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Final Case Report with Work Samples:

Ellie Smith
Kathryn Webster
Carroll University

Assessment for Entry for Cardiac Rehabilitation Program


Patient Information

Running header: FINAL CASE REPORT AND WORK SAMPLES


Ellie is a 45 year old female who is diagnosed with postural orthostatic tachycardia
syndrome (POTS), which is also known as dysautonomia. Ellie was diagnosed with POTS
approximately four years ago. It presented with flu like symptoms, but when these symptoms
lasted for four months she decided to contact her primary care physician (PCP). She then
underwent various testing such as sweat tests and tilt table testing which lead to positive
autonomic testing. Over the summer Ellie was able to walk for 20 minutes continuously and had
energy to go out to dinner or watch her sons baseball game. However, once school resumed, she
returned to working fulltime as a school counselor, where she began feeling rundown. She also
reports napping 15-20 minutes on lunch and battling dizziness, nausea, and vomiting on and off
throughout the workday. Ellie does not have a documented ejection fraction, however it is stated
that her ejection fraction is within normal range. Ellies anthropometric measures are presented
in Table 1. Due to her diagnosis of POTS, she is currently participating in phase II of the cardiac
rehabilitation program.
TABLE 1. Patient anthropometric measures.
Height
Weight
BMI
O2
Blood
2
(inch)
(lbs.)
(kg/m )
Saturation Pressure
(%)
(mmHg)

Heart
Rate
(bpm)

Respirations Fall
(#/min)
Risk

63

72

16

113

20.32

100

112/64

Yes

According to the American College of Sports Medicine (2014), Ellies body mass index
(BMI) classifies her at a normal healthy weight. This could be due to her POTS disease and her
regular exercise that she self reports getting at least three days per week. Ellie currently is at an
optimal blood pressure according to the ACSM, her blood pressure should be <120 systolic and
< 80 diastolic. Resting heart rate is also optimal as resting heart rate should be between 60-<100
beats per minute. Respirations per minute were also within normal range of 12-20 respirations
per minute. Ellie informed staff that she has fallen more than once in the last 12 months, and she
considers herself a fall risk, therefore, the clinical decision was made to make her a fall risk at
cardiac rehabilitation class as well.
Physical Examination
During the physical examination, the registered nurse performed an assessment that
covered multiple areas which will be further discussed in this and following sections. Each part
of the assessments is important factors when considering and designing an individualized
treatment plan. Ellie reported having blurred vision, which is a side effect on more than one of
her current medications but no hearing discrepancies. In the neurological assessment Ellie does
report fainting in February 2014 after rushing downstairs in the middle of the night to get her
daughter medicine. Patient states she was not on salt tablets at that time. In February of 2014
Ellie states she hit the kitchen floor and woke up vomiting after she had rushed down the stairs.
Ellies doctor checked her and said everything was alright. She also presyncopal episode at work
9/9/14 which could have occurred do to the amount of stress, pressure, and walking Ellie was
performing that day. The nurse also states that her lung fields sound clear and does not note a
cough. It was also noted that Ellie has a normal sinus rhythm with no ectopy noted as well as no
edema as she wears compression stockings. She also does not have any mobility concerns but
does state she feels steady on her feet most of the time. Patient does sit frequently because of
dizziness. However, she does self-report she has fallen within the last year.
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Client Intake Interview


Smoking Assessment. Ellie has never smoked and does not plan to start or try smoking
in her lifetime. Follow up questions would include: Are you subjected to any environmental
smoke? If so, for how long and often are you exposed? Are there any barriers that would keep
you from staying away from second hand smoke or environmental smoke?
Exercise Assessment. Ellie is currently in the action stage for exercise. She currently
exercises a minimum of three days per week for at least 20 minutes as she feels she is able. Her
estimated intensity for her current activities would be fairly light or 11-12 /20 on the rate of
perceived exertion scale. POTS, makes her uncertain every day of how much she can do. She
enjoys exercise especially yoga and tries to continue to this at least once a week. Ellie does not
use an assistive device at this time. Follow up questions may include: What forms of exercise or
physical activity do you enjoy the most? Are there any activities that you do not enjoy doing?
Have you ever experienced pain while exercising, please explain? If pain is experienced, what do
you do to make the pain stop? How long does this pain intervention last for?
Nutritional and Weight Management Assessment. Ellie was assessed for her
nutritional and weight management. Her anthropometric measures were discussed and are
presented in Table 1. According to the ACSM guidelines, Ellie is classified as having a normal
healthy weight (American College of Sports Medicine, 2014). As she is of a normal weight, we
encouraged her to continue her current exercise regimen while also continuing to come to cardiac
rehabilitation. Ellie has stated that she would like to meet with a dietician. Follow up question
and responses are as follows:
Appetite: Depends on the day
Diet Teaching History: Through MD office
Current diet: Gluten free digests better, not truly gluten intolerant. Nuts, turkey,
chicken, 3 servings of vegetables daily
Caffeine: 1-2 cups of green tea daily and caffeinated water to get to kids sporting
events
Servings of meat per day: Two
Dietary counseling desired: Yes
In regards to weight management, it is recommended that Ellie stay at her current weight or try
to gain some weight according to her doctors as their goal is to have her maintain a weight of
110-120 pounds. Her POTS condition does not allow her to gain weight easily, nor does it allow
for her to have a healthy appetite as she is not always hungry and at times when she is she is only
craving sweets or unhealthy foods. Therefore, her weight management will be focused with her
dietician.
Psychosocial Assessment. Based on Ellies intake interview she states that she does
have anxiety and some concerns related to her anxiety. These concerns include: Uncertainty of
how she will feel day to day and how much she has already had to cut back in her life.

TABLE 2. Quality of Life Survey Scores.


