Prehabilitation interview Flashcards
1
Q
What Cardio-Pulmonary Exercise Testing Value is indicative of low physical function?
A
<80% of age predicted maximum
2
Q
What peak oxygen consumption value is determine high risk and very high risk for peri-operative complications?
A
High risk: 10-14 ml/kg/min
Very high risk <10ml/kg/min
3
Q
What VO2 at the anaerobic threshold is considered high and very high risk for post-operative complications?
A
High risk: <11ml/kg/min
Very high risk: <9ml/kg/min
4
Q
What ventilatory efficiency slope is considered very high risk and high risk for post-operative complications?
A
High risk: 34-36
Very high risk >36
5
Q
How is the anaerobic threshold physiologically related to outcomes in cancer patients
A
Oxygen demand increases 10 to 50% from surgery. Anaerobic metabolism can exacerbate tissue injury and indicates decreased ability to deliver and oxygen impairing tissue perfusion.
6
Q
How is the VE/VCO2 slope physiologically related to outcomes in cancer patients?
A
Ventilatory efficiency reduces increasing demand on the heart to make up for it. Anaesthetic can depress ventilatory drive which if already poor can lead to hypoxemia.
7
Q
What are the 10 absolute contraindications to to symptom-limited maximal exercise testing?
A
1) Acute myocardial infarction (within 2 days)
2) Ongoing unstable angina
3) Uncontrolled cardiac arryhythmia with hemodynamic compromise
4) Active endorcaditis
5) Symptomatic severe aortic stenosis
6) Decompensated heat failure
7) Acute pulmonary embolism, pulmonary infarction or DVT
8) Acute myocarditis or Pericarditis
9) Acute aortic dissection
10) Physical disability precluding safe or adequate testing
8
Q
What are the 8 relative contraindications to symptom limited maximal exercise testing?
A
1) Left main coronary artery stenosis
2) Asymptomatic aortic stenosis
3) Tachyarrhythmia with uncontrolled rate
4) Acquired advanced or complete heart block
5) Recent stroke or TIA
6) Mental impairment with limited cooperation
7) Resting hypertension >200 mmHg or diastolic >110 mmHg
8) Uncontrolled medical conditions such as significant anaemia, important electrