Fall

08
15

Fall

Case Report: Practicum III

Kelly Van Berkel
EXP:600

St. Josephs Hospital

Table of Contents
CLIENT MEDICAL PROFILE

PATIENT HISTORY
COMORBITIES
INTERPRETATION

3
3
3

INITIAL INTAKE

ANTHROPOMETRIC AND LABORATORY RESULTS

MEDICATIONS
PRE-QUALITY OF LIFE QUIZ SCORES
RISK CLASSIFICATION
FOLLOW-UP
INITIAL ASSESSMENTS

3-5
5
8
8-9
9
9

SPECIAL CONSIDERATIONS
CARDIORESPIRATORY
MUSCULOSKELETAL
FLEXIBILITY
REASSESSMENTS

10
10
11
11
11-12

EXERCISE PRESCRIPTION

12

SPECIAL CONSIDERATIONS
CARDIORESPIRATORY
MUSCULOSKELETAL
FLEXIBILITY
HOME EXERCISE
CLINICAL DECISION

12
12-13
13-14
14
14
14-15

GOAL SETTING/CLINICAL OUTCOMES

LONG TERM GOALS AND OUTCOMES
SHORT TERM GOALS AND OUTCOMES
PATIENT EDUCATION

15
16
16-17
17

HYGIENE/WOUND CARE
MEDICATION ADHERENCE
NUTRITIONAL GUIDELINES
GROUP PATIENT EDUCATION

17
17-18
18
18

REFERENCES

20-22

Client Medical Profile

Patient History
The patient is a 67-year-old male that is a retired machinist, who
was referred to St. Josephs Hospital Cardiac rehab after he suffered a non-ST
segment elevation myocardial infarction (NSTEMI), which led him to having a
percutaneous coronary intervention (PCI) just short of a month later. This
patient has a long history of significant cardiovascular complications, which
began in his thirties. These would include a previous PCI, coronary artery
bypass graft (CABG) x4, valve surgery, giving him a ejection fraction of 6065%, chronic atrial fibrillation (a-fib), and chronic heart failure (CHF).
Comorbities
Also based off of the patients charts he shows a long history of
multiple comorbities including hypertension (HTN) and dyslipidemia (HLD).
Additional conditions include pulmonary disease, restrictive lung impairment,
obstructive sleep apnea in which he uses continuous positive airway
pressure (CPAP). The patient was also diagnosed with Type I diabetes early
on in life, so currently dependent on his insulin pump, and has had poor
glycemic control over the past couple years. Complications that tie directly to
his long history of health complications include; neuropathy, peripheral
vascular disease (PVD) with a history of peripheral stents. This patient also
had a below the right knee amputation (R BKA) just over a year ago, with this
he has had skin breakdown from prosthesis, and right phantom limb pain.
Other significant conditions and values include gastroesophageal reflux
disease (GERD), hypothyroidism, and a right carotid endarterectomy (R CEA).
Interpretation
The patients current primary diagnosis of a PCI and secondary of
NSTEMI has more than likely developed after his other conditions have
damaged and weakened his heart as we can see looking directly at his
patient history (33,36). With the patients long list of conditions, not only his
current diagnosis, we as clinicians need to take into account the patient may
have complications due to his R BKA, such as sores or phantom limb pain.
Another area to take into consideration is his a-fib, CHF, COPD, which may
lead to shortness of breath or weakness during minimal exertion due to
blood backing up into the liver, abdomen, lower extremities, and lungs
(3,15). With this patients extensive background on heart disease and health
complications more preventive measures need to be taken in order to
prevent worsening conditions (33,34,36).
Initial Intake
Anthropometric and Laboratory Results
Based on the patients most recent medical exam he stands 72 inches
tall and weighs in at 231.2 lbs. These values equate to a body mass index

4
(BMI) of 31.4 kg/m2. The patients resting vitals include a resting heart rate
(RHR) of 76bpm and a resting blood pressure (RBP) of 128/64 mmHg (see
TABLE 1 and 2). Laboratory values obtained indicated a total cholesterol (TC)
level of 193 ml/dL, a high-density lipoprotein (HDL) of 27 ml/dL, triglycerides
(TG) at 563 mmHg, and fasting blood glucose (FBG) of 162 mg/dL. Lowdensity lipoprotein (LDL) level could not be calculated (see TABLE 3). Also,
the patient has been a non-smoker since 1996 and has been sedentary since
his R BKA making him mainly wheel chair bound without his prosthetic.
TABLE 1. Baseline Anthropometrics
Variables
Height
Bodyweight
Waist Circumference
Body Mass Index

Results
72
231.2lbs
45.75
31.4 kg/m2

TABLE 2. Hemodynamics
Variables (Resting)
Blood pressure
Systolic
Diastolic
Heart Rate

128 mm Hg
64 mm Hg
76bpm

TABLE 3. Laboratory Results

Measures
Total Cholesterol
LDL-C
HDL-C
Triglycerides
A1c

Results
193 mg/dL
Unable
27 mg/dL
563 mg/dL
9.1%

Results

Based on the medical examination results and ACSM guidelines, the

patients BMI would place him in the obese class I category. When analyzing
his self-reported physical activity, he does reach the level needed for
negating sedentary lifestyle; however, his amputee condition should be
noted. His current blood pressure is indicative of a risk factor, based on
guidelines, his BP medication places him in the hypertension category. The
patients cholesterol levels and medication indicate that he is currently
dyslipidemic, given the elevated TG levels of 563 ml/dL and low HDL-C of 27
ml/dL. Lastly, in terms of patients A1c percentage of 9.1%, is well above the
normal limits.
TABLE 4. Positive Risk Factors for CVD
Measures
Age

Positive Criteria
67 yoa 45yoa

5
Family History
Sedentary Lifestyle
Obesity
Dyslipidemia
Hypertension

Father MI before 55yoa

No report of current PA
W.C. 45.75
Slo-Niacin/niacin
Toprol-XL/metoprolol succinate