Category
Quality of Life Index

Score out of 30
20.69
3

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Health Functioning
Social & Economic
Psychological & Spiritual
Family

15.47
25.43
21.57
28.50

Cholesterol management assessment. Ellies most current cholesterol levels are


displayed in Table 3. Based on Ellies current lipid results she is classified as having
dyslipidemia. She meets ACSM criteria based upon Ellies total cholesterol, LDL, and
HDL levels as well as current medication (American College of Sports Medicine, 2014).
TABLE 3. Patient cholesterol values.
Value
ACSM criteria
Total cholesterol
200 mg/dL

Patient Criteria
231 mg/dL

Triglycerides

150 mg/dL

148 mg/dL

LDL

130 mg/dL

144 mg/dL

HDL

<40 mg/dL

35 mg/dL

Medication

Currently on medication

Currently on medication

Medication compliance assessment. Ellie has discussed that she is 100% compliant in
taking her medications. For her medication compliance stages of change she is placed into the
action stage as she wants to get better and return to her daily activities with a reduction of her
current medications. Follow up questions might include: Are you still taking your medications as
described? Have you had any medication changes since your last cardiac rehab exercise session?
Have you been experiencing any side effects related to you medications? If so, can you please
describe what you are experiencing?
Blood pressure assessment. As stated in a previous section, Ellie does not have
hypertension based on ACSM criteria. Her blood pressure is displayed in Table 4. Ellie is
currently not on any blood pressure medication nor is she on a beta-blocker due to her POTS
condition.
TABLE 4. Patient blood pressure results.
Value
ACSM criteria
Systolic
140 mmHg

Patient criteria
112 mmHg

Diastolic

90 mmHg

64 mmHg

Medication

Currently on medication

Not currently on medication

Risk Factor Classification

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According to the ACSM, Ellie does currently meet two cardiovascular risk factors
(CVD). Ellie has a known cardiovascular disease, causing her to be high risk as well as
dyslipidemia (American College or Sports Medicine, 2014). The criteria are displayed in Table 5.
However, it could also be argued that stress is a cardiovascular risk factor, that being in a
constant state of stress, the sympathetic nervous system is in a constant release of hormones.
Having a constant release of corticosteroids, is not beneficial to the body, especially the heart. As
Ellie is constantly under a large amount of stress due to her POTS condition, it will be important
to educate her on multiple stress management techniques as well as finding a healthy way to
relieve her stress with the help of her support system. With Ellies POTS condition she is
considered high risk as she can become dizzy, hypotensive, and tachycardic by simply moving
too quickly.
TABLE 5. Patient cardiovascular risk factors.
Value
ACSM criteria
Dyslipidemia
Total cholesterol 200mg/dL
LDL: 130 mg/dL
HDL: < 40mg/dL
Currently on medication

Patient criteria
Total cholesterol: 231 mg/dL
LDL: 144 mg/dL
HDL: 35 mg/dL
Currently on medication

POTS

Known CV disease

Known CV disease

Considerations for exercise prescriptions


Based upon Ellies CVD, she is classified as high risk due to her known cardiovascular
disease. Therefore, it will be important to discuss primary prevention, which would be exercise
and participation in a healthy diet (American College of Sports Medicine, 2014). With exercise
as the primary prevention, Ellies stress risk factor may be reduced. Secondary prevention will
also be important and will be further discussed in another section. As Ellie has a known
cardiovascular disease there are other factors that need to be considered when designing an
individualized exercise prescriptions.
Symptoms. Ellie was experiencing flu like symptoms, of vomiting, nausea, fever, and
chills lasting on and off for four months before she went to see the doctor. She experienced
syncope episodes where she would faint and collapse, usually when she was in a rush to go
somewhere or get something done quickly. Ellie is only able to exercise for short bouts of time
otherwise she get severely worn out and can not perform any duties or activities of daily living
for the remainder of the day into the next day. This is how POTS affects individuals. During
exercise it will be important to continually ask and monitor any symptoms such as syncope or
rapid increase in heart rate as this could indicate a POTS episode. Her blood pressure will also be
monitored closely because the POTS condition causes tachycardia with a severe drop in blood
pressure. Assessing and being observant as a detective would be for these symptoms and signs
will be important in how exercise can be prescribed as well as progressed.
Medications. Ellie is currently on multiple medications since she was diagnosed with her
POTS condition. As she is on multiple medications it will be important for her to continually
ensure she is 100% compliant in taking these medications at the specified time that was
prescribed. Ellies medications are displayed in Table 6. As previously stated by Ellie, she is
100% compliant with her current medications. With multiple medications, there are side effects

Running header: FINAL CASE REPORT AND WORK SAMPLES


as well as affects to exercise heart rate, blood pressure, and exercise capacity. It will be important
to monitor each of these factors as well as signs and symptoms throughout exercise.
TABLE 6. Patient medications
Medication
Medication Use

Exercise HR,
BP, Exercise
Capacity
HR: no affect
BP:decrease
EC: no affect

Side Effects

Drug/Food
Interactions

-Rash
-wheezing
-severe stomach
pain
-constipation
-heartburn

Moderate
interaction with
Florinef. Affects
the absorption of
fludrocortisone.

Questran
2 grams 2x/d

Cholesterol
lowering.

Celexa
10mg 1x/d

Anti-depressive

HR: decrease or
no change rest
and exercise
BP: variable rest
EC: no affect

-Confusion
-chest pain
-fast, uneven
heartbeat
-unusual
bleeding or
bruising
-dry mouth

Major interaction
with Zofran. Can
increase risk of
irregular heart
rhythm, more
susceptible to
congenital long
QT syndrome, or
electrolyte
disturbances.

Clobevate
PRN

Antiinflammatory
steroid

HR: no affect
BP: no affect
EC: no change or
increase
performance
dose related

-burning
sensation of skin
- dry skin
-flushing of skin
-hair loss
-thinning of hair

N/A

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Medication

Medication Use

Florinef
100 mcg 2x/d

Exercise HR,
BP, Exercise
Capacity

Side Effects

Drug/Food
Interactions

Corticosteriod.
HR: no affect
Causes the
BP: no affect
kidneys to retain EC: no affect
sodium and
acting as a
replacement for
cortisone when
the body does not
produce enough.

