Reducing the risks associated with exercise
To help reduce the risks associated with exercise there are several screening tools which can be used to gather relevant information about your patient before you prescribe exercise. This is especially important if you intend on using an exercise test to help determine how fit your patient is. Remember that it is also standard practice to get informed consent from your patient prior to conducting an exercise test.
It is important to screen patients before exercise. We have included some examples of screening questionnaires and useful tools below:
- Physical Activity Readiness Questionnaire - PARQ
- AHA/ACSM Health/Fitness Facility Pre-participation Screening Questionnaire and risk stratification categories
- American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) Risk stratification for cardiac patients.
- AHA risk stratification criteria
- A checklist of the signs, symptoms and risk factors of coronary artery disease
It is important to be vigilant. Recognise the difference between normal exertion and the signs and symptoms of excessive exertion which can indicate a serious event. Without causing alarm, you can also educate your patient about the major signs and symptoms of myocardial infarction. By exercising in your presence, your patient can become accustomed to what it feels like to reach a healthy safe level of physical exertion.
Common signs and symptoms of a major event include:
- Pain or discomfort in the chest, neck, jaw, arms
- Shortness of breath at rest or with mild exertion
- Dizziness or syncope
- Orthopnea/paroxysmal dyspnea
- Ankle oedema
- Palpitations or tachycardia
- Intermittent claudication
- Known heart murmur
- Unusual fatigue or shortness of breath with usual activities
To encourage safe exercise always carry out a warm up. This not only prepares the body and mind for exercise but allows the coronary arteries to dilate. Even in healthy individuals there can be a time lag between the increased energy demand on the heart as a result of exercise and increased blood flow to the heart. It can take up to 15 minutes for the coronary arteries to dilate.
This is especially important in patient populations and the elderly.
A warm up generally includes rhythmic movements of the large muscle groups of the body. Examples include marching on the spot, punching the air, gentle cycling or jogging.
Similarly a cooling down period is important. This can help prevent post exercise hypotension and venous pooling. When a patient is tired at the end of an exercise session, encourage a gradual reduction in exercise over sitting down straight away. Something as simple as walking slowly or marching on the spot, even with upper limb support, can suffice to redistribute blood gradually.
Educate your patients on the importance of incorporating a warm up and cool down into their exercise sessions to encourage safe exercise when you are not there to supervise.
Other important considerations
Other simple but often overlooked considerations are equipment, clothing, facilities and the environment in which exercise takes place.
- To reduce risk when exercising always ensure that your patient has appropriate footwear, clothing, and supervision. For resistance training it may be necessary to use spotting techniques.
- Also ensure that if supervising exercise you have sufficient time to dedicate to your patient. In a hospital setting, it can be difficult to ensure that there is adequate space to exercise; however, you should try to minimise obstacles. In a home setting, tripping hazards should be removed.
- Ensure that the environment is not too hot and that there is sufficient ventilation. Watch for signs of overheating including headache, dizziness, nausea, faintness, crams or palpitations.
- Where appropriate know how to call for emergency services and where the nearest defibrillator is. If in a hospital setting know how to call for the crash team. The most common number to activate emergency services is 112.
Normal side effects of exercise
Delayed Onset Muscle Soreness (DOMS) is a common side effect of exercise training. Your patients should be made aware that some soreness is expected and that this allows muscles to become stronger than they were before exercise took place. Muscle soreness can present from 12 to 24 hours after exercise. However, persistent or intense muscle pain that starts during or immediately after exercise, or muscle soreness that lasts more than 10 days is not normal and warrants attention.
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