Based on the patients positive risk factors and the levels of those risk
factors, he meets all four of the criteria for metabolic syndrome. These
criteria include waist circumference, insulin resistance/glucose, dyslipidemia,
and elevated blood pressure. The positive criteria are listed below in TABLE
5.
TABLE 5. Metabolic Syndrome
Measures
Waist Circumference
Blood Glucose
Dyslipidemia
Hypertension

Positive Criteria
45.75 > 40
175mg/dL 110mg/dL
HDL 27 < 40mg/dL, TG 563mg/dL
150mg/dL, and Treatment
Treatment of previous diagnosed

Medications
Below are two tables, the first being all the patients medications, their
side effects and interactions. The second table consists of general
medication the patient is on and its effects on exercise.
TABLE 6. Medications
Medication
Bayer Aspirin
Aspirin

Common Side Effects

Dyspepsia, nausea, vomiting,
abdominal pain, Tinnitus, dizziness,
hyperuricemia, bleeding,
ecchymosis, constipation, diarrhea

Interactions
Avoid/use
alternative: Plavix,
clopidogrel (may
bleeding).
Monitor/Modify:
Lasix, Toprol-XL
Caution Advised:
Cymbalta, SloNiacin, Tylenol

Combivent
Respimat
ipratropium
bromide/
albuterol
inhaled

URI sx, cough, headache, dyspnea,

nausea, pain, hyperlactatemia

Monitor/Modify:
Lasix, magnesium
citrate.
Caution Advised:
Toprol-XL

6
Cymbalta
Duloxetine

Nausea, xerostomia, headache,

diarrhea, constipation, insomnia,
dizziness, somnolence, fatigue,
appetite decr., hyperhidrosis,
abdominal pain, vomiting, agitation,
erectile dysfxn, libido decr.,
ejaculatory dysfxn, anorgasmia,
tremor, anxiety, blurred vision,
muscle spasms, weight changes,
urinary hesitancy, yawning,
abnormal dreams, hot flashes, BP
elevated, ALT, AST elevated

Monitor/Modify:
Lasix, magnesium
citrate, Toprol-XL.
Caution Advised:
Plavix

Ditropan
Oxybutynin

Xerostomia, dizziness, constipation,

somnolence, nausea, headache,
blurred vision, diarrhea, urinary
hesitancy/retention, dyspepsia, UTI,
nervousness, insomnia, dry eyes, dry
mucous membranes, fatigue, cough,
xeroderma, dysuria, abdominal pain,
confusion

Caution Advised:
Imdur, Mirapex,
Neurontin, Xanax

Humalog
insulin lispro

Hypoglycemia, injection site rxn,

injection site, lipodystrophy, myalgia,
pruritus, rash, URI, weight gain,
headache, edema, peripheral
hypersensitivity rxn, influenza

Avoid/use
alternative: ToprolXL (adrenergic
antagonism).
Monitor/Modify:
Lasix, Slo-Niacin

Imdur
isosorbide
mononitrate
Lasix
Furosemide

Headache, dizziness, nausea,

hypotension

Caution Advised:
Slo-Niacin

urinary frequency, dizziness,

nausea/vomiting, weakness, muscle
cramps, hypokalemia,
hypomagnesemia, hypotension,
orthostatic, ALT, AST elevated,
blurred vision, anorexia, abdominal
cramps, diarrhea, pruritus, rash,
hyperuricemia, hyperglycemia,
hypocalcemia, tinnitus, paresthesia,
photosensitivity, cholesterol incr.,
triglycerides incr.

Monitor/Modify:
Protonix,

magnesium
citrate
generic

abdominal cramps, diarrhea,

flatulence, hypotension,
hypermagnesemia, respiratory

Monitor/Modify:
Neurontin

7
depression, electrolyte disorders
Mirapex
Pramipexole

hypotension, orthostatic, dyskinesia,

somnolence, nausea, extrapyramidal
sx, insomnia, dizziness,
hallucinations, headache,
fatigue/asthenia, constipation,
rebound/augmentation (RLS use),
abnormal dreams, confusion,
xerostomia, diarrhea, influenza,
amnesia, urinary frequency,
peripheral edema, muscle spasms,
anorexia, dyspepsia, vomiting, visual
disturbance, malaise, sudden sleep
episodes, abdominal pain, appetite
incr., cough, dysphagia, weight loss,
impotence, depression, back pain,
compulsive behaviors

Mucomyst
Acetylcystein
e

anaphylaxis (IV use),

nausea/vomiting, urticarial,
tachycardia, rash, pruritus, flushing,
URI sx, stomatitis, fever, drowsiness

Neurontin
Gabapentin

Dizziness, somnolence, ataxia,

fatigue, fever, peripheral edema,
nystagmus, nausea/vomiting,
hostility (peds pts), tremor, diplopia,
asthenia, diarrhea, infection,
xerostomia, emotional lability (peds
pts), amblyopia, headache,
constipation, hyperkinesia (peds
pts), abnormal thinking, weight gain,
dysarthria, dyspepsia, amnesia, back
pain, depression, impotence

Plavix
Clopidogrel
Potassium
chloride
Generic

Bleeding, pruritus

Protonix
Pantoprazole

Headache, diarrhea,
thrombophlebitis (IV use), abdominal
pain, nausea/vomiting, dizziness,
flatulence, arthralgia, ALT, AST
elevated, vitamin B12 deficiency
(long-term use)

Nausea, vomiting, flatulence,

abdominal discomfort/pain, diarrhea,
hyperkalemia

Caution Advised:
Neurontin, Xanax

Caution Advised:
Xanax

8
Slo-Niacin
Niacin

Flushing, pruritus, paresthesia,

nausea, dyspepsia, vomiting,
abdominal pain, rash,
hyperglycemia, ALT, AST elevated,
LDH elevated, hyperuricemia,
hypotension

