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BACPR Exercise Professionals Group study day 

Friday 12th May  2017 - Aston University, Birmingham

These are one delegate’s take home messages from BACPR-EPG study day May 2017. The full presentations will be available shortly on the BACPR and ACPICR websites in the members only areas.

How much should we worry about sitting – Dr Jason Gill

Sedentary behaviour is any waking behaviour with low energy expenditure in a sitting or reclined posture.  Is sedentary behaviour itself a risk factor for CVD?  It seems that is you undertake sufficient amounts of physical activity you can ‘get away with’ some sedentary behaviour, whereas if you are generally inactive, you are more at risk from your sedentary behaviour.

It seems that not all sitting is the same.  TV viewing is an especially ‘bad’ form of sitting. However there are limitation to the studies looking at the sedentary behaviour associated with TV viewing:

a)      The subjectivity in reporting – most people underestimate the duration of their inactivity

b)      Confounding factors – you are more likely to eat junk food/drink beer when watching TV so is it the dietary factors or the inactivity causing the increased CVD risk?

c)       Reverse causality – do you sit more because you have heart disease or do you get disease because you sit?

Studies have shown that breaking up continuous sitting is beneficial in terms of insulin and blood glucose levels.  The higher your risk the more benefit you can gain.  For example every 20 minutes do x 10 sit to stand exercises?

 

Standing up in work – latest in cardiometabolic and mental health effects – Lizzy Parker, Dr Nicola Hopkins and Dr Richard Neil

In one study looking at call centre staff who were provided with sit-stand desks after 6 months sitting time reduced from 9 hours a day to 7 hours a day and this change was sustained at one year.  There were also benefits in terms of BP and blood glucose levels.

Another study which measured middle cerebral artery velocity found that sit to stand desks also improved endothelial function.  Walking for just 2 minutes every 30 minutes prevented the decline in blood flow caused by sitting.

The use of a sit to stand desk can also have a profound impact on mental health and well-being including improved job satisfaction, reduced job stress, increase self-esteem, increased perception of control and more reporting their role felt meaningful.

 

Patient perspective – Mike Duddy

Mike is a 55 year old endurance cyclist who underwent Mitral Valve surgery and shared his journey through cardiac rehabilitation.  He shared the emotional challenge that having a health event can be for an athlete.  During his recovery he had to cope with dealing with uncertainty, making sense of his diagnosis, taking ownership of his future, setting goals and finding support.

He highlighted the importance of the following:

a)      Consistency of information exchange with the patient

b)      Continuity of decision making

c)       A tailored care pathway

d)      To be able to start rehabilitation at initial presentation rather than after an event/surgery.

Exercise recommendations in athletes with heart disease: Fact and fiction – Dr Michael Papadakis

The role of the sports cardiologist was examined in this new and rapidly evolving sub-speciality.  There has been an increase in the number of amateur athletes, and an expansion of pre-participation screening.

Exercise is a potential trigger for sudden cardiac death if you have an underlying condition as this predisposes you to myocardial ischaemia and arrhythmias.

Normal variants on investigations such as echocardiograms/ECG’s in athletic individuals can look like a cardiomyopathy to the untrained eye, which is why having an experienced sports cardiologist interpret the results is important.

 

Developing a diabetes consensus statement – Professor John Buckley

John continues to work with others in developing a diabetes consensus statement.  This is intended to provide guidance on the acute management of diabetes whilst exercising.  There is a realisation that the contraindications to exercise for type II diabetics need to be eased from the current BACPR guidance.

During and after exercise, blood glucose levels should be kept > 4mmols and < 12 mmols (type I diabetics) or < 15 mmols (type II diabetics).  Remember that after warm-up blood sugar levels tend to begin to fall.  If a patient arrives with blood sugar levels higher than these limits, start exercise and recheck after the warm up.

30% of those with CVD have diabetes.  There is a growing prevalence of type II diabetes.  In the UK 70% of diabetics are inactive.  It is the 3rd most common co-morbidity in the CR population.

