Katie of daily living. These activities include;

Katieis a 25-year-old female that has been classified with fair cardiorespiratoryfitness. Her CRF classification was determined using her measured VO2 max of 38ml.kg-1.min-1) (Cooper Institute of Aerobic Research, 2005).

Fair cardiorespiratory fitness in young adults is associatedwith the development of cardiovascular disease risk factors (Carnethon, M.R. et al, 2003), diabetes, colon andbreast cancer, and depression (Warburton, D.E. et al, 2006). There is indisputableevidence that regular physical activity is effective in the primary andsecondary prevention of such chronic diseases (Warburton,D.

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E. et al, 2006). An individual may present with a fair CRF classification dueto decreased physical activity; this is defined as any bodily movement producedby skeletal muscle that requires energy expenditure (World Health Organisation,2012). It is also likely to be due to unhealthy lifestyle behaviours that mayhave been established during younger years (Nabi, T et al, 2015) as it has beenevidenced that children who are physically active go on to be healthier adults(Boreham, C. and Riddoch, C.,2001). Negativeexperiences during school physical activity classes are the strongest factorthat discourage participation in physical activity in teenage girls and thiscontinued anxiety and lack of self-confidence are factors that continue in toadulthood (Allender, S.

et al, 2006). Aswell as the numerous health benefits that have been associated with increasedcardiorespiratory fitness, patients with lower cardiorespiratory fitness mayhave difficulty performing more strenuous activities of daily living. Theseactivities include; walking for long distances and climbing the stairs and maycause Katie to experience shortness of breath or to feel unwell (Hetz, S.P.

et al, 2009). It is essential that Katie improvesher cardiorespiratory fitness to help make it easier for her to do theseactivities of daily living and also to allow her to get back to the leisureactivities that she enjoys.  Barriersthat may be currently preventing Katie from reaching the recommended physicalactivity guidelines include; lack of time, lack of socialsupport, inclement weather and disruptions in routine (Dunn, A.

L. et al, 1999). By prescribing a goalorientated treatment plan that fits around Katie’s lifestyle the intention isto help improve her VO2 max and therefore increase her cardiorespiratoryfitness. TheAmerican College of Sports Medicine (2013) recommends that to see improvements inKatie’s health, she should be exercising at a moderate intensity on at least 5days per week. Moderate intensity exercise includes; brisk walking, houseworkand cycling (World Health Organisation, 2018). Katie’s CRF classification canbe used to recommend a more individualised exercise programme and it issuggested that individuals with fair cardiorespiratory fitness levels shouldexercise at a moderate to vigorous intensity a minimum of three times per weekto produce significant changes in aerobic endurance (ACSM, 2013). Anappropriate combination of exercise intensity and duration is required so thatthe individual adequately stresses the cardiorespiratory system withoutoverexertion (Heyward, V. H and Gibson, A.

L, 2014). Therefore, Katie should belooking to complete a combination of moderate and vigorous intensity exercises,such as walking, running and climbing the stairs) for 20-60 continuous minutesin order to see improvements in her cardiorespiratory fitness (World HealthOrganisation, 2012). The greatest conditioning effects will occur during thefirst 6 to 8 weeks of the exercise programme. For Katie to continue to seeimprovements in her cardiorespiratory fitness, the system must be overloadedthrough adjustments in the intensity and duration of the exercise to the newlevel of fitness (Heyward, V. H and Gibson, A.

L, 2014).Cardiorespiratoryfitness classification is classified using the patient’s VO2max. The VO2 max reflects thecapacity of the heart, lungs, and blood to deliver oxygen to the workingmuscles during dynamic exercise involving large muscle mass (Heyward, V.

H andGibson, A.L, 2014). Katie’s CRF classification can be used to understand thepercentage of heart rate reserve, percentage heart rate max or percentage ofVO2 max that she should be working at in order to improve her cardiorespiratoryfitness. VO2max can be usedas an outcome measure for cardiorespiratory fitness (Bennett, H.

et al, 2016), the graded exercise testsallow for the patient to reach voluntary exhaustion allowing a direct and thereforemore likely accurate measurement. However, VO2max can be more difficult tomeasure than alternative outcome measures such as heart rate and in Katie’scase I decided not to use VO2 max due to Katie’s fair cardiorespiratory fitnessand safety concerns that may come with allowing her to reach full exertion andalso due to the lack of equipment available. Heart rate is an alternativeoutcome measure that can be used that is easily measured using heart ratemonitors that can be worn around the patient’s chest (Machado, F.A. and Denadai, B.

S., 2011). They are easy to use andoften more available than gas analysers that are required when directly measuringVO2 max. Limitations to using heart rate however are that it be affected bymedication, emotional states and environmental factors such as; temperature,humidity and air pollution (Heyward, V. H and Gibson, A.L, 2014). Twoalternatives of heart rate measurements can be used when prescribing an appropriateexercise intensity; the percentage of heart rate max and the percentage ofheart rate reserve. Percentage of heart rate reserve is the preferred outcomemeasure due to the inclusion of the patient’s specific resting heart rate, thecalculation is therefore more individualised to the patient.

Exclusively usingheart rate to develop intensity recommendations however, may lead to largeerrors in estimating relative exercise intensities for some individuals. Thisis especially true when HRmax is predicted from age (220-age) instead of beingdirectly measured (Heyward, V. H and Gibson, A.L, 2014). It is thereforerecommended that when using heart rate as an outcome measure, it should be usedin combination with ratings of perceived exertion in order to accuratelyprescribe an individualised exercise plan. A Borg scale is used so that thepatient can rate their perceived exertion.

They are very easy to use and can beused by patients during physiotherapy sessions and when completing thetreatment plan at home. They are cheap and subjective and can help patients whoare afraid of increasing their heart rate to understand the appropriate levelshe should be working at.The treatment approach I decided to use was to focus on a Katie’sindividual health goals. This involves focusing on health goals within dimensionssuch as; symptoms, physical functional status and social functions (Reuben, D.B. and Tinetti, M.E.

, 2012.). Katie’s main goal was toget back to the leisure activities she previously enjoyed and to makeactivities such as walking long distances easier.

In a goal-orientated treatmentplan the goals set should be specific, measurable, attainable, realistic andtime-based (Bovend’Eerdt, T.J. et al,2009.). Itherefore worked with Katie to create goals that could realistically beachieved in the ten-week time frame, and that were individualised to herlifestyle and that I could use an outcome measure to ensure achievement.

Inorder to increase Katie’s cardiorespiratory fitness, she needed to increase hermaximal oxygen consumption. Using Katie’s CRF classification I was able todetermine the percentage of heart rate reserve she should be working at and hertarget heart rate range (125-144bpm). By using a Borg scale in conjunction withthe heart rate monitor, Katie is able to understand the intensity she should beworking at using a visual aid. I calculated Katie should be working an RPE of12-13, which is categorised as fairly light-somewhat hard. I was then able touse Katie’s rating of perceived exertion alongside the reading from the heartrate monitor to either progress or regress her exercises to ensure she isworking at the appropriate intensity. Katie’streatment plan involves exercises from the class, it also involves helping herto understand other ways she can incorporate her 30 minutes of moderateexercise on 5 days a week into her lifestyle. During the exercise class I wasable to use the heart rate monitor and Katie’s RPE to progress and regress theexercises to the appropriate level.

I recommended to Katie that at home she didthis set of exercises on three days a week for 30 minutes as in accordance withthe guidelines for someone of Katie’s age with her level of fitness. UsingMetabolic Equivalents, an alternative to VO2max, I was able to determine howKatie would be able to get back to her leisure activities that she set out inher goals.  One of Katie’s goals was toget back to swimming on a regular basis, and using the calculation thatconverts her intensity level to METS I was able to prescribe that Katie tookpart in 30 minutes of moderate intensity swimming, such as breaststroke, onceor twice a week. Using a Borg scale, she is able to understand the appropriate levelshe should be working at whist swimming, and I also suggested that she wentswimming with a friend so that she was be able to make sure she was still ableto talk during the exercise. Moderate intensity exercise involves theindividual getting hot and slightly sweaty, however they should still be ableto hold a conversation (Nhs.uk, 2018). Whilst talking to Katieabout other aspects of her daily life I was able to create an alternative goalfor another day of the week.

I was able to calculate the walking speed that canbe classified as moderate intensity exercise and suggested to Katie that shetried to walk the two-mile trip to the shop and back in 30 minutes on one day aweek, therefore allowing her to reach the 30-minute exercise goal, increasingher cardio-respiratory fitness, whilst also allowing her to get back toactivities of daily-living. There may be anumber of reasons as to why Katie’s adherence to the programme does not remainhigh. For example, Katie may not continue to adhere to the plan is due to painshe may experience after the first few sessions. Katie will be doingunfamiliar, high-force muscular work that may result in delayed onset muscle soreness(Cheung, K. et al, 2003.

). Although the symptoms shouldsuppress within a few days, the pain may cause Katie not to want to continuewith her plan, this is one example of when physician communication issignificantly related to patient adherence (Zolnierek, K.B.H. and DiMatteo, M.R., 2009), as if Katie understandswhy she is experiencing these symptoms she will hopefully continue to completethe plan as recommended.

It is essential to evaluate and measure patientadherence reliably (Atreja,A. et al, 2005).To ensure that Katie is reaching her activity goals I have decided to provideKatie with an accelerometer so that I am able to track her levels of physical activity.Accelerometers are small, discrete devices that measure the magnitude of thebodies accelerate that are able to provide information on duration, frequencyand duration of activity (Yang,C.C. and Hsu, Y.L.

, 2010). Although they cannot detect a gradient and can be inaccurate atmeasuring cycling and upper limb movements (Scheers, T. et al, 2012) I think that it will be a useful tool to provide me withinformation on Katie’s activity patterns and establish her adherence to thetreatment plan. I intend to continue to have regular assessments of Katie’sadherence to the programme using both this method and self-reports provided tome by Katie throughout the programme. Katiewas classified as having a CRF of fair using her measured VO2 max. There is agreat deal of evidence that shows cardiorespiratory fitness can be increasedand the health benefits that come with this are massive. Katie’s main goals forthe programme were to increase her fitness to allow her to get back to leisureactivities she enjoys, the added health benefits that will come with thisincrease in physical activity are great.

The key to setting appropriate goalswas to understand the reasons as to why Katie’s cardiorespiratory fitness hasreduced and the current barriers that are preventing her from reaching theguidelines that are set for someone of her age. I was able to determine theheart rate range and perceived exertion Katie should be working at during bothset exercises and when incorporating physical activity into her daily life. Thesemeasures allowed me to set an achievable goal-orientated treatment plan thatwill allow Katie to get back to the activities she enjoys whilst alsocontinuing to increase her cardiorespiratory fitness. 


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