-abdominal pain
-anxiety
-blindness
-blurred vision
-chills
-confusion
-convulsions

Moderate
interaction with
Questran. Affects
the absorption of
fludrocortisone.
Moderate
interaction with
ProAmatine. Can
lead to an
increase in blood
pressure and
intraocular
pressure.

ProSynbiotic
Daily

Probiotic

HR: no affect
BP: no affect
EC: no affect

-Rapid heart beat


-trouble sleeping

N/A

Catalyn GF
Daily

Vitamin

HR: no affect
BP: no affect
EC: no affect

N/A

N/A

Zofran ODT
4mg 3x/d

Prevents nausea
and vomiting

HR: no affect
BP: no affect
EC: no change
with performance

-Confusion
-dizziness
-SOB
-decrease
urination
frequency
-cough
-painful urination

Major interaction
with Celexa. Can
increase risk of
irregular heart
rhythm, more
susceptible to
congenital long
QT syndrome, or
electrolyte
disturbances.

Pyridoxine HCI
1x/d

Vitamin B6

HR: no affect
BP: no affect
EC: no affect

-nausea
-vomiting
- headache
-loss of appetite

N/A

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Medication

Medication Use

Exercise HR,
BP, Exercise
Capacity

Side Effects

Drug/Food
Interactions

Salt Tablets
10x/d

Increase sodium
retention

HR: no affect
BP: no affect
EC: no affect

N/A

N/A

(Drugs.com, 2014)
Return to work. Ellie is currently employed as a school counselor at a middle school.
Her job has physical requirements of which use a long of energy for standing and walking for
almost half of the school day.
Orthopedic limitations. Currently, Ellie has no orthopedic limitations that would hinder
her from and form exercise. She may feel more fatigued due to the POTS condition she currently
is suffering from, which also makes her deconditioned due to lack of regular aerobic exercise.
Exercises for each major muscle group will be encouraged as a way to improve her muscle
strength and endurance. Communication between the patient and staff will also be important to
ensure that the best results and benefits are achieved.
Personal goal. Through the cardiac rehabilitation program, aerobic and strength training
will be performed to aid in Ellies recovery as well as returning to work. Ellie has also stated that
she has other personal goals that she would like to begin accomplishing throughout the program
as well. These goals would include: blood pressure control, which can be done through exercise
and medication management, stress management which can be performed through the education
classes that are offered, increasing her exercise abilities, return to work, and lastly, overall
medication management. Medication management can be assisted with the increase in exercise
capacity and ability, but will ultimately be done through her physicians, with the cardiac rehab
exercise results from the exercise physiologist.
Clinical Decisions for Aerobic Exercise.
As Ellie is currently at a normal weight according to ACSM criteria, maintaining her
weight will be important. Throughout cardiac rehabilitation patients complete at least 45 minutes
of supervised aerobic exercise. However, this duration is too much for Ellie currently due to her
POTS condition. Therefore modification aerobic guidelines will need to be made and defined. As
Ellie began aerobic exercise at six minutes, therefore it will be a gradual increase starting at her
six minutes of aerobic exercise.
The ACSM recommends the intensity based upon the individual patients rate of perceived
exertion (RPE) due that most individuals in outpatient cardiac rehabilitation are on beta-blockers,
leaving heart rates blunted (American College of Sports Medicine, 2014). If a patient had
baseline exercise test data, 40-80% of exercise capacity using heart rate reserve (HRR), oxygen
uptake reserve or peak oxygen uptake methods. Ellie however, did not have a baseline exercise
test performed; therefore an RPE of 11-16/20, which is of moderate intensity, will be used.
According to the ACSM, there are specific recommendations for exercise duration which
include a 5-10 minute warm up with an RPE of <11/20. The goal duration of the aerobic

Running header: FINAL CASE REPORT AND WORK SAMPLES


conditioning phase is recommended at 20-60 minutes per session (American College of Sports
Medicine, 2014, p.243). However, due to Ellies POTS this duration will be a long-term goal
achievement. Duration of will increase 1-5 minutes each exercise session or an increase in time
per session of 10-20% (American College of Sports Medicine, 2014, p. 243).
Dyslipidemia. Ellie currently suffers from dyslipidemia (hyperlipidemia). Through her
cardiac rehabilitation program, Ellie will perform aerobic exercise, which will aid in the decrease
of her dyslipidemia. In a review of literature performed by Chatzlefstratlow, Glakoumidakis, and
Brokalaki (2013), 16 studies were reviewed from 1995-2012. Specific criteria needed to be met
to be included into this study, which included: cross sectional and cohort studies testing the
outcomes of cardiac rehabilitation, randomized control trials observing the effects of cardiac
rehabilitation, and longitudinal studies testing the effects of cardiac rehabilitation among patient
who currently had heart disease (Chatzlefstratlou et al., 2013). Through the examination of these
studies, the conclusion was made that cardiac rehabilitation programs lead to an overall reduction
in lipid values.
A different study performed by Giannuzzi et al.(2008), included 3241 coronary heart
disease patients participating in an outpatient cardiac rehabilitation program. This randomized
control trial study found that through consistent attendance and exercise through the cardiac
rehabilitation program that there was a decrease in blood pressure as well as lipid values
(Giannuzzi et al., 2008).
Onishi et al. (2010), performed a study comparable to the previously discussed studies.
This prospective study included 159 coronary heart disease patients. The study took place in the
phase II and phase III of cardiac rehabilitation. There was a follow up of 3500 days duration. The
results found that cardiac rehabilitation programs assist in the decrease of total cholesterol,
triglycerides, and systolic blood pressure, as well as total cardiac mortality and all-cause
mortality (Onishi et al. 2010).
Postural orthostatic tachycardia syndrome (POTS). As Ellie has a known
cardiovascular disease known as POTS, it will be important to gradually progress her through
exercise as certain exercises can cause an exacerbation where her blood pressure drops and her
cardiac rhythm goes into tachycardia. Therefore, modifications may be necessary throughout her
cardiac rehabilitation exercise program.
In a study performed by Shibata, Fu, Bivens, Hastings, Wang and Levine (2012), studied
how the short-term exercise training can improve cardiovascular response to exercise in the
POTS population. There were 25 participants including 24 women and 1 male, this was due to
more women having POTS then men. These participants have had a POTS diagnosis for six
months to five years. The study lasted for approximately three months, which in comparison is
approximately as long as cardiac rehabilitation programs. Participants participated in aerobic
exercise using a recumbent bike, rowing or swimming, 2-4 times per week for 30-45 minutes per
session (Shibata et al., 2012). The results of this study found that emphasizing cardiovascular
control during exercise is normal in patients with POTS. Overall Shibata et al. (2012), there was
an improvement in physical fitness level and cardiovascular responses during the three month
exercise intervention.
In a comparable study Fu et al. (2011), observed the differences in exercise training
versus propranolol in the treatment of POTS. There were 19 participants, 18 females and 1 male,
who completed a four-week double-blinded study with propranolol or placebo and then exercise
training for three months. The major findings of this study included: both propranolol treatment
and exercise training lowered standing heart rate and patients quality of life was improved with

