Conference 2015HIGH PERFORMING HEALTH CARE

UCOL U-Kinetics Te Huinga WaioraDelivery & Effectiveness of Specialised

Clinical Exercise Programmes for Cardiac, Respiratory and Diabetic Clients

Dreyer, L.I.1,2, Rankin, D.1,2, Dreyer, S.1& Wormgoor, S.1

1Exercise & Sport Science DepartmentUCOL, Palmerston North,

2Clinical Exercise Physiology NZ

U-Kinetics Te Huinga WaioraRATIONALE

CHRONIC DISEASE (NCD’S)

• NCD’s Leading Cause of Mortality– 2020 – 7 out every 10 deaths

– 2030 – Estimated Worldwide Mortality = 52 million/year

• Major Public Health and Economic Burden

• Importance of Physical Activity– Direct cost of inactivity estimated to be $60 million in NZ in 1991

– 2 in every 3 NZ’s diagnosed with at least 1 NCD

– Indirect cost of physical inactivity in 1991 estimated at $104 million

• Loss in productivity due to premature morbidity, and mortality

– Hospitalisations and Readmissions

– Access to Exercise Rehabilitation

– Survivorship & Prolonged Functional Weakness

• Research: Cardiovascular Disease (Van Hees et al.,1994)– 527 men with CVD, VO2 directly measured, 6.1 year study

– Highest all-cause mortality = FC < 4.4 METs

– No deaths in cohort with FC > 9.2 METs

• Research: Cardiac Exercise Rehabilitation (Martin et al., 2013):– Trained MI patients for 12-weeks

– 5600 men; 1300 females

– Each 1 MET increase in FC = 22% reduction in mortality 1 year later

• Research: Heart Failure Patient Study (Feuerstadt et al., 2007)– 600 patients; Ejection fraction <35%

– 12-weeks training

– Each 1 MET increase in FC = 28% reduction in

mortality

FUNCTIONAL CAPACITY(RESEARCH)

CLINICAL EXERCISE PHYSIOLOGY – THE GAPS

• 80% of health care cost from 10-20% of population

• Traditional Health Care does not generally target improvement of functional ability (or prevention)

• How to attain sufficient levels of fitness in groups that can benefit most is the major challenge– Along with providing a safe exercise environment

• No specific profession targeting Exercise Rehabilitation– Along with Associated Funding Issues

U-Kinetics Te Huinga WaioraClinical Exercise Physiology Centre Development

“Development of an Applied Clinical Exercise Physiology Qualification to prepare graduates to work with medically

‘at-risk’ individuals”

“Developing the role of the ‘Clinical Exercise Physiologist’ in New Zealand”

Considerations:

• International Recognition/Models for Specialised Exercise Physiology

• Fit with Current Health Services and Health & Allied Professionals

• Support from the Health System

• Future Health Needs for NZ

CLINICAL EXERCISE PHYSIOLOGY EDUCATION

WHAT IS A ‘CLINICAL EXERCISE PHYSIOLOGIST?’

“Development of an Advanced Applied Exercise Physiology Qualification to prepare graduates to work with medically

‘at-risk’ individuals”

“Developing the role of the ‘Clinical Exercise Physiologist’ in New Zealand”

Considerations:

• International Recognition/Models for Specialised Exercise Physiology

• Fit with Current Health Services and Health & Allied Professionals

• Support from the Health System

• Future Health Needs for NZ

A clinical exercise physiologist can be defined as an individual who specialises in the delivery of exercise, lifestyle and behavioural

modification programmes for the prevention and management of chronic conditions and diseases, and

musculo-skeletal injuries

(adapted from Exercise and Sport Science Australia, 2010)

POSTGRADUATE QUALIFICATION

Entry to Programme:• Bachelor of Exercise & Sport Science or Equivalent• Completion of a Health-related degree with industry experience in

Exercise• Pathway for other Health & Allied Health Professionals (Training Scheme)

Clinical RequirementsMinimum of 540 Hours Clinical Exercise Physiology Experience:

180 hours – Cardiovascular or Metabolic (incl. Diabetes) conditions 120 hours – Respiratory, Neurological conditions or Cancer 180 hours – Orthopaedic/Musculoskeletal injuries or conditions 60 hours either additional to above or

other clinical exercise activities

POSTGRADUATE DIPLOMA IN CLINICAL EXERCISE PHYSIOLOGY

WORK INTEGRATED LEARNING (APPLIED)