Toprol-XL
metoprolol
succinate

Fatigue, dizziness, diarrhea, pruritus,

rash, depression, dyspnea,
bradycardia

Tylenol
Acetaminophe
n
Vitamin D3
(common
name)
Cholecalcifero
l
Xanax
Alprazolam

Nausea, rash, headache

Monitor/Modify:
Toprol-XL

Hypercalcemia, Cr elevated,
hypercalciuria, nausea, vomiting,
anorexia, polyuria, anemia,
weakness, renal impairment
Drowsiness, fatigue, impaired
coordination, irritability, amnesia,
appetite changes, confusion,
dysarthria, dizziness, impaired
concentration, xerostomia, libido
changes, urinary retention,
sialorrhea, hypotension, rash,
diplopia, LFTs elevated, disinhibition,
incontinence

TABLE 7. Medication Effects on Exercise

Medication
Type
Beta-Blocker

HR
R&E

BP
R&E

Exercise
Capacity
in Pt with angina
/ in Pt w/o
angina

Diuretics

R&E

Antilipemic
Agents

R&E

R&E

R&E

Blood Modifiers

R&E

R&E

R&E

Bronchodilators

R&E

R&E

in Pts limited by
bronchospasm

R&E

, except possibly
in patients w/CHF

9
Antidepressants

Insulin

R&E

R&E

Variable rest

R&E

R&E

R&E

Pre-Quality of Life Quiz Scores

At the initial intake session, an overview of what cardiac rehabilitation
is and does for someone such as the patient and initial exercise assessment
is done, the patient is also asked to complete a packet of multiple surveys
and quizzes approved by AACVPR and brought back prior to their next
session. This packet includes; a Quality of life assessment (QoL), patient
health questionnaire (PHQ-9), and rate your plate. With what this patient has
been through, more so recently with his R BKA, his lower than normative
scores are predicable (31,35). Along with these assessment tools within the
packet there is a SMART goal setting sheet for exercise and nutrition,
informed consent, insurance policies, etc.
TABLE 8. Quiz Scores
Assessment

Normative
Data

Pre-Score

Post-Score

Overall Quality of
Life

>20

16.65

---

Rate your plate

>60

55

---

PHQ-9

<5

---

Risk Classification
Based on ACSM guidelines, the patient presents with the following
cardiovascular risk factors: age, family history, sedentary life style, obesity,
dyslipidemia, and hypertension. According to ACSM guidelines, this patient
would be classified as high risk, given his symptomatic state, type I diabetes,
and the presence of two or more positive risk factors for CVD (10,11).
Following the guidelines of AACVPR the patient would also be classified as
high risk due to his CHF and arrhythmia (1,10,11). According to the
Framingham risk score calculator, the patient has a 25% chance of suffering
a myocardial infarction within the next ten years.
Follow-Up
Currently, the patient has been suffering from multiple health
conditions and comorbities that are directly related to his heart complication
diagnosis (10,24). These include CHF, uncontrolled diabetes, GERD, and lung
disease. All in which have been adding continuously to inhibiting his ability to
perform everyday tasks. It is important to address each of his health issues

10
individual but relate it back to underlying diagnosis of a PCI and how it might
effect his exercise prescription.
Two of his comorbities that relate in the way they may affect the
patient in his treatment is the patients diagnosis of CHF and lung disease. In
patients with CHF the prevalence of COPD ranges from 20% to 32%
(4,15,20,36). Exertion dyspnea is the recurrent symptom common to COPD
and CHF. Fatigue is also a common complaint of patients with COPD and CHF,
which the two together result in some activity intolerance. Depression and
anxiety are also common in both the conditions, which is also more likely
seen with amputees (10,31,36).
Another concern for our patient that actual relates back to his original
diagnosis, his CHF and COPD, is his GERD. Though they are to separate
entities it is important because they give the patient the same feeling of a
heat attack and/or heart failure. These symptoms include but are not limited
to a crushing pain in ones chest identical to a heart attack, shortness of
breath, and fatigue. These are all relevant because there needs to be a
distinction between the comorbities so the patient is confortable on his own
(23,25,29).
The last area of concern is his uncontrolled diabetes. The first
symptoms of diabetes are related to the affects of high blood sugars. Though
we all know the common effects of hyperglycemia areas that need to be
noted for exercise is when BG levels get too high, glucose starts to pass
through ones urine and the kidneys excrete excessive water. Due to the
excess urine output the patient may have to urinate often (10,24,31). The
patients uncontrolled BG may be the lead/underlying causes to a lot of his
other diagnoses and complications.
Initial Assessments
All components of fitness are needed to improve the patients overall
health to ensure proper risk-evaluation and an optimal, individually tailored
rehabilitation; exercise testing should remain a preferred option for all
patients discharged after a cardiac event. Also, as people age all
components of fitness decline if one does not remain physically active
(1,21,27). Exercise testing allows us as clinicians to compare to normative
data for the patients characteristics, and reach goals defined by ACSM and
AACVPR. Therefore, baseline measures are necessary to develop an effective
program. For each protocol the patients characteristics, goals, lifestyles,
along with other factors that pertain directly to his condition were all taken
into consideration. However, for older individuals with a lower-limb
amputation, a standard exercise test is not available (11,38).