Running header: FINAL CASE REPORT AND WORK SAMPLES


exercise training but not with propranolol treatment, despite the lower heart rates (Fu et al.,
2011). The aerobic exercise training performed in this study was the same exercises performed
by Shibata et al. (2012). Aerobic exercise consisted of using a recumbent bike, rowing or
swimming. These pieces of equipment were used as they are exercises that are done seated or
lying flat as one does in a pool. Therefore it was hoped that no postural changes would trigger an
excessive drop in blood pressure and increase in heart rate. Patients performed aerobic exercise
2-4 times per week for 30-45 minutes per exercise session. Fu et al. (2011), also found that as
patients become relatively fit, the duration of the base training sessions was prolonged and
session increased in intensity were added once and twice per week and were always followed by
recovery sessions. Upright exercise was then gradually added as tolerated and by the end of the
training patients were exercising 5-6 hours per week and were encouraged to use and upright
bike, wall on the treadmill or even jog (Fu et al., 2011).
It will be beneficial and important for Ellie to participate in aerobic exercise to assist in
her reduction of lipid levels but also to assist in conditioning to get her back to doing upright
activities and lessen the amount of symptoms associated with POTS. Cardiac Rehabilitation will
be critically important and beneficial, as Ellie will be monitored constantly in the event that she
would have a POTS event occur.
Aerobic Exercise Testing. As the current facility does not participate in aerobic exercise
testing prior to entrance of cardiac rehabilitation, current standards of practice would discuss a
six-minute walk test as Ellie has POTS. As Ellie has POTS, a six-minute walk test would be
performed, as her walking is a functional motion that she performs everyday and becomes tired
when doing. A study performed by Hill et al. (2011), found that the six-minute walk test elicited
a large cardiorespiratory response with minimal symptoms and the VO2 elicited at te end of the
six minute walk test is dependent on the distance walked.
Aerobic exercise. Based on the current research and standards of practice at St. Josephs
Hospital facility, aerobic exercise is three days per week (MWR) in cardiac rehabilitation.
Patients are encouraged to participate in 40 minutes of continuous aerobic exercise. For Ellie the
starting duration will be much less as she is highly deconditioned and on her initial intake day of
cardiac rehabilitation she was only able to perform five minutes of exercise. This can however,
be performed on multiple pieces of equipment. It is also encouraged that patients incorporate
machines that used different major muscle groups.
For Ellie the recumbent bike, Nustep, and possibly the treadmill. The arm ergometer and
treadmill could be incorporated further in the rehabilitation process, as that is a fully upright
exercise and may cause a POTS event to occur. The ACSM guidelines recommend that
outpatient cardiac rehabilitation intensity is based on RPE due to patients are usually taking betablockers which blunts the heart rate. For patients in cardiac rehabilitation it is recommended that
their RPE stay between 11-16/20 (American College of Sports Medicine, 2014, p. 239). An RPE
of 11-16/20 allows for a moderate intensity, which will produce the best benefits for patients
(American College of Sports Medicine, 2014).
Ellie started on the Nustep as she is highly deconditioned and could only exercise for a
total of five minutes. She was only able to exercise at 1.0 METS on level one. As stated
previously, this is due to her severe deconditioning due to her POTS. At week three Ellie is able
to use the Nustep, and treadmill as she requested to try the treadmill. She does however, stop to
rest half way through the exercises otherwise she feels more fatigued and the resting allows her
to feel in control of her symptoms. She also is aware that if she does not feel good that she tells
the staff right away and a chair is provided for resting until she feel better or exercise is stopped.

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Ellie has found that a rest period of two minutes is a good fit for her and something that she is
comfortable with, therefore in order for Ellie to continue exercising that is the rest break that was
used for her exercise prescription for higher compliance. Ellies eight-week aerobic exercise
prescription is displayed in Table 7. Exercises are subject to change based upon Ellies needs as
well as necessary modifications. At week 6 Ellie tried the arm ergometer and only used this piece
of equipment for one minute and did not like it. She stated she would rather focus on the other
pieces and use resistance training for her arms.
Currently, Ellie has not needed any modifications to exercise; however, the reasons for
modification may include: inability to perform at prescribed level due to a bad day as POTS
patients experience fatigue much easier than a non-POTS individual, unwillingness to want to
exercise, not feeling well or an exercise session has been missed. If these reasons would occur,
the exercise physiologists will continue to encourage and motivate Ellie to do her best and
further explain or repeat how important and beneficial aerobic exercise is for her heart.
TABLE 7. Eight week aerobic exercise prescription for phase II cardiac rehabilitation.
Week
Intensity
RPE
Duration
Equipment
Week 1
MWR

Level: 1
Mets: 1.0
Steps/min: 50

11-13/20

5 minutes: Rest for


2 minutes half way

Nustep

Week 2
MWR

Level: 1
Mets: 1.2
Steps/min: 52

11-13/20

8 minutes: Rest for


2 minutes half way

Nustep

Week 3
MWR

Level: 1
Mets: 1.4
Steps/min: 55

12-13/20

10 minutes:
Rest for 2 minutes
half way

Nustep

Speed: 1.5mph
Grade: 0%
Mets: 1.5

11-13/20

5 minutes: rest at
2.5 minutes

Treadmill

Level: 1
Mets: 1.4
Steps/min: 55

12-13/20

12 minutes: Rest
for 2 minutes half
way

Nustep

Speed: 1.7 mph


Grade: 0%
Mets: 1.7

12-13/20

7 minutes: Rest for


2 minutes half way

Treadmill

Week

Intensity

RPE

Duration

Equipment

Week 5

Level: 1

12-13/20

14 minutes: rest

Nustep

Week 4
MWR

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MWR

Week 6
MWR

Week 7
MWR

Week 8
MWR

Mets: 1.6
Steps/min: 60

for 2 minutes half


way

Speed: 1.8mph
Grade: 0%
Mets: 1.9

12-13/20

10 minutes: rest
for 2 minutes half
way

Treadmill

Level: 1
Mets: 1.5

11-13/20

4 minutes: rest for


2 minutes half way

Recumbent Bike

Level: 2
Mets: 2.0
Steps/min: 60

12-14/20

15 minutes: rest
for 2 minutes half
way

Nustep

Speed: 2.0
Grade: 0%
Mets: 2.2

12-14/20

12 minutes: rest
for 2 minutes half
way

Treadmill

Level: 1.2
Mets: 1.8

12-13/20

6 minutes: rest for


2 minutes half way

Recumbent Bike

Level: 2
Mets 2.2
Steps/min: 65

12-14/20

15 minutes: rest
half way for 2
minutes if needed

Nustep

Speed: 2.0mph
Grade: 0.5%
Mets: 2.5

12-14/20

Level: 1.4
Mets: 2.0

12-14/20

Level: 3
Mets: 2.6
Steps/min: 65

12-16/20

Speed: 2.2 mph


Grade: 1.0%
Mets: 2.8

12-16/20

Level: 1.6
Mets: 2.4

12-16/20

Clinical Decisions for Resistance Training.

12

15 minutes: Rest
half way for 2
minutes if needed
8 minutes: Rest
half way for 2
minutes if needed
15 minutes: rest
half way for 2
minutes if needed
15 minutes: rest
half way for 2
minutes if needed
10 minutes: rest
half way for 2
minutes if needed

Treadmill

Recumbent Bike
Nustep

Treadmill

Recumbent Bike

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Resistance Testing. As the current facility does not participate in resistance exercise
testing prior to entrance of cardiac rehabilitation, current standards of practice would discuss a
10-RM as Ellie has POTS and is highly deconditioned. Resistance training is also an important
component to incorporate into Ellies physical activity regimen. Resistance training can help
improve completing activities of daily living and can assist in reducing the amount of peripheral
muscle wasting she is experiencing. It is recommended that Ellie complete a 10-RM, to better
determine which areas could use improvement to assist in completing activities of daily living.
10-RM. The 10-repetition maximum test is recommended for Maria to participate in as
the results can be used to determine the intensity of specific exercises. The 10-repetition
maximum test allows for a decrease in stress being placed on the heart when compared to the
one-repetition maximum test. In a study by Abdul-Hameed, Rangra, Shareef and Hussain (2012),
the reliability of the 1-RM in assessing strength of the upper and lower body in untrained middleaged individuals was performed. In this study, individuals participated in the supine bench press,
leg press, lateral pull, leg extension and seated biceps curls. 1-RM was estimated for all
individuals using the Brzyeki 1-RM predication equation. The test was performed one week later
to measure test-retest reliability. As Ellie suffers from deconditioning it will be recommended
that she participate in a 10-RM. Also, if she has no previous resistance training experience, the
10-RM will be better suited for Maria than the 1-RM. She will perform the 10-RM supine bench
press to determine her upper body 1-RM and the 10-RM leg extension to determine the 1-RM of
her lower body.
As Ellie does not currently participate in strength training exercises, resistance training
will be beneficial for her to participate in. Through strengthening her body she will further be
able to perform her activities of daily living. Resistance training may also assist Ellie to become
stronger to aid in the process of her return to work goal. It will be important for Ellie not to
overdo the amount of resistance training, as she will experience delayed onset of muscle
soreness. Having POTS will also exaggerate these symptoms of soreness.
As there is not much information on POTS and resistance training, the studies used in the
above section of aerobic exercise also discusses resistance training. Shibata et al. (2012), discuss
that resistance training using weight lifting was incorporated. Resistance training began once per
week for 15-20 minutes per exercise session and built up to twice per week for 30-40 min per
session. Through the performance of resistance training as well as aerobic training, participants
were able to increase overall muscle and strength (Shibata et al., 2012). A comparison a study
performed by Fu et al. (2011), resistance training began once per week for 15-20 minutes per
session and was increased to twice per week for 30-40 minutes each session.
According to Dysautonomia International (2012) patients can benefit from overall
increase in tone and strength. The stronger our muscles are, the more efficiently the use oxygen,
the better will be able to tolerate orthostatic stress. Dysautonomia International (2012), discusses
emphasizes can be place on strengthening leg and core muscles. It is recommended to begin with
light weights, and use them in a reclined or seated position. It will also be important to not have
individuals with POTS lifting their arms over their head as this can cause patients to become
extra symptomatic (Dysautonomia International, 2012).
Resistance training. Based on the current standards of St. Josephs hospital and research,
patients participating in cardiac rehabilitation programs do participate in resistance training. For
Ellie it will be important to find exercises that do not allow for her to lift her arms above her
head. It is also important to begin with lightweights and few exercises. The resitance exercises