• What we needed:– Delivery of Individualised & specialised

Exercise Testing and Training for:• Cardiac Conditions

• Respiratory Conditions

• Diabetics

• Musculoskeletal Conditions & Injuries

• Other Medical Conditions

– Exercise for Management of Co-Morbidities

• Services were not currently available to meet requirements

• Concept Paper/Business Case• Qualification - Curriculum

Development & NZQA Approval

• Exercise Programme • Facility• Research Programme• Equipment

– Technogym Wellness System

• Health & Safety• Client Reporting

COLLABORATION:KEY PARTNERS

UCOL MIDCENTRAL DHB / CENTRAL PHO

• Funding

• Targeted Conditions

Respiratory, Cardiac, Diabetes

• Existing Programmes/ Services

• Referral pathways

• Client Safety

• On-going Collaboration/Communication

• Physiotherapy, Occupational Therapy, Orthopaedic Surgeons & Exercise Therapists

• Multi-Disciplinary Philosophy

• Services Related to Musculoskeletal Rehabilitation, Chronic Pain, Vocational Rehabilitation

• Shared U-Kinetics Reception

TBI HEALTH HEALTH WORKFORCE NZ

• Demonstration Site

• New Workforce Development

COLLABORATION:KEY PARTNERS

U-Kinetics Te Huinga WaioraSERVICE DELIVERY

CLINIC SERVICES & STAFFING

• Merging Education with Health Service Delivery

– Curriculum with Practical Learning Focus• Student Progression through the programme

– Observation to Delivery

• Client pathway through the service– One-on-One through to Self-Managing Exercise

– Staffing• Dual Professionals - Senior Academic / Clinical Exercise Physiologists• Our Graduates & Internships• Students Utilised to Supervise Clients

– Safety• Supervision (Client & Students)• Entry requirements• Emergency procedures

Referral Pre-Assessment Consultation

Client Exercise Testing

Client ReportsClient, Referrer & Clients GP

Client Exercise Programme

Client Exercise Retesting

1

2

DHB ReportsEvery 3 Months

6 Month Report of Data

CLIENT JOURNEY

U-Kinetics Te Huinga WaioraENVIRONMENT & CLIENT BENEFITS

CLIENT OUTCOMES

Data Presented in these Results are for:

366 Clients – completed 12 week program

117 = Cardiac clients

103 = Respiratory clients

146 =Diabetic clients

133 Clients - completed 24 week program

46 = Cardiac clients

53 = Respiratory clients

34 = Diabetic clients

CLIENT STATUS AT START OF PROGRAMME

Cardiac:• Low functional capacity

• Impaired ejection fraction

• Low/high resting BP

• Orthostatic intolerance

• Angina

• Peripheral arterial disease

• Overweight/fragile

• Poor response on exercise– Post-exercise dizziness

– ECG changes

– Poor BP response

– Intermittent claudication

Respiratory:• Low functional capacity

• Regular exacerbations– Chest Inflammation

– Hospitalization

• Borderline resting O2

saturation levels

• Fragile

• Muscle atrophy/circulatory steal

• Exercise desaturation

Diabetic:• Foot ulcers

• Overweight

• Poor glucose control

• Limited understanding of need to control glucose

• Poor dieting habits

• High insulin usage

• Multiple conditions– Heart disease

– PAD

– Elevated BP

– Stroke

• Poor exercise response– Post exercise hypoglycemia

– Rhythm changes

– Silent angina

– Intermittent claudication

Functional Capacity in METs

<4.31 4.32-4.99 5.0-7.99 8.0-9.99 10+

28.3% 15.9% 48.5% 6.9% 0.5%

Dyspnoea and Angina During CyclingNone Mild Moderate Severe

37.0% 30.1% 17.6% 15.3%

Resting Blood Pressure (mmHg)

<110/70 112-140/72-90 160-180/90-100 180/102+

SBP 8.5% 63.4% 27.3% 0.8%

DBP 19.3% 67.6% 11.1% 2%

Peak Cycle Wattage

<25 watt 25-35 watt 36-50 watt 51-100 watt > 100 watt

6.8% 17.3% 24.9% 46.2% 4.8%

CLIENT STATUS AT START OF PROGRAMME

CLIENT SAFETY

Early Warning Score (EWS)SCORE 3 2 1 0 1 2 3

Respiratory

Rate

< 8 9-14 15-19 20-30 >30

Pulse/min < 40 40-50 51-100 101-110 111-130 >130

30 sec ECG Normal Some

arrhythmia’s

< 6 PVC/min >6 PVC/min

Systolic Blood

Pressure

(mmHg)

< 90 90-99 100-110 111-140 141-160 161-170 >170

Medication All meds

taken

Took meds later

or earlier

Forgot to take

medication

Glucose Levels

mmol.l-1< 5.55 >13.8 with no

ketosis

>16.6 with no

ketosis

>13.8 with

ketosis

Complexion Red, hot,

confused

Fully alert Slow to respond Confused Pale, cold and

low alertness

Symptoms No Angina

or other

symptoms

Light barely

noticeable

symptoms

Moderate

bothersome

angina or

symptoms

ENVIRONMENT – SUPERVISION & STUDENT CONDUCT

• Scope of Practice

• Profession Development

• Team Work– Off the ball contributions

• Professional conduct

• Running a Tight Ship– Privilege, Not a Right– Rather Safe than Sorry

• Building partnerships– Understand the history of CEP– Cherish and nurture the privilege

to have place to serve

“Creating an Environment where

Clients feel Comfortable,

Supported and Safe”