Special Considerations

11
For testing patients with lower-limb amputation, special consideration
concerning the exercise mode and protocol are essential. Patients with
amputation are at higher risk concerning exercise due to impaired motor
system, reduced muscle mass, balance problems, and problems associated
with prolonged stump loading may make the recommended protocols
inapplicable (15,38). To tie into this, the patients physician has a restriction
on time wearing the prosthetic due to the patients frequent sores and
phantom limb pain. Another consideration is the patients CHF and lung
disease. Prior to performing any of these exercise tests the patient received
instructions on pursed lip breathing, dietary intake prior to testing, proper
shoes and socks, and instructions on how to avoid the Valsalva maneuver
during musculoskeletal testing and flexibility (7,15). The clinician should also
be aware of the effects of hypoglycemia and the signs and symptoms
associated with hypoglycemia. Thus, the staff should have a pure CHO food
at hand to treat a hypoglycemic state. It is also recommended that the
clinician giving care should also test the patients blood glucose prior to
initiating the exercise tests. If the blood glucose is low or elevated the
clinician must follow the proper procedures for treating hypoglycemic
patients. Additionally, the clinician must be aware of all contraindications to
exercise and indications for testing termination while performing these tests;
specifically regarding his HTN.
For this patient he is also prescribed multiple medications and the one
medication that will have an effect on his exercise HR and BP, is specifically
his -blocker. Therefore, exercise intensity was and will also be monitored by
using the rating of perceived exertion (RPE) scale to accommodate for the
blunted BP and HR response. Again the patients prescribed medications and
their effects are listed in TABLE 6 and 7.
Cardiorespiratory
Based on the patients current special considerations and diagnoses,
the use of an upper body ergometer was thought to be the proper clinical
decision. Also, taking into consideration that the patient did not bring his
prosthetic with him to the initial session. Based on current research and
protocols that SJH utilize the test consisted of a two minute warm up at an
intensity level of 0 Watts at a constant cadence of 45-50rpm, increasing five
Watts every 2 minutes until fatigue is reached. The patient was allotted oneminute increments of rest in-between the five-Watt increases. Initial scores
can be seen in TABLE 9.
Research has shown the for amputees that cannot ambulate or have
balance problems that the arm ergometer exercise stress test was feasible
and provided a valid assessment of peak aerobic capacity and exercise
tolerance in older individuals with a lower-limb prosthesis. It is also a
respectable predictor of prosthetic fitting, along with anticipating the
possibility of cardiovascular complications during rehabilitation programs
(9,19,22,38). One study in particular showed that participants reached on

12

average, 89.1% of their age predicted heart rate values. Neither hear rate of
RER values differed between the controls and the participants with a lowerlimb amputation, showing that both groups reached similar levels of exertion
(19). Overall arm ergometer tests with rest intervals are a good predictor for
lower limb amputation patients peak aerobic capacity.
*Inverted T-waves noted, common with NSTEMI
Musculoskeletal
With muscle wasting being a complication for amputees due to the loss
of mobility (9,10,31). This loss of mobility and muscle strength can lead to a
negative spiral of becoming less active, losing muscle strength, loss of
independence, and a reduced quality of life (31). Therefore, muscular
training is important for this particular patient. In order to prescribe a
resistance training program for this patient we needed to access his maximal
lifting capacity to safely establish an initial routine and monitor adaptations
over time (1,11). Within our facilities we have limited free weights so we
utilize multiple RM, which according to the research novice lifters, such as
the patient, should perform a multiple RM rather than a 1-RM to reduce the
chance of muscle soreness and further exacerbation of the patients
neuropathy. Also, this particular patient should not be performing vigorous
resistance training because of his diabetic nephropathy and previously
sedentary state, supporting the use of a multiple RM (11,21,31). Therefore,
multiple RM testing was performed on all major muscle groups (11). An
estimated 1-RM or multiple RM was found to have excellent test-retest
reliability of 0.98 for middle-aged untrained diabetics/amputees (19,23,31).
The exercises performed included bicep curl, chest press, lateral raise, and
shoulder shrug. There is no specific reasoning behind exercises chosen; it
was apart of hospital protocol, though there are more beneficial exercises for
amputees stated in ACSM's Exercise Management for Persons with Chronic
Diseases and Disabilities. Initial scores can be seen in TABLE 9.
Flexibility
Flexibility is often downplayed in the fitness regimen for many
populations, even for the apparently healthy population. However, flexibility
is important in order to maintain a full range of motion and reduce the
chances of injury in middle-aged and older adults (10,27). At our hospital we
too are guilty in not assessing flexibility but we do encourage and reinforce
stretching at the end of every session during the cool down.

13

Reassessments
TABLE 9. Assessments
Area

Assessment

Initial Score

Reassessment

Time: 6 minutes

Time: 16 minutes

Mets: 1.5

Mets: 3.4

Bicep Curl

10lbs per arm

12lbs per arm

Chest Press

Total 20lbs

Total 30lbs

Lateral Raise

7.5lbs per arm

7.5lbs per arm

Shoulder Shrug

15lbs per arm

20lbs per arm

Cardiorespirato
ry

UBE

Musculoskeleta
l
8=RM

Flexibility

N/A

---

---

For the patients overall fitness there was great improvement

throughout the 9 weeks, with 2 weeks absence for wound care. There was
some minor set back through the patient being absent due to complications
with amputation. Even with these obstacles the patient showed the greatest
improvement in his Met level and time with the UBE test. This may be due to
the patient having more confidence or his aerobic capacity just improved
that much in 9 weeks with a total of 7 weeks in rehab.
Exercise Prescription
Although amputees may fear that the loss of a limb severely limits
their ability to be active, exercising is still important. Exercise is not only to
support your physical health, but it can have a significant impact on mental
health as well. Overtime, a combined aerobic and resistance training
program results in greater improvements and reduced risk for CVD, the
reason the patient is here. Improvements among studies ranged from
improved metabolic control, lowered HbA1c levels, reduced LDL, lowered
systolic pressure, significant weight loss or maintenance, improved quality of
life and an overall decrease in CVD mortality (6,13,16,32).
Special Considerations
As with any population, there are special considerations that must be
taken into account when creating an exercise prescription. Energy
expenditure for lower-extremity amputees is much higher and directly
related to the level of amputation. For example, the energy costs for a
unilateral trans-femoral amputee is much higher than a unilateral trans-tibial
amputee. Skin breakdowns or infections can also further exacerbate a
disability, limiting all exercise as well as recreational activities, work-related