13

Running header: FINAL CASE REPORT AND WORK SAMPLES


which include: bicep curls, lateral raises, tricep kickback as well as beginning with squats will
be performed after the aerobic exercise is completed on Monday, Wednesday, and Fridays
outside of cardiac rehabilitation class as there should be 48 hours between resistance exercise
sessions. Ellies resistance exercise prescription is displayed in Table 8. Ellie has begun using
one-pound weights, which she feels is a good starting position as she is highly deconditioned as
stated previously.
Recommendations for resistance training according to the ACSM (2014), are 8-12
repetitions. The resistance training is performed in a group setting in cardiac rehabilitation; it is
recommended that patients participate in resistance training at home as well. For Ellie it will be
recommended to begin resistance training at cardiac rehabilitation and slowly progress to home
exercise with weights. Modifications will be given if necessary to ensure that Ellie is still
receiving the best workout, in order to achieve the best benefits as well as aid in his return to
work goal. Progressions are assessed weekly based on how much and how well Ellie is able to
perform that week. Progressions are based upon observations, communications from Ellie such
as the weights are too light or two heavy which can also be monitored throughout the 2-for-2
rule, which states that once an individual can perform two or more repetitions on at least two
consecutive training sessions, the intensity or weight should be increased (American College of
Sports Medicine, 2014).
Modifications are an important topic to discuss with Ellie. This is to ensure that her safety
is maintained as well as to achieve the highest benefits for resistance training. It will be highly
important to encourage Ellie to use the modifications if necessary, as we do not want to put
excess stress on the body as this could lead to injury or excessive fatigue. Discussing the
importance of resistance training and using modifications will be beneficial in performing
resistance training exercises.

TABLE 8. Resistance training program. *All exercises are done seated, except squats*
Week
Exercise
Intensity
RPE
Important Tips
Modifications

14

Running header: FINAL CASE REPORT AND WORK SAMPLES

Week 1
MWF

Bicep Curl
Lateral Raise
Tricep Kickback
Squats

Weight: 1 lb
Sets: 1
Reps: 8

11-14/20

Do not hold
breath!
Bicep Curl: keep
elbows to sides.
Lateral Raise: only
bring arms up to
should height.
Squat: keep knees
behind toes. Keep
a straight back.

Week 2
MWF

Bicep Curl
Lateral Raise
Tricep Kickback
Squats

Weight: 1 lb
Sets: 2
Reps: 8

11-14/20

Do not hold
breath!
Bicep Curl: keep
elbows to sides.
Lateral Raise: only
bring arms up to
should height.
Squat: keep knees
behind toes. Keep
a straight back.

Week

Exercise

Intensity

RPE

15

Important
Tips

Modifications
are based
upon how the
individual is
progressing. If
should hurt or
are too sore,
only perform
exercises until
point of
discomfort,
not pain.
Modifications
are based
upon how the
individual is
progressing. If
should hurt or
are too sore,
only perform
exercises until
point of
discomfort,
not pain.

Modifications

Running header: FINAL CASE REPORT AND WORK SAMPLES

Week 3
MWF

Bicep Curl
Lateral Raise
Tricep
Kickback
Squats

Weight: 2 lb
Set: 1
Reps: 8-10

11-14/20

Do not hold
breath!

Week 4
MWF

Bicep Curl
Lateral Raise
Tricep
Kickback
Squats

Weight: 2 lb
Set: 2
Reps: 8-10

11-14/20

Do not hold
breath!

Week

Exercise

Intensity

RPE

Important
Tips

16

Modifications
are based upon
how the
Bicep Curl:
individual is
keep elbows
progressing. If
to sides.
should hurt or
are too sore,
Lateral Raise: only perform
only bring
exercises until
arms up to
point of
should height. discomfort,
not pain.
Squat: keep
knees behind
toes. Keep a
straight back.
Modifications
are based upon
how the
Bicep Curl:
individual is
keep elbows
progressing. If
to sides.
should hurt or
are too sore,
Lateral Raise: only perform
only bring
exercises until
arms up to
point of
should height. discomfort,
not pain.
Squat: keep
knees behind
toes. Keep a
straight back.

Modifications

Running header: FINAL CASE REPORT AND WORK SAMPLES

Week 5
MWF

Bicep Curl
Lateral Raise
Tricep
Kickback
Squats

Weight: 3 lb
Set: 1
Reps: 8

11-14/20

Do not hold
breath!

Week 6
MWF

Bicep Curl
Lateral Raise
Tricep
Kickback
Squats

Weight: 3 lb
Set: 2
Reps 8-10

11-14/20

Do not hold
breath!

Week

Exercise

Intensity

RPE

Important
Tips

17

Modifications
are based upon
how the
Bicep Curl:
individual is
keep elbows
progressing. If
to sides.
should hurt or
are too sore,
Lateral Raise: only perform
only bring
exercises until
arms up to
point of
should height. discomfort,
not pain.
Squat: keep
knees behind
toes. Keep a
straight back.
Modifications
are based upon
how the
Bicep Curl:
individual is
keep elbows
progressing. If
to sides.
should hurt or
are too sore,
Lateral Raise: only perform
only bring
exercises until
arms up to
point of
should height. discomfort,
not pain.
Squat: keep
knees behind
toes. Keep a
straight back

Modifications

Running header: FINAL CASE REPORT AND WORK SAMPLES

Week 7
MWF

Bicep Curl
Lateral Raise
Tricep
Kickback
Full Squats

Weight: 4 lb
Set: 2
Reps: 8-10

11-14/20

Do not hold
breath!

Modifications
are based
upon how the
Bicep Curl:
individual is
keep elbows
progressing. If
to sides.
should hurt or
are too sore,
Lateral Raise: only perform
only bring
exercises until
arms up to
point of
should height. discomfort,
not pain.
Squat: keep
knees behind
toes. Keep a
straight back

Week 8
MWF

Bicep Curl
Lateral Raise
Tricep
Kickback
Full Squats

Weight: 4-5lb
Sets: 2
Reps: 8-10

11-14/20

Do not hold
breath!