Those at highest risk have the most to gain from exercise.  We should be recommending moderate and vigorous physical activity, but don’t forget the benefits of light activity (and preventing sedentary behaviour) for blood sugar control.

Drug interactions – diabetics tend to have delayed HR and VO2 responses to exertion.  Statins, thiazides and betablockers can reduce glycaemic control.

High intensity Interval training (HIIT): has been shown to provide better insulin resistance reduction and equal improvements in HbA1c and fasting blood glucose levels.   If well controlled HIIT training can be safe even in type I diabetics.  Be aware that hypos can occur 2-3 hours after exercise.

 

How much should we worry about obesity – Dr Jason Gill

There is more risk associated with obesity for men than for women.

BMI and diabetes prevalence differs for different ethnic groups. A South Asian woman with a BMI of 22 has the same risk of diabetes as a white woman with a BMI of 30.

The average BMI at which you are likely to develop diabetes differed for your age.  Men develop diabetes at a younger age than women.

BMI is often disregarded as an inaccurate measurement tool.  BMI and waist circumference are actually highly correlated in the population.  BMI performs as well as other measures in determining future health risk.  There is no evidence that we should replace it in health assessment.  Waist circumference is difficult to measure accurately.

The first place you gain fat is as subcutaneous fat. Once subcutaneous fat areas are ‘full’ you then start putting on visceral fat, which has greater health risks.

Some people seem to have less capacity to increase their subcutaneous fat than others which explains why some people can be relatively healthy and others have health issues at the same BMI.  For example South Asians – it is thought than because they can’t store as much fat subcutaneously, visceral fat is stored at lower BMI and they have an increased risk of CVD/diabetes.

Can you be fit and fat?

If you are obese increasing your activity will reduce your risk but you are still at risk.  You do however have a lot to gain in terms of diabetes risk from being active.

Some people do have a genetic predisposition to obesity.  If you have a low genetic risk of obesity you will probably be ‘thin’ independent of your activity levels.  If you have a high genetic risk of obesity physical activity can have a greater impact on your body weight.

Be aware of under-reporting of dietary intake in research studies.  Normal weight people under report by 25%, obese people under-report by 50%.

Effects of different diets on body weight.  It is the overall calories that are important, not whether the calories are made up of sugar, carbs or fat.  The biggest determinant of dietary success is adherence, not what the diet is made up of.  However, low Gi, high protein diets tend to be more effective than most.  Sugary drinks are not good – because you can consume a lot of calories without feeling full.

How much physical activity should someone do to maximise weight loss?  You need to burn 2500 calories a week.  That equates to 225-300 minutes a week of moderate intensity exercise.  That is double the current government recommendations of 150 mins a week.

There are some benefits to early morning (pre-breakfast) exercise – as when your body is exercising in a fasted state your body is forced to burn more fat.

There is a lot of variability in weight loss in response to exercise.  Some people will naturally start to eat more when they become more active.  Some people will spontaneously reduce their physical activity outside of a structured exercise programme.

The importance of sleep is different dependant upon your genetic predisposition to obesity.  If you are predisposed to obesity it is more important to get the right amount of sleep and physical activity.

 

 

 


BACPR Exercise Professionals Group study day 

Friday 13th May  2016 - Aston University, Birmingham

 

These are one delegate’s take home messages from BACPR-EPG study day May 2016. The full presentations are available on the BACPR and ACPICR websites in the members only areas.

 

Diabetes & the heart by Professor Andre La Gerche

There is a 3-5 x increased risk of systolic heart failure (HF) with diabetes as seen in epidemiological data. However diabetic cardiomyopathy is controversial as the pathology is not understood.

Is the link between diabetes and HF due to a decreased exs tolerance, being overweight ie lifestyle factors or something else. A study of 1441 Type 1 diabetic patients saw only 0.8% with HF and they were as active as the control group. Type 2 diabetics tend to have lower activity levels. Is the decreased exs tolerance in T2 diabetics due to reduced pulmonary ability or reduced heart size associated with inactivity? Data supporting exs training to reduce CV events in diabetes is lacking.