14
activities, or activities of daily living. Avoid these injuries by checking the fit
of the prosthetic and avoid activities that promote friction between the
amputated limb and prosthetic (18,35).
Cardiorespiratory
According to the American College of Sports Medicine, the goal of
aerobic physical activity for amputees is to increase cardiovascular fitness
and endurance of both the involved and uninvolved limbs as well as increase
efficiency of ambulation and activities of daily living (11,17). Though the
patient is present at our clinic for heart complications, it is important that we
accommodate all the patients comorbities in order to reach the best results
and outcomes for the patient.
Frequency and Duration
Lower-extremity amputees should be exercising aerobically four to
seven days per week as an end goal, for a total of 30 to 60 minutes per day.
However, due to the level of amputation or physical fitness it may be
appropriate to begin with 10 to 20 minutes of activity and gradually build-up
to 30 to 60 minutes to avoid exhaustion (10,11,31). At SJH we initial
prescribed 3 days per week starting with 15-20 minutes session to start.
Intensity
Intensity should begin at a fairly low level, research shows starting at
34-50% od maximal work level met during aerobic assessment is best, or at
a 11-12 rating on the RPE scale (11,24,31). For this particular patient we
started him fairly conservatively with working at 40% of his initial
assessment, and an RPE of 10-11. Even though he is also on a beta-blocker,
as protocol at SJH, we take HR into consideration as well. With his resting HR
being 76bpm his upper limits is +30bpm (1).
Type
Mode of exercise can be limited if prosthetic cannot be utilized. The
most recommended mode of exercise based off of research includes any
seated arm-leg ergometry; this includes Schwinn Air-Dyne, Nu-Step, Rowing
ergometry, and/or recumbent bicycle (11,31). All the equipment above
should incorporate sufficient muscle mass to improve cardiovascular fitness
and function (7,31). With this patient being fairly deconditioned we started
him on the Nu-Step, where he could utilize his arms and his non-effected leg.
When patient was able, prosthetic was also used on this particular machine
to work the major muscles on stub as well.
Progression
Continue to increase frequency on days outside of rehab to five days
per week, gradually reaching seven days per week to meet weight loss
needs. Once duration has been met of 30-60 minutes intensity can also
increase to 40-80% HRR or an RPE of 11-16 (11,23,31).

15
Musculoskeletal
Strength training is important in this population to increase strength in
the trunk, hips, and uninvolved limb as well as increase efficiency of
ambulation and efficiency of activities of daily living (7,19,31).
Frequency and Duration
Resistance training should be performed two to three days per week
(11,31). With the patient we waited to initiate his resistance program until
the second week of the program due to his debilitated state. Once the
program started exercises were performed starting at 2 times a week,
nonconsecutive days.
Intensity
Based on the current research and recommendations of ACSM
amputation and PCI patients should be performing exercises at 40-80% 1 RM
or at a weight allowing for 8-10 repetitions (11,19,31). For this patient again
at SJH we start conservative, especially with all the other comorbities the
patient is dealing with, starting the patient at 3-5 lbs for upper body at 8
repetitions. Lower body and abdominal exercises were all done at body
weight due to the deconditioning of patient.
Type
These individuals should be performing at least 2 upper-body, 1 core,
and 2 lower body exercises per session (7,31). The mode of exercise that was
utilized was a circuit of exercises consisting of chest press, bicep curls,
triceps extensions, seated reverse abdominal curl, seated leg extension/lifts,
lateral hip extension using free weights or body weight.
Flexibility
Flexibility was performed at the end of every exercise session to
maintain range of motion for this patient (1,11). Depending on the level of
amputation, stretching exercises should include muscles of the neck,
shoulder, trunk, back, hip, and all the muscles of the nonamputated limb
(10,31). Stretching exercises for this patient included upper body, trunk, and
lower body including residual muscle of the amputated limb.
TABLE 10. Aerobic Exercise Progression
Week
1
MET Level
Total
Time

Week
2

Week
3

Week
4

Week
5

Week
6

Week
7

1.5
Mets

1.5
Mets

1.9
Mets

2.4
Mets

2.7
Mets

3 Mets

3.4
Mets

6 min.

15 min

12 min

25 min

30 min

35 min

40 min

16
*Met level was taken from highest level for the week as well as total time of
exercise for the day not on one individual aerobic exercise machine.
Home Exercise
Although a cardiac rehab program shows great benefits, home-based
activities are needed to meet the recommended amount of physical activity
by ACSM and AHA. At SJH we tailor home exercise to what is available at
home. The patient currently has an Air-Dyne at home, which actually
correlates directly with best exercise for amputees according to the research
as seen above. After a week or two of cardiac rehab SJH starts to implement
a home exercise contract.
Frequency and Duration
Home exercise started at adding one more day outside of cardiac
rehabilitation at 15-20 minutes of aerobic exercise.
Intensity
Again, intensity started fairly minimal, having the patient exercise at
an RPE of 11-13, and not exceeding a heart rate +30bpm of his resting.
Type
Mode of exercise was the Air-Dyne due to the resources the patient had
at home. This equipment ties to the research in a mode of exercise that
should incorporate sufficient muscle mass to improve cardiovascular fitness
and function for amputation patients (19,31).
Progression
Continue to increase frequency on days outside of rehab, to a total of
five days per week, gradually reaching seven days per week to meet weight
loss needs. Once the duration has been met of 30-60 minutes intensity can
also increase to RPE of 11-16 (11,19,31).
Clinical Decision
Given the patient is an older gentleman, having multiple risk factors
with the combination of his previous history of CAD, comorbities, his recent
absences for blisters and sores, and his psychological outlook, many factors
need to be taken into consideration when making a clinical decision on the
best exercise testing and treatment. His exercise treatment is designed to be
rehabilitative and is meant to increase muscle strength, endurance, and
cardiovascular fitness to allow this patient to perform a greater range of
activities if daily living. Another issue that is not noted in the patients chart
but is of importance is his psychosocial factors (31,35). Again, to access this
we use the PHQ-9, see Pre Quality of life Quiz scores above. Activities that
improve the patients daily function and overall quality of life need to be
incorporated throughout his daily schedule, along with medication adherence
to not only manage his long list of medications to treat multiple conditions
but to possibly prevent future conditions as well (20,28,34).