Modifications
are based
upon how the
Bicep Curl:
individual is
keep elbows
progressing. If
to sides.
should hurt or
are too sore,
Lateral Raise: only perform
only bring
exercises until
arms up to
point of
should height. discomfort,
not pain.
Squat: keep
knees behind
toes. Keep a
straight back.

Patient Education
As Ellie continues with cardiac rehabilitation, education will be an important part of her
recovery process. Topic of education would include: Blood lipid management, medication
compliance and stress management and continuation of increasing the amount of exercise she
participates in outside as well as after completion of the cardiac rehabilitation program. These
topics of education are important factors that contribute to cardiovascular disease. Addressing
each of these will be important.
Blood lipid management. According to ACSM guidelines Ellie meets dyslipidemia
criteria. This means it will be important to discuss lipid management with her. The American
Association of Cardiovascular and Pulmonary Rehabilitation (2013), discusses that research has

18

Running header: FINAL CASE REPORT AND WORK SAMPLES


shown that if individuals with high LDL and total cholesterol are able to reduce these values
have an overall decrease of cardiovascular mortality, recurrent cardiac events and
hospitalizations. As part of the cardiac rehabilitation program education about cholesterol
management is provided as well as a handout. This handout is displayed in Appendix A. Two
important factors need to be discussed with Ellie, which include, medication adherence and
therapeutic lifestyle changes.
The American Association of Cardiovascular and Pulmonary Rehabilitation (2013),
discusses the importance of understanding the difference between fats and the calories that come
from these fats. The Mediterranean food guide is highly recommended. This diet consists of
eating whole grain foods, fish, fiber, nuts and fruits and vegetables. Liebman (2011), discusses
that omega-3 fatty acids have an anti-inflammatory component. For Ellie, this will be important
as she feels as she has pain due to her POTS, which causes inflammation as well. The
Mediterranean food guide handout is displayed Appendix B. This handout came from a different
hospital and is one that I found to be more beneficial for Ellie as it consists of more information
about the Mediterranean diet. It will be important however for Ellie to not watch her sodium
intake as she is on sodium medication to help her body and is prescribed these per her physician
so it would not be clinically correct to tell Ellie to watch her sodium intake. It is however,
important for everyone to follow a healthy diet.
Medication Compliance. Ellie is currently prescribed multiple medications, it will be
important to educate her as to what each medication was, what is was used for and how to take
each medication. There is an education class that is geared toward common medications along
with a handout for further reference. The educational handout is displayed in Appendix C. It has
been estimated that approximately 50% of patients are non-compliant with their medications
because they do not understand their disease or are not involved in the decisional process (Brown
and Bussell, 2011).
Stress Management. As Ellie has POTS it is difficult for her to manage her stress. She is
a mother, wife, school counselor and has many other activities that she wants to be participating
in but is limited at times due to her POTS. In a meta-analysis performed by Kivimaki et al.
(2011), the risk of coronary artery disease is highest among individuals with higher amounts of
stress and unhealthy lifestyles. Therefore, it will be important for Ellie to receive different
methods on stress management to ensure that she is living a healthier lifestyle and is coping
correctly and healthy with her current situation. The educational handout that was presented in
the education class can be found in Appendix D.
Increase in Physical Activity. Through increasing the amount of physical activity that
Ellie participate in will assist in controlling her other cardiovascular risk factors. According to
the AACVPR (2014), it is estimated that less than 50% of adults meet the minimal physical
activity recommendations. As Ellie has self-reported that she does participate in physical activity,
but admits to not exercising the recommended amount of minutes per week (150 minutes). It
would be recommended that during as well as after cardiac rehabilitation is completed that Ellie
make small increases in duration and amount of physical activity she is participating in. The
increases in physical activity can be as easy as incorporating small bouts of physical activity
throughout her day, will be beneficial in reducing her current CVD risk factors. These increases
could occur through taking a longer walking route to office or meetings, using the stairs instead
of an elevator, and parking her car a further distance from the entrance of a building. Each of
these changes will assist in reducing her risk for future negative cardiovascular events as well as
assist in controlling her POTS condition.

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Running header: FINAL CASE REPORT AND WORK SAMPLES

Outcomes
As Ellie is currently in cardiac rehabilitation for POTS, per recommendation from her
cardiologist, it will be important for her to make lifestyle changes. Each of these changes will
assist Ellie in better managing her cardiovascular risk factors. These lifestyle changes will
include: improvements in blood lipid values, increasing physical activity, and stress
management. These improvements can be achieved using dietary changes and increased physical
activity. Using the S.M.A.R.T. goal format, Ellies goal can be further specified in order for
increased program adherence to achieve positive outcomes. Ellies specific goals will be outlined
for her based upon her baseline levels and the reasoning for her lifestyle changes.
Recommendations for Ellie would be that she document her dietary and sodium intake. For Ellie,
she is not a sodium restriction as she is on sodium medication because her body does not retain
any sodium. This can be done using a computer spreadsheet or a paper notebook.
Ellie could also use an app for her iPhone such as MyFitnessPal to track her dietary
intake. This app has a scanner function that allows for a simple scan of the food label and it is
uploaded into the apps database. If only half the serving was consumed there is an option to
manually change the portion that was consumed. Ellie was open to the idea of this app and
agreed to try it. She has since stated that she likes the app and that is has been beneficial for her
to track the foods she is eating to make sure they are healthy and contain the proper nutrients that
she requires for a healthier lifestyle. A fitbit or bodymedia band will be recommended as
beneficial as these can track physical activity such as steps per day. With the use of the fitbit or
bodymedia band, steps per day will be encouraged. This goal will start out small, as Ellie is still
very deconditioned. According to the ACSM (2014), steps should be increased by 10-20% each
week. Ellies goals will be structured in a way that he will achieve smaller goals as a way to
reach her overall goal. Through focusing on the smaller goals in progression to her long-term
goals will also assist Ellie as she faces possible barrier along the way. Finally, Ellies goals will
be bound by time, creating a specific time frame in which she should work to achieve her goals.
A study performed by Fox (2013), found that one in three cell phone owners have used
their phone to look up health information and half of smartphone users have done the same. Fox
(2013), also discovered that 19% of smartphone owners have downloaded a health app for easier
tracking and documentation of health data. Lastly, Fox (2013), found that 7 in 10 U.S. adults
track a health indicator for themselves or a loved one and many have stated that this activity has
changed their overall approach to health. Therefore, Ellie may have a better chance of remaining
compliant with her exercise program as other adults have in accordance to the study that was just
discussed.
As Ellie has dyslipidemia, it will also be important for her to continue monitoring her
blood lipid values. Her blood lipid values should be monitored every eight weeks to determine if
there have been any changes in her levels that are benefiting her health. In a research study
performed by Paoli, Bianco, Grimaldi, Lodi, and Bosco (2013), observation of overweight and
obese subjects participated in the Mediterranean diet for one year. The findings of this study
displayed that with adherence to the Mediterranean diet, weight loss as well as a decrease in total
cholesterol, LDL cholesterol, and triglycerides were found. There were, however, no significant
changes in HDL cholesterol values. Therefore, if Ellie were able to adhere to the Mediterranean
diet plan, she would be able to reduce and improve her blood lipid values. These are important to
decrease and improve, as it will assist in the decrease of further risks of cardiovascular disease.