U-Kinetics Te Huinga WaioraCLIENT OUTCOMES

Variable Pre-training Post-training P-value

X SD X SD

Physical Function 39.3 11.3 44.0 10.4 0.0001

Role-Physical 39.2 11.1 45.0 10.5 0.0001

Body Pain 45.0 11.2 48.9 9.7 0.0001

General Health 40.5 11.0 45.2 11.1 0.0001

Vitality 45.4 10.1 50.7 11.1 0.0001

Social Function 43.9 11.7 48.9 10.4 0.0001

Role-Emotion 42.6 14.4 48.2 10.9 0.0001

Mental Health 49.1 10.5 52.7 9.6 0.0002

Physical Component 39.2 10.3 43.9 9.2 0.0001

Mental Component 47.9 11.4 52.8 10.1 0.0001

CES-D 12.9 10.2 9.5 7.9 0.0004

HADS Anxiety 5.9 3.8 4.5 3.1 0.0001

HADS Depression 4.8 3.3 3.2 2.8 0.001

QUESTIONNAIRE RESULTS

SF-3

6v2

QU

ESTI

ON

NA

IRE

ALL

QU

ESTI

ON

NA

IRES

SH

OW

ED

SIG

NIF

ICA

NT

IMP

RO

VEM

ENTS

Variable Pre-training Post-training P-value

MEAN SD MEAN SD

RSBP 136.0 16.5 131.6 14.6 0.0001

RDBP 80.8 9.9 78.1 9.4 0.0001

Body Weight 92.6 23.7 91.8 22.9 0.62

BMI 33.5 8.2 32.1 8.4 0.31

Percentage body fat 28.1 14.2 26.9 13.4 0.32

Watt3 58.9 25.7 80.7 35.1 0.0001

VO2 peak 19.6 6.1 23.2 7.0 0.0001

MET 5.6 1.7 6.6 2.0 0.0001

PHYSICAL FUNCTION RESULTS

EFFECT ON HAEMODYNAMIC VALUES OF CARDIAC PATIENTS

Baseline Assessment

12 Week Assessment

Final Assessment % Change

Category Mean (± STDEV)

Mean (± STDEV)

Mean(± STDEV)

Baseline to 12

Weeks

Baseline to 24

Weeks

% of Total Change Achieved in First 12

Weeks

Systolic BP 136.6 (±16.7) 131.1 (±14.2) 126.4 (±12.2) -4% -8% 50%

Stroke Volume 56.2 (±16.5) 53.8 (±14.1) 52.0 (±12.9) -4% -7% 57%

mVO2 87.2 (±18.1) 84.4 (±16.9) 78.5 (±15.0) -3% -10% 30%

MAP 99.1 (±10.5) 95.2 (±10.9)* 91.8 (±6.75)* -4% -7% 57%

SBPslope 205.7 (±49.5) 189.8 (±39.5) 187.4 (±32.2) -8% -9% 89%

Wattpeak 60.2 (±21.8) 89.2 (±35.9)* 110.4 (±46.2)* 48% 83% 58%

RPEslope 19.9 (±8.47) 15.2 (±5.19)* 13.9 (±7.44)* -18% -22% 82%

mVO2 s3 218.3 (±37.9) 223.4 (±34.9) 240.3(±49.9) 2% 10% 20%

VO2peak 19.6 (±5.67) 24.7 (±7.22)* 28.2 (±6.88)* 26% 44% 59%

CRI 39.3 (±13.3) 36.2 (±10.3) 32.5 (±6.67) -8% -17% 85%

PROGRAMME EFFECT ON FUNCTIONAL CAPACITY (VO2peak)

28.3

15.5

47.5

6.42.3

10.5 11.9

47

23.3

7.3

0

5

10

15

20

25

30

35

40

45

50

<4.30 4.31-4.99 5.0-7.99 8.0-9.99 10.0+

Per

cen

tag

e re

spo

nd

ents

Functional capacity in MET

Pre

12-wks

N=366'Functionally able' increased from 8.7% to 30.6%

2522.1

47

5.9 01.58.8

51.5

26.4

11.8

0

10

20

30

40

50

60

<4.3 4.31-5.0 5.1-8.0 8.1-10.0 10.1+

Pre

24-wks

N=133

Reduce functionally Impaired from47.1% to 10.3%

Functionallydependent

Functionallyrestricted

Borderline

Perc

enta

ge r

esp

on

den

ts 38.2% of ‘strugglers’ functionally able after

24-wks

PROGRAMME EFFECT ON FUNCTIONAL CAPACITY (MET)

