice for home-based programmes involve either having a few instructional sessions with the patients as part of an outpatient clinic before patients exercise at home, and/or supporting this with a video (see the British Heart Foundation: www.bhf.org.uk) or an individualised home programme using Physiotools (2005), etc.

For monitoring exercise subsequent to more practical assessments (step test, cycle test, shuttle walk) the appropriate level should be one that equates to the intensity that the patient can sustain. These tests are designed to raise intensity incrementally to a level which elicits an HR of <60%HRRmax or 75%HRmax and an RPE of 13 to 15 as per the upper limit guidelines in Table 3.1 (see page 54). From the MET level or 75%HRmax that corresponds with the end of the test, subsequent exercise intensities can be monitored relative to this. This principle can be used even when patients are beta-blocked, but the HR has to be adjusted, as recommended in Table 3.3 (see pages 61-2).

The cue to progressing intensity in all the above cases is when, for a given work rate, there is a noticeable decrease in both HR (>5 beats.min-1) and RPE (>1.5 RPE points). If there is a noticeable decrease in HR there should be a corresponding decrease in RPE. If there is not a corresponding decrease in RPE with HR, this is a sign that the accurate use and understanding of RPE is yet to be established. In addition, the skills of the exercise leader to observe the participant are vital in delivering safe and effective CR.

Finally, it is important that patients learn to self-monitor changes by reporting and/or associating their improved levels of fitness relative to changes they experience in activities of daily living (away from the structured class). When patients are able to recognise their changes and benefits, they are better able to judge their own level of functional health or change of symptoms that could occur in the future.

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