 

Encouraging everyday exs in T1 and T2 diabetes by Dr Richard Braken

17% of NHS spending is on managing diabetes.

T1 diabetes

Insulin adjustment and carbohydrate intake around exs should be made dependent on the type of exs eg endurance or resistance. Main aim is to develop an individualised programme which reduces acute glycaemic fluctuations whilst improving long term glycaemic control. High intensity interval training (HIIT) is less likely to bring on a hypo. One study used a 10 sec sprint to prevent post exs hypoglycaemia!

Evidence is that regular exs improves glycaemic control, reduced insulin post exs eliminates nocturnal hypoglycaemia and progressive resistance training increases strength.

T2 diabetes

Aim is more related to generally improving levels of physical activity

2 hours of TV watching daily increases risk of developing T2 diabetes by 20%. Exs training x 3 week decreases Hba1c by 12 weeks. 1 session of HIIT improves glucose control over next 24 hours. Resistance training also reduces Hba1c but not as much as aerobic training.

 

The importance of muscle mass across the lifespan Dr Brendan Egan

Loss of muscle mass and function (sarcopenia) as we age is a major threat to health and independence in older adults. Physical inactivity worsens outcomes as does enforced bed rest and immobilisation. Bed rest should only be when there is clear medical indication e.g. hip fracture. Older adults (over 70) lose 900g of muscle mass for every 10 days of bed rest. Young healthy people lose 150-500g in the same time period.

The traditional focus on aerobic exs has changed in favour of combining it with resistance training (RT). Study of RT  only in adults over 85 years for 12 weeks,  VO2 improvement seen but smaller compared to aerobic training. Combination of aerobic and RT is key. Strength and mortality are linked , the stronger you are the longer you live.

For T2 diabetics glucose uptake into muscle is 50-60% reduced compared to normal. This can be improved with exs training. In diabetic patients loss of muscle mass will also reduce size of reservoir for absorbing glucose .

Exercise and adequate protein equal a good response giving the muscle the signal to grow. Exercise and poor nutrition equals a poor response. Older adults need more protein. Oral supplements immediately post exercise is optimal to increase muscle strength. Omega 3 is also important.

 

Practical ways to assess aerobic fitness in exs class Prof John Buckley

The Assessment 2  percentages for programmes as reported by NACRe is nationally only 51%. John was encouraging us all to repeat our FC test. He also talked about other ways to measure physical improvement eg using other data collected at exs sessions. However he recognised that currently we can only record shuttle walk and 6 mwt on NACRe.

 

Use of heart rate walking speed index HRWSI

To determine physiological  improvement in 6mwt the equation peak HR divided by walking speed x 10 can be used. This would be particularly useful  to show improved  cv fitness for patients who do not increase their distance in metres, maybe due to co-morbidity.

 

High Intensity Interval training (HIIT) Dr Gordon McGregor/Alison Welsh/Stefan Birkett

World wide research continues to show benefit as an alternative to conventional exs training. Gordon and Stefan are part of the HIIT or MISSUK trial investigation HIIT for the CR population in the UK. You can follow them on twitter. Alison, for her MSc, exercised cardiac patients in Liverpool using HIIT. However she did not do a max exs test first and used RPE to determine high intensity. As her research had only just been completed she did not have any stats to present but she had had no events during training. The debate continues.

 

When and at what does dose exercise become injurious to the heart? Prof Andre La Gerche

Emerging data links large doses of exs (eg iron man, triathlon participants) with some arrhythmias, particularly AF. The damage to the heart doesn’t appear to be reversible even when the exs is ceased. There could be a genetic predisposition to it.


 

BACPR Exercise Professionals Group study day 

Pushing the Boundaries in Cardiovascular Prevention and Rehabilitation

Friday 16th May  2014 - Aston University, Birmingham

 

BACPR-EPG were overwhelmed by the response to this years study day having to extend the delegate numbers at the last minute to cater for the vast interest. A record 130 delegates attended Aston University in Birmingham.  BACPR-EPG werevery pleased to welcome 3 international speakers along with expertise from our own home talent to discuss the increasing diversity in our cardio-vascular population and the up and coming physical interventions.