TRAINING EFFECT LOW FINISHERS (Post exercise MET <4.3)

Angina Scale

1 Light,

Barely Noticeable

2 Moderate, Bothersome

3 Severe,

Very Uncomfortable

4 Most severe pain ever

experienced in the past

Variable Pre-exercise Post-exercise p-value ES

x SD x SD

RSBP 140.3 18.8 135.1 13.8 0.27 0.27

RDBP 80.8 12.6 76.4 11.1 0.21 0.35

Weight (kg) 105.8 34.3 104.8 33.1 0.91 0.03

Watt3 32.7 7.1 40.3 9.3 0.01 0.81

RPEslope18.1 6.5 14.9 6.6 0.10 0.48

SBPslope203.0 65.1 186.8 70.4 0.41 0.23

Angina 3.2 1.5 2.6 1.7 0.23 0.35

CLIENT FEEDBACK THEMES

• Well-resourced

• Friendly, well trained and encouraging staff and students

• Supervision is excellent

• Removed my fear for exercise

• Significant impact on my health and well-being

• My blood sugar levels mean I need to inject less insulin during

the day.

• Love the personal approach

• I feel more in control of my health

• Feel I can cope with my situation now

• The program has given me my life back

FUTURE CHALLENGES & OPPORTUNITIES

• Rehabilitation vs Prevention Focus

• Recognition of Clinical Exercise Physiologist Role

– Professional Registration – CEPNZ

– Recognition from Health Funders

• Determining Cost-Effectiveness of Programme

• Expansion of Clinical Exercise Physiology Services

– Other Areas & Other Conditions

• Showcasing Role Within Other Settings

• Increasing Graduate Opportunities

– Making use of this new workforce

Appendix slides

Additional slides for Q&A part

MidCentral Award

2013 MidCentral DHB Peoples’ Choice AwardThe judges commented that this is a service that has been very well received by its clients:

“This is a new programme demonstrating exciting potential to achieve improved outcomes from participants.”

Respiratory Client:

In one case, a 22-year-old patient came into the clinic suffering from severe asthma. Unable to distinguish the difference between being short of breath due to exercise and asthma, the client had very little exercise IQ as she had always been scared of triggering an asthmatic episode.

By the end of her 12-week programme, the client had learned to distinguish between the two; increasing her confidence and making huge improvements to all aspects of physical and psychological measured parameters. The patient now aims to walk a half marathon later this year.

CLIENT EXAMPLE

Client Data

Pre-training

• Age: 48• Height: 187.6• Weight: 235.8 kg• Resting BP: 150/98• Random Glucose: 9.2• Type 2 diabetic on Metformin• Obstructive sleep apnoea score: 9/24• Using GTN spray 3 to 4 times per week• Walk with crutches; can’t walk more than 150

meters• Wattmax: 60 Watt• Bpmax: 174/110• RPEmax: 14

After 11 weeks of training

• Lost 24 kg• Taken off Metformin• Pre-exercise glucose dropped from always above

8.5 (spiking to 11 some days) to rarely being higher than 6.0

• Training Watt increased form 40 Watt to 60 Watt (+67%)

• Highest training RPE: 12• Pre-exercise BP: 120-130/86 • Highest Exercise BP: 168/90• Use GTN less than once a week• Sleep apnoea score: 5/24 • Can walk 60 minutes non-stop without crutches

Letter From Client

I thought long and hard if I wanted to write this letter. But as many steps as I was taking during my participation in Relay for Life – held in my hometown Porirua – I know I had to put it on paper.

Last year – captured in the world of the obese; ashamed of myself; staying homebound; food was my comfort; I moved around on specially made crutches.

When I did try to get my A into G – trying to go for a walk; I managed 100 to 150 meters before running out of puff; had extreme pain in legs and back, and legs cramping. So much pain that when I got home I wanted to be left alone and didn’t want to hear or think about my problem.

This weekend – an unlimited amount of laps have been completed without crutches; my family showed - for the first time- pride in me for the weight I’ve lost, how I look and for walking without crutches.

Now I am looking forward to dancing with my daughter on her 21st this coming Saturday. Our first father/daughter waltz – something that I didn’t even imagined possible just a few months ago.

My goal was to lose 10 kg but with your help I’ve now lost 24 kg since starting at U-Kinetics 3 months ago.

Anxiety PAI SwayGrip

Strength

% Change -22 121 -15 23

-22

121

-15

23

-60

-40

-20

0

20

40

60

80

100

120

Pe

rce

nta

ge c

han

ge

Effect on anxiety, activity patterns, body sway and grip strength