17
Goal Setting/Clinical Outcomes
Based on the current recommendations for patients with an
amputation and heart complications by the ACSM and AHA, this patients
goals should focus on reducing the following: BP, LDL, triglycerides, HbA1c,
and body weight (12,30,39). In patients with an amputation it is important to
increase the overall aerobic capacity to enhance their ability to perform daily
activities. In order for us to do this with the patient a certified dietitian comes
in whenever appointments are scheduled, the target being a reduction in fat
mass and preservation of muscle mass. Along with weight loss, the main
goals of our particular patient with an amputation, CHF, and lung disease
along with his PCI, in cardiac rehabilitation are to increase functional
capacity, reduce the symptoms of dyspnea, and improve overall quality of
life (11,14,17).
Recent studies support the use of cardiac rehab for amputee patients
to increase the overall health and quality of life (10,31), as we could see with
our particular patient at SJH. These improved measures are primarily due to
the education and exercise treatment plan that has been prescribed for the
patient. The long-term goals that have been established for the patient
include a decrease in weight, waist circumference, blood pressure,
cholesterol levels, and A1c, a long with an increase in cardiovascular function
and time. The recommended long-term as well as the short-term goals that
the patient should achieve are listed in TABLE 11 and TABLE 12. By
establishing these goals listed in the tables below the patients diabetic
control may be improved. Also, by establishing these goals, exercise
adherence may increase and the patient may become more motivated to
change his lifestyle increasing his quality of life since his amputation.
In order to set attainable and time oriented goals, St. Josephs uses the
SMART goal system by asking a continuum of questions about an exercise
goal and nutritional for the patient to fill out at orientation, and then
reassessing every 30 days. These questions insure that the goals are
specific, measurable, attainable, realistic, and time oriented. From here we
as the Exercise Physiologists can then break down those larger goals into
short and long term to be utilized in the prescription.
Long Term Goals & Outcomes
TABLE 11. Long-Term Goals Outcome Chart
Goal criteria

Initial Data

Goal

Lose Weight

BMI=31.4 kg/m2,
231.2lbs

BMI<30 kg/m2, 220lbs

Waist

45.75

<43

18
Circumference
Resting BP

128/64 mmHg

<120/80 mmHg

HDL

29 mg/dL

>40 mg/dL

TG

536 mg/dL

<150 mg/dL

A1c%

9.1 mg/dL

<7% mg/dL

CRF: Frequency

None

>5(most days of the

week)

Intensity

RPE 11-13

RPE 11-13

Time

None

40-60min total exercise

All long-term goals were set to reach recommended cardiac rehabilitative

outcomes. Goals were all set using AACVPR and ACSMs guidelines for
average or beneficial values for the patients age and risk factors.
Short Term Goals & Outcomes
TABLE 12. Short-Term Goals Outcome Chart
Goal
Criteria

Baseli
ne
Data

Weight
Loss

231.2lb
s

Diet

Medicati
on
Adheren
ce

None

None

Goal (week
1-2)

1-2lbs

Goal (week
3-4)

1-2lbs

Goal (week
5-6)

12lbs/Measure
waist

Result
s

225.4l
bs

All
500-1000 Adopt MyPlate sodium & fat
Adopte
kcal/day and DASH diet
intake
d
Create
Medication
Card

---

Download
All
Medication
Adopte
Adherence
d
App

With all short-term goals nothing increases more than 20% during that 1-2
week period. CRF goals can be seen in home-based walking program. With

19
retesting being at week six due to neural versus morphological adaptations.
The end goal for the patient is to reach the average norms for his age group
within limitations of his condition.
Patient Education
Hygiene/Wound Care
The amputated limb should be washed daily, especially days after
exercise to prevent skin breakdown (i.e., blisters) or hair follicle infections
that can significantly affect the activity level of the patient (10,18). Practicing
proper hygiene will help prevent skin problems. It is important for the
amputee to determine the right size of stump socks and the correct number
of stump socks to be worn, to change stump socks daily and when they are
damp or wet. Again, this is essential to help prevent skin irritations and
blisters (18,31).
Education Implementation
In order to implement this education, prior and after exercise the RN or
exercise physiologist would inspect the patients stump. Along with a line of
direct questioning, asking hours prosthetic was worn, is there pain, and
whens the last time he changed his sock, and did you take your medication?
For home care the patient and his wife was both directed on daily hygiene as
well as exercise, along with what to look for when inspecting stump for skin
breakdown.
Medication Adherence
Medication compliance is fundamental to the self-management of most
chronic illnesses, yet low compliance to prescribed medical interventions is
an ever present and complex problem (35,37). It is important that the patient
understands the effects and interactions of the medications he is on, to
ensure adherence and reduce the risk of recurrent MI or worsening his
multitude of conditions. There are many studies on the effects of tools and
methods designed to enhance medication adherence that have been
pursued. Though there is no one method better than another, research has
shown that some type of reminder for the client improves adherence up to
38% (35,37). These reminders can be anything that the client is most
comfortable with, such as: alarms, mailed reminders, apps on smart devices,
etc. (37). In a study of medicine adherence and chronic illness 89% of
participants believed that their prescribed medication was necessary for
maintaining health. However, it is estimated that over 30% of prescribed
medication is not taken as directed (37). A large part of this adherence is the
patients beliefs about their treatment and particularly their views about
medicines in general (35,37). The patient is currently prescribed medications
can be reviewed in TABLE 6. Although medication compliance is important in