The key note speaker was Dr Jenny Adams, from the Baylor Heart and Vascular Hospital in Dallas, Texas. Internationally, acclaimed for her ‘Return to Work’ lab that provides occupation specific rehabilitation. Her talks focused on the ‘one size’ does not fit all.

The delegates were welcomed by Dr Gordon McGregor, BACPR-EPG Chair and Professor Gill Furze, BACPR President provided the opening address for the day.

Dr Jenny Adams, PhD, a Senior Research Associate /Exercise Physiologist, Dallas, Texas, kick started the morning with an inspiring talk on the Art of Exercise Prescription. She highlighted how our traditional Cardiac Rehab approaches are failing to cater effectively for our younger, fitter patients who may have very differing needs to our older clients.  She encouraged us to think outside of the box and on the need for our programmes to become more “specific”. She  described for a training effect to occur, specific muscle tissue must be challenged at the same intensity or frequency required for them to conduct their job, thus preparing our patients to perform more strenuous tasks safely and more efficiently as they return to work. From adapted/weighted lawn-mowers to fire hoses, she runs an enviable lab, that offers a varied and occupation specific approach to her rehabilitation.

Dr Neils Vollard is an Exercise Physiologist working at the Department of Health, University of Bath. The interesting, emerging concept of high intensity training (HIT) was discussed and proposed as an alternative regime to try and get patients to adhere to exercise. HIT is continuing to produce promising results in laboratory based studies and may help to strive towards overcoming barriers to physical activity. If patients can do less and achieve the same benefit will they stick to it? Does it come with a price? Dr Vollard attempted to address these implications. He summarised different types of HIT protocols. He concluded that high-intensity interval training gives superior clinical effects compared with moderate-intensity training but the key question that arises is whether high-intensity interval training is transferable to larger populations and whether it is safe. Dr Vollard advised that although the results are promising and give us a glimpse of what could be our future, until larger trials have been performed showing similar clinical effects and fewer adverse events this exercise regime should be limited to controlled settings.  References discussed:

 

 Cardiovascular risk of high- versus moderate-intensity aerobic exercise in coronary heart disease patients.Circulation. 2012;126:1436–1440

The higher the better? Interval training intensity in coronary heart disease: J Sci Med Sport. 2013 Aug 9, 1440-2440(13) 

 

Professor Maureen McDonald, director of  the Vascular Dynamics Laboratory and Faculty member at the Department of Kinesiology, McMaster University, Hamilton, Canada.

Prof McDonald continued the theme on HIT. She discussed her research, looking at the role of HIT training in altering arterial structure and function. She found that HIT training is suitable for patients with CAD. She demonstrated that both cardio-respiratory fitness and endothelial function improve to a comparable level to that of a more moderate intensity. However, despite no reported adverse events, the safety and long term adherence of HIT remains a concern for many Cardiac Rehab programmes at present.

 

Dr Sara Thorne Consultant Cardiologist at QE Hospital Birmingham and specialist in Adult Congenital Heart Disease (ACHD) and Heart Disease in Pregnancygave an informative and educational look at Physical Activity for children and adults with congenital heart disease. She described that the risk of sudden cardiac death is not generally increased by moderate levels of exercise other than in those with high risk ventricular arrhythmia and severe hypertrophic cardiomyopathy. With reference to the Mitchell et al. JACC Vol. 45, No. 8, 2005, Task Force 8: Classification of Sports and Pellicia et al European Heart Journal (2005) 26, 1422–1445

She described the anatomical and structural changes to be aware of and how the corrective surgery affects the circulation. Also, which sports and activities are safe to return to with specific conditions.

 

Samantha Breen MCSP, MPhil Clinical Lead Physiotherapist, Manchester Royal Infirmary

Reflected on how adults with congenital heart defects may be dealing not only with the heart defect itself but the deconditoning effect of physical inactivity from a young age. Fear, low confidence and avoidance of exercise may lead to a pattern of sedentary living and hence risk of developing obesity, coronary artery disease amongst other conditions. Her talk focussed on the considerations that exercise professionals need to work through to ensure safe exercise prescription and advice to the population. Key messages are to avoid burst type activity, extreme environmental conditions, adrenergic activities, intense static activities with valsalva manoeuvre and extreme sports.  With reference to the New ACPICR Standards – Appendix on ACHD due out imminently.

 

Dr Steven Cox Bsc (hons) PHDDeputy Chief Exec and Director of screening at CRY Cardiac Risk in the Young), gave a heart felt talk on managing uncertainties around exercise. He described how exercise can be the first trigger to a fatal arrhythmia amongst athletes who have a silent, hereditary or congenital heart defect and how it leads to a spiral of questions to what could have been done to prevent such a tragedy. It focussed on the early identification of people who have cardiac conditions whom want to participate in exercise. CRY has developed a screening programme where people aged 14-35 can access free screening and if a cardiac diagnosis is identified, appropriate follow up and advice is arranged.

 

Oral Abstract Presentations

Dr John Buckley Department of Clinical Sciences, University of Chester and Centre for Sports and Exercise Science, University of Essex presented his abstract on The Incremental Shuttle Walk (ISWT) – METS revisedHe discussed how only one article by (Woolf-May & Ferrett, 2008 Br J Sports Med) has set out to  report on metabolic equivalents for the ISWT and how they reported that that the METS differed greatly to those estimated b y the American College of Sports Medicine’s equations and secondly that METS were greater in post MI vs. non cardiac patients. This most recent study by John Buckley et al has set out to re-evaluate the METS of the ISWT in 3 groups, established coronary heart disease (CHD), non-cardiac high CHD risk factors and apparently healthy older adults. His conclusions to date are that there is no difference in MET value between healthy and non cardiac high risk CHD but similarly to Woolf-May & Ferret CHD patients worked harder than non CHD. We eagerly await the revised MET values for the ISWT.

Tim Grove Imperial College Healthcare Trust, Londonpresented an abstract on changes in the oxygen pulse ratio at each stage of the Chester step test following a 12 week MYAction Cardiovascular Prevention and Rehabilitation programme. Concluding that following the MyAction programme, there was a 2.8ml/kg/min and 55 second improvement in VO2max and CST respectively, demonstrating that the use of the O2 pulse ratio provides transparency on the physiological changes following the programme and can also be used to help patients recognise the benefits of exercise training.

Dr Mike Fisher Consultant Cardiologist Royal Liverpool University Hospital and Cardiothoracic Centre Liverpool. His talk was on ‘Exercise and the heart - How much is too much?   He explained that exercise, or lack of it, is an important factor in whether or not you develop CVD.  His studies have shown that exercise encourages laminar blood flow in blood vessels (rather than turbulent flow) which encourages nitric oxide, which in turn improves endothelial function.  He also spoke of how adipose tissue is an inflammatory organ which leads to increases in CRP and an increase in the risk of ACS.  It is therefore important to encourage weight loss where appropriate to aid the reduction in this inflammatory process.

 

Professor Peter Brubaker, PhD, Professor in the Department of Health and Exercise Science at Wake Forest University, Winston-Salem, NC discussed Exercise for Cardiovascular Disease Prevention, titled, Are they getting the Right ‘dose’?

He advised that the traditional FITT principle for prescribing exercise is being replaced by a new paradigm of exercise prescription that centers on the volume (dose) of physical activity. Epidemiology studies suggest that expending >1000 kcal/week is sufficient to decrease all cause mortality and cardiovascular mortality but exceeding >2000 kcal/week is necessary for disease regression and significant weight loss.  Unfortunately, most cardiac rehabilitation participants do not achieve this. Our programmes should focus on tools that allow patients to reach theses activity goals and should include behavior orientated goal setting, self monitoring and consideration of devices such as accelerometers and pedometers to facilitate this.