20

Running header: FINAL CASE REPORT AND WORK SAMPLES


A review of literature performed by Robson (2014), found that through the use of the
Mediterranean diet, individuals reduced the incidence of major cardiovascular events by 30%.
After a follow up period of 4.9 years the finding of the study concluded that through the use of
the Mediterranean diet, people with high cardiovascular risk had a reduced incidence of
cardiovascular events (Robson, 2014). It was also concluded by Robson (2014), after the 46
month follow up there was a calculated 50-70% lower risk of recurrent heart disease in the
experimental group as compared to the control group.
By decreasing the amount of stress that Ellie is currently experiencing will also be
beneficial to her health. In a meta-analysis performed by Chida and Steptoe (2010), found that
greater responsitivity to acute mental stress has an adverse effect on future cardiovascular risk
status, supporting he use of methods to manage stress responsitivity in the prevention and
treatment of cardiovascular disease. Therefore it will be important for Ellie to attend the
education classes as well as find healthy outlets for her stress such as exercise, meditation or a
hobby.
Measures and Monitoring
Throughout Ellies participation in cardiac rehabilitation, she will have multiple factors
that are monitored before, during and after each exercise session. These measures would include:
heart rate, heart rhythm, blood pressure, RPE, and signs and symptoms that could be related to a
POTS event, medication compliance, falls since last exercise session, possible tobacco use, and
how much exercise was done outside of the last cardiac rehabilitation exercise session.
Heart rate and heart rhythms are measure before, during and after each exercise session.
These measures are monitored via the telemetry software program that is displayed on a
computer screen. For this specific facility ScottCare was used to monitor telemetry. The
telemetry is measured via heart rate monitors that each participate wears throughout the duration
of their exercise session. The monitors have a standard three lead placement. This monitoring
allows for a continuous recording of heart rhythm as well as heart rate throughout exercise. With
the continuous recording, the exercise physiologists and nurses are able to observe these
measures throughout the exercise session as well as review them for any abnormalities after the
exercise session is complete. If abnormalities were found and determined, the patients
cardiologist would be notified and proper action per protocols would then occur.
Blood pressures are measured before exercise to determine a baseline pressure for
comparison with post exercise pressure. Blood pressures are also taken during exercise to ensure
those proper hemodynamics are occurring. Each of these measures is put into the computer
telemetry system to determine if there are any patterns of blood pressures occurring. If there are,
the patients cardiologist will be notified. This will allow for better medication management.
Blood pressures are taken before and after exercise to again, determine if there are any patterns
occurring related to hyper or hypotension events.
Rate of Perceived Exertion is asked on each piece of equipment that a patient uses to
determine their exercise intensity. The RPE range that the patient is encouraged to be between
11-16/20, which classifies them in the moderate intensity. If the intensity is not between this
range, modifications will be made to ensure the patient is not working too hard, but also to
ensure that the patient is not taking it too easy so that there are no benefits coming from the
exercise session. With RPE, the staff also asks shortness of breath. Usual responses to exercise
would be a slight shortness of breath as they are exerting themselves doing exercise, however the

21

Running header: FINAL CASE REPORT AND WORK SAMPLES


patient should be able to carry on a conversation without being winded. This technique is often
referred to as the Talk Test. If the patient is unable to carry on a conversation or cannot catch
their breath, the exercise professional staff will modify the exercise intensity. Also if the patient
rates their RPE less than 11 out of 20 on the RPE scale, intensity, steps/min, or level would be
adjusted on the specific piece of equipment in order to ensure the patient is between 11-16/20 on
the RPE scale to achieve the best clinical benefits during the cardiac rehabilitation exercise
session.
Prior to each exercise session, the cardiac rehabilitation staff asks a series of questions to
each patient to determine if there have been any medication changes, recent or upcoming doctor
visits, and if the patient has taken all of their medications today as prescribed. The patients are
also asked if they are experiencing any symptoms such as bodily or chest pain over the last 24
hours. The patients are encouraged to answer each of these questions honestly as the staff is
there to assist them and ensure that they are recovering properly in order to get them back to
participating in daily activities as well as what they were doing prior to their cardiac event. There
are many times that the staff asks these questions again while the patient is on a piece of
equipment not directly seated next to another patient. This allows for more patient privacy and
they are more willing to reveal important information that the staff can then record into their
chart and computer system.
With each of these factors being continuously measured, monitored, and re-assessed,
Ellie can feel that she is well monitored and in a safe environment to participate in exercise. This
will also allow Ellie to achieve the most clinical, physiological as well as psychological benefits
from exercise to further assist in her recovery process to return to work as well as perform
activities of daily living with more energy.

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live&scope=site

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Liebman, B. (2011). Fighting inflammation. Nutrition Action Health Letter, 38(9), 9-11.
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