20
the prognosis for the patient, other preventative measures must also take
place to reduce the chances adverse changes in health.
Education Implementation
In order to get the patient active in the patient education we had them
fill out a individualized patient medication card was filled out with dose and
how to take. Since the patient is in Cardiac Rehabilitation we had the patient
highlight all his heart medications and then went over what the effects of
those medications were, such as aspirin, beta-blockers, statins, etc. We then
had the patient show or verify with us in later weeks how he would improve
his adherence to his medications, through an alarm or app on his phone.
Nutritional Guidelines
Nutritional counseling is one of those areas that can help reduce high
cholesterol, HTN, excess weight, and assist in diabetes management, all
major risk factors of cardiovascular disease that the patient has developed.
The American Heart Association has developed dietary guidelines that help
lower fat and cholesterol intake, reducing the risk of CVD (13,18). With the
patients current risks, along with the prior incident of heart disease and
comorbities, at SJH, we suggest that a diet such as the DASH diet be
adopted. This diet appearing to be heart-healthy showed in a multiple longterm studies of patients whove suffered from heart disease, have a decrease
in overall risk factors specifically blood pressure (18,29). The DASH diet is a
total diet plan that is based on the increased consumption of vegetables,
fruits, and low-fat dairy food, and a decreased intake of fats (18,29).
Education Implementation
Along with this informational handout on what and how the DASH diet
works, we gave out a 3 day food log to be completed then we entered in to
the MyPlate tool that was developed by the Department of Agriculture. The
patient was also urged to set an appointment up with the dietitian in order to
understand portion size and various misunderstood concepts of eating
healthy. However, the use of the DASH diet alone will not provide a
significant increase in the quality for the patient. Thus, an increase in the
amount of physical activity is also warranted (11).
Group Patient Education
At SJH besides the individualized patient education to each patient
they also host group patient education classes on general topics, which
everyone and their families are welcome to attend. These classes consist of
heart medications, physical activity versus exercise, heart healthy diet,
hypertension, and dyslipidemia to just name a few. Though it is not required
many patients make it a priority to make it to these sessions. To go with each

21
session multiple handouts are usual given to patients along with physical
demonstration if need be.
Dyslipidemia, hypertension, fat distribution, psychosocial factors,
diabetes management, and exercise, along with a few other factors all have
been shown throughout multiple studies to be associated risk factors
contributing to the patients current diagnosis, in white middle-aged men.
Through a large study done by INTERHEART, collecting data from facilities
worldwide on these risks and showed the likelihood to be attributed to heart
disease was found for multiple populations. For men in this study abnormal
lipids had the highest attribute to risk at 49.5 %, with psychosocial risk
factors contributing to 28.8%, abdominal obesity being 19.7 % and
hypertension of 14.9%. All contributing risk factors studied accounted for
90% of recurrent MI causes (32,36). Which all relate directly to the patients
previous and current history of heath conditions and assessment scores.
These risks and their contribution to an MI need to be taken into
consideration due to the patients previous diagnoses and his current PCI. By
managing the patients diet, symptoms, exercise, and medication through an
exercise prescription and patient education, could increase his health
significantly and provide him with the tools to improve his quality of life.

22
References
1. AACVPR. (2013). Guidelines for Cardiac Rehabilitation and secondary
prevention programs(5th ed.).
2. Abdul-Hameed, U., Rangra, P., Shareef, M. Y., & Hussain, M. E. (2012).
Reliability of 1-repetition maximum estimation for upper and lower body
muscular strength measurement in untrained middle aged type 2 diabetic
patients. Asian Journal of Sports Medicine, 3(4), 267-273.
3. Ades, P. A. (2014). A controversial step forward: A commentary on the
2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce
atherosclerotic cardiovascular risk in adults. Coronary Artery Disease,
25(4), 360-363. doi:10.1097/MCA.0000000000000086 [doi]
4. Ades, P., Keteyian, S., Balady, G., Houston-Miller, N., Kitzman, D., Mancini,
D., & Rich, M. (2013). Cardiac Rehabilitation Exercise and Self-Care for
Chronic Heart Failure. JACC: Heart Failure, 540-547. Retrieved June 30,
2015.
5. Akbari, M., Jafari, H., Moshashaee, A., & Forugh, B. (2012). Do diabetic
neuropathy patients benefit from balance training? Journal of
Rehabilitation Research and Development, 49(2), 333-338.
6. Al-Ani, F. S., Al-Nimer, M. S., & Ali, F. S. (2011). Dyslipidemia as a
contributory factor in etiopathogenesis of diabetic neuropathy. Indian
Journal of Endocrinology and Metabolism, 15(2), 110-114.
doi:10.4103/2230-8210.81940 [doi]
7. Alberto Esquenazi and Robert DiGiacomo (2001) Rehabilitation After
Amputation. Journal of the American Podiatric Medical Association:
January 2001, Vol. 91, No. 1, pp. 13-22.
8. Albright, A. (2010, February 9). Exercise and Type 2 Diabetes. Retrieved
April 20, 2015, from http://www.medscape.com/viewarticle/715313
9. Alst, J., Cruts, H., Huisman, K., & Vries, J. (1985). Exercise testing of leg
amputees and the result of prosthetic training. International
Rehabilitation Medicine, 7(3), 93-98. Retrieved December 7, 2015.
10. American College of Sports Medicine. (1997). ACSM's exercise
management for persons with chronic diseases and disabilities.
Champaign, IL: Human Kinetics Publishers.
11. American College of Sports Medicine. (2005). ACSM's guidelines for
exercise testing and prescription 7th ed. Philadelphia, PA: Lea &
Febiger/Lippincott Williams & Wilkins.
12. American Diabetes Association. (2003). Peripheral arterial disease in
people with diabetes. Diabetes Care, 26(12), 3333-3341.