The final session of the day was presented again by Dr Jenny Adams. This lively presentation was an excellent finish to the day and discussed her abstract of incorporating specificity of training in a Cardiac Rehabilitation Setting. She stated that exercise professionals should ask patients about the activities that are important to them and then develop exercises that will help patients meet these goals. A case by case approach from fire-fighters to basket-ball players demonstrated how we can be inventive to make our exercise sessions more ‘specific’ to the individual’s job or hobby.

Key Messages to take away:

1.     Our rehabilitation programmes should be specific for the individual

2.     We have a changing population and we too need to adapt to ensure we are meeting the needs of our clients

3.     HIT training is becoming more evidence based for our population

 

 


 

BACPR Exercise Professionals Group study day:

Challenges in heart failure in relation to physical activity and exercise

Friday 10th May 2013 - Aston University, Birmingham

BACPR-EPG were very pleased to welcome Peter Brubaker, past vice-president of the American Association of Cardiovascular Prevention and Rehabilitation (AACVPR), Professor Klaus Witte on behalf of the British Heart Foundation, as well as a number of cardiac rehabilitation practitioners with expertise to speak at this year’s Spring conference.

The aim of the day was to provide professionals with up to date evidence and guidance for patients with heart failure in order to assist them in gaining the most benefit from physical activity and exercise.

The delegates were welcomed by Samantha Breen, BACPR-EPG Chair and Jenni Jones, BACPR President then provided the opening address for the day.

Laura Burgess, a clinical lead cardiac rehab physiotherapist at Wythenshawe Hospital started the morning’s presentations with a review of the exercise evidence and current guidelines in heart failure (HF) in relation to the typical patient profile. Whilst the consensus is that exercise training is beneficial in HF, much of the research on which it is based has been carried out on participants who were younger and had less significant co-morbidity than the heart failure population seen typically in clinical practice. This mismatch between the research and the ‘real life’ clinical population, poses the question as to whether  the FITT targets currently recommended in standard CR guidelines apply to the typical HF patient seen in practice.

Peter Brubakercontinued with a presentation on the exercise lessons from HF ACTION. This was the largest randomized controlled trial of aerobic training in heart failure which aimed to determine the effect of exercise training (ET) on morbidity and mortality. The results indicated that ET significantly improves exercise tolerance and quality of life in heart failure. However the effect of ET on all-cause mortality and all-cause hospitalization were only marginally reduced compared to usual care. The major limitation to the trial was exercise adherence in the ET group with the average participant in this group only accruing 60 minutes per week of exercise rather than the goal of 120 minutes per week. It was seen that there was a dose-response relationship between the exercise volume and CV outcomes. In patients with HF a 1 MET-hr increase in the volume of exercise performed per week is associated with around a 5% lower estimated risk of all-cause death or all-cause hospitalization.

Paul Stern, a senior cardiac rehab practitioner in North Staffordshire, then spoke about assessment of the HF patient. Despite patients presenting with similar common symptoms, there is a huge variability in symptom severity and resulting limitations as described by the New York Heart Association (NYHA) classification of the disease. This broad spectrum, along with varying age, accompanying co-morbidities and the individual goals of HF patients makes working with this group of patients challenging. An initial assessment combining subjective and objective elements, including functional capacity testing and quality of life measures, is key to providing the appropriate exercise prescription, identifying exercise concerns and for developing patient-specific goals.

Ros Leslie, clinical specialist physiotherapist in Wolverhampton, continued with a presentation reviewing the current guidelines for exercise training. She highlighted that HF patients are typically older with low fitness levels (estimated at 5 METS or less). The delineation between rest, moderate and high intensity exercise is difficult to differentiate and patients are at risk of working in the high intensity zone.  Achieving the frequency, intensity and duration (FITT) targets as recommended in standard cardiac rehabilitation guidelines is difficult to achieve suggesting that these guidelines may need altering for the HF patient.

Samantha Breen, clinical lead physiotherapist in cardiac rehabilitation at Manchester Royal Infirmary continued with the challenges of prescribing exercise for the wide spectrum of HF patients. Exercise intolerance is a result of several factors: cardiovascular and peripheral muscle abnormalities and metaboreflex and ergoreflex activation. Using a case study approach Samantha compared an exercise prescription for a NYHA I patient to one with NYHA III heart failure. The prescription for each was very different.

Louisa Beale, Senior Lecturer in Sport and Exercise Science at the University of Brighton,  gave an oral abstract presentation of a study ‘Is cardiopulmonary exercise testing useful for exercise programming in patients with heart failure?’ For this research VO2 peak was assessed for seven HF patients during a cycle ergometer CPET and via ambulatory oxygen consumption during a group exercise class. It was discovered that during the exercise class the patients appeared to be exercising above their VO2 threshold, as determined by CPET, despite tolerating the exercise class well and showing an appropriate heart rate response. This raises the questions as to whether patients really were exercising above their max or was CPET not allowing  them to reach their max.

Adrian Roose, Exercise Physiologist from Southdene Primary Care Resource Centre, delivered the second oral abstract presentation on ‘ Increasing the uptake of cardiac rehabilitation for heart failure patients using an integrated service approach, and offering a goal orientated menu of choice’.  The Knowsley Cardiovascular Team recognising the importance of trying to increase the uptake of rehabilitation for HF patients, adapted their existing rehabilitation model to provide an integrated approach with the HF nurses ensuring patient centred, individualised, goal orientated approach. This included for example circuit-based classes, gym sessions, home exercise programme, telehealth, accelerometry, supervised walks and cycle rides. This new approach has resulted in a 10.59% improved uptake and a 66% completion rate.

The meeting broke for a lunch break which included the ACPICR and BACPR Instructor Network AGMs plus the opportunity to view the poster presentations and visit the exhibition stands presented by Care4today hearthealth, Human Kinetics, BHF, University of Chester, Imperial College, London and AstraZeneca.

Dr Klaus Witte, Senior Lecturer at the University of Leeds and Honorary Consultant Cardiologist at Leeds General started the afternoon sessions on the subject of heart rate and exercise intolerance in HF. A lack of heart rate rise (chronotropic incompetence) is regarded as a poor prognostic sign in those with HF but Dr Witte believes that this is not the case if it is medication induced and that a low heart rate is protective and may actually be a compensatory mechanism by which the failing heart preserves cardiac filling and therefore cardiac output.

Mark Campbell, Clinical Referral Manager employed by Blackburn with Darwen Borough Council continued with the topic of resistance training (RT) in heart failure. There is much evidence to support RT as a means to prevent the deleterious physical effect of losing muscle mass and muscle function such as that seen in heart failure. RT helps to maintain and develop fast twitch muscle fibres, promotes independence and improves quality of life. Mark showed that RT is safe and effective and beneficial in heart failure giving examples of his current practice via case studies.

Professor Peter Brubakerclosed the sessions with the topic of high intensity training  (HIT) in heart failure. There is growing evidence to suggest that moderate intensity continuous training may not provide the optimal stimulus given the pathophysiological derangements that limit HF patients. Mayer et (1997) has shown that three weeks of HIT in stable HF patients can provide intense muscle stimuli on peripheral muscle  with minimal cardiac strain necessary to reverse skeletal muscle abnormalities seen in heart failure. More recently Wisloff (2007) showed that 12 weeks of HIT produced improvements in exercise capacity, vascular function, mitochondrial biogenesis and neurohormonal activity. However despite no reported adverse events, safety and long term adherence of HIT remains a concern in HF patients and more research is needed.

Samantha Breen closed the day and was thanked for her work during her term as Chair of BACPR-EPG Steering Committee which has now come to an end. Gordon McGregor, Clinical Research Fellow at University Hospital, Coventry now takes over the role of BACPR-EPG Chair and is already planning next year’s study day.


 

BACPR Exercise Professionals Group Conference 2012

Meeting the Challenges in Diabetes and Exercise

Aston University, 11 May 2012

The BACPR EPG conference 2012 was a huge success. Over 120 delegates attended Aston University in Birmingham on 11 May from all over the UK and were representative of the cardiac rehabilitation multidisciplinary team.