23
13. American Diabetes Association. (2007). Nutrition recommendations
and interventions for diabetes: A position statement of the american
diabetes association. Diabetes Care, 30 Suppl 1, S48-65.
doi:30/suppl_1/S48 [pii]
14. Amputation : NCHPAD - Building Inclusive Communities. (2015).
Retrieved December 14, 2015, from
http://www.nchpad.org/51/386/Amputation
15. Arena, R., & Sietsema, K. (2011). Cardiopulmonary Exercise Testing in
the Clinical Evaluation of Patients With Heart and Lung Disease.
Circulation, 668-680. Retrieved June 19, 2015.
16. Cheung, B., & Li, C. (2012). Diabetes and hypertension: Is there a
common metabolic pathway? Current Atherosclerosis Reports, 14(2)
17. Chin, T., Sawamura, S., & Shiba, R. (2008). Effect of Physical Fitness on
Prosthetic Ambulation in Elderly Amputees. American Journal of Physical
Medicine & Rehabilitation, 85(12), 992-996. Retrieved December 8, 2015.
18. Collins, N. (2013). Diabetic Wound Healing Through Nutrition and
Glycemic Control. Today's Wound Clinic, 7(2). Retrieved December 6,
2015.
19. Davidoff, G. (n.d.). Exercise testing and training of persons with
dysvascular amputation: Safety and efficacy of arm ergometry. Archives
of Physical Medicine and Rehabilitation, 334-338. Retrieved December 8,
2015.
20. Ehrlich, S. F., Quesenberry, C. P.,Jr, Van Den Eeden, S. K., Shan, J., &
Ferrara, A. (2010). Patients diagnosed with diabetes are at increased risk
for asthma, chronic obstructive pulmonary disease, pulmonary fibrosis,
and pneumonia but not lung cancer. Diabetes Care, 33(1), 55-60.
doi:10.2337/dc09-0880 [doi]
21. Ehrman, J. (2013). Clinical exercise physiology. Champaign, IL: Human
Kinetics.
22. Erjavec, T., & Presern-Strukelj, M. (2008). The diagnostic importance of
exercise testing in developing appropriate rehabilitation programmes for
patients following transfemoral amputation. European Journal of Physical
Rehabilitation, 133-139.
23. Frugoli, B., Guion, K., Joyner, B., & Mcmillan, J. (2000). Cardiovascular
Disease Risk Factors in an Amputee Population. JPO Journal of Prosthetics
and Orthotics, 80-87. Retrieved December 7, 2015.
24. Frugoli, B., Guion, K., Joyner, B., & Mcmillan, J. (2000). Cardiovascular
Disease Risk Factors in an Amputee Population. JPO Journal of Prosthetics
and Orthotics, 80-87. Retrieved December 8, 2015.

24
25. GERD Causes and Complications: Esophagitis, Asthma, Cancer, and
More. (n.d.). Retrieved August 13, 2015, from
http://www.webmd.com/heartburn-gerd/understanding-gerd-basics
26. Guidelines for cardiac rehabilitation and secondary prevention
programs (5th ed.). (2013). Champaign, IL: Human Kinetics.
27. Heyward, V., & Gibson, A. (2014). Assessing flexibility. Advanced
fitness assessment and exercise prescription (7th ed., ). Champaign, IL:
Human Kinetics.
28. J.J. Cranley, M.D., R.J. Krause, M.D., E.S. Strasser, M.D., C.D. Hafner,
M.D. (1969), Below-the-Knee Amputation for Arteriosclerosis Obliterans
With and Without Diabetes Mellitus, Archives of Surgery, Vol. 98.
29. J.W. Anderson, M.D.(1976), Metabolic Abnormalities Contributing to
Diabetic Complications, II. Peripheral Nerves, American Journal of Clinical
Nutrition, Vol., 29.
30. Lange, L. (1982). Prosthetic Implications With The Diabetic Patient.
Digital Resource Foundation for the Orthotics & Prosthetics Community.
31. LeMura, L. (2004). Exercise and Lower Limb Amputation. In Clinical
exercise physiology: Application and physiological principles. Philadelphia:
Lippincott Williams & Wilkins.
32. Miller, M. (2009). Dyslipidemia and cardiovascular risk: The importance
of early prevention. QJM, 657-667.
33. Myers, J. (2015). Exercise and Cardiovascular Health. Circulation, 2e-5.
Retrieved February 16, 2015.
34. Perk, J. (2007). Cardiac Rehabilitation. In Cardiovascular prevention
and rehabilitation. London: Springer.
35. Pham, D., Fortin, F., & Thibaudeau, M. (1996). The Role of the Health
Belief Model in Amputees' Self-Evaluation of Adherence to Diabetes SelfCare Behaviors. The Diabetes Educator, 126-132. Retrieved December 12,
2015.
36. Stewart, K. (2003). Cardiac Rehabilitation Following Percutaneous
Revascularization, Heart Transplant, Heart Valve Surgery, and for
Chronic Heart Failure. Chest, 2104-2111. Retrieved May 30, 2015.
37. Vermeire, E., Hearnshaw, H., Royen, P., & Denekens, J. (2002). Patient
adherence to treatment: Three decades of research. A comprehensive
review. Journal of Clinical Pharmacy and Therapeutics, 331-342. Retrieved
February 16, 2015.
38. Wezenberg, D., Haan, A., Woude, L., & Houdijk, H. (2011). Feasibility
and Validity of a Graded One-Legged Cycle Exercise Test to Determine
Peak Aerobic Capacity in Older People With a Lower-Limb Amputation.
Physical Therapy, 329-338. Retrieved December 8, 2015.
39. Yoffee, L. (2015). Heart Disease: The Diabetes Connection. Retrieved
December 7, 2015, from http://www.everydayhealth.com/hearthealth/heart-disease-and-diabetes.aspx