This year’s study day focussed on meeting the challenges in diabetes and obesity in relation to physical activity and exercise.

Jenni Jones, BACPR President opened the conference by discussing the prevalence of both diabetes and obesity in the UK, putting into context where both these conditions fit in with the BACPR Standards and Core Components.

Dr David Stensel, from the school of Sport, Exercise and Health Sciences at Loughborough University gave an interesting presentation which discussed how the increasing prevalence of obesity appears to be driving an increase in type II diabetes. David discussed the role that physical activity has to play in reducing obesity and provided evidence to demonstrate that the less sedentary and fitter population are less likely to develop type II diabetes.

The following presentation by Dr John Buckley, Past President BACPR, built on the evidence presented in the previous session for energy imbalance leading to the development of obesity and subsequently diabetes. John discussed that the population is becoming increasingly sedentary both occupationally and in our home lives. John showed that there has been a decline in energy expenditure of approximately 175 Kcals a day in our working lives and double that decline in Kcals by being generally more sedentary. He concluded that the sedentary nature of our lifestyles was contributing to the energy imbalance irrespective of the lack of participation in exercise and sport and therefore our management strategies should also concentrate on health behaviour to reduce sedentary time. John also gave us an insight into how the current guidelines for the management of diabetes and obesity are confusing.

The second session of the morning was dedicated to the management of diabetes. Dr Ian Gallen, Consultant Physician and Endocrinologist in Buckinghamshire has a specific interest in the management of diabetes and sport. His session focused on the management of the Type I diabetic and was an excellent and informative session on clinical management strategies to maintain glycaemic control during and after exercise. Dr Gallen showed through these strategies he had helped to normalise physical performance in many athletes who had gone on to achieve huge successes in their chosen sport.

Dr Frank Joseph, Consultant Physician and Endocrinologist, Chester followed with an entertaining session in which he discussed advances in both blood glucose monitoring and the management of diabetes. Dr Joseph discussed how and when monitoring should be done. He highlighted that it was essential for individuals to have knowledge of their fluctuations in blood glucose levels in order to adjust their carbohydrate or insulin intake accordingly, particularly in relation to exercise. He concluded that a rigid regime is not acceptable and glucose management must be individualised.

The afternoon session focussed on obesity and sedentary behaviour. Professor Stuart Biddle, Professor of Physical activity and Health at Loughborough University provided extensive evidence for sedentary behaviour being associated with poor health outcomes. Professor Biddle defined sedentary behaviour, explaining that time spent lying and sitting was different to low levels of physical activity. He discussed potential management strategies to reduce sedentary time, but highlighted that sedentary behaviour is very difficult to change as it has a strong habitual element. This message from this presentation will certainly change current practice of engaging individuals to participate in physical activity and exercise to meet the guidelines to also include strategies to habitually reduce their sedentary time.

The final session of the day was presented by Dr Jason Gill, Reader in Exercise Science, University of Glasgow. This lively presentation was an excellent finish to the day. Dr Gill summarised the evidence for obesity and its link to diabetes and cardiovascular disease. He focused on how obesity is difficult to manage and as physical activity only induces moderate weight loss in the obese it can be very demotivating for the patient. Dr Gill provided evidence that exercise will induce substantial fat loss particularly in the visceral region even without weight loss. he proposed as a management strategy that we should shift our emphasis from weight loss a primary outcome to focus on getting people more active in combination with a healthy eating plan.

 

Three key messages from this conference:

  1. Reduce sedentary time
  2. Individualised regimes are essential to maintain glycaemic control
  3. Focus on getting people active rather than loosing weight

If you are interested in reading about the evidence behind these messages, the presentations are available to download on the BACPR website using the following link: http://www.bacpr.com/pages/page_box_contents.asp?pageid=861&navcatid=173

The evaluations from the delegates demonstrated that the day was a resounding success which provided much information and take home messages. Copies of the presentation can be accessed from the member only section of the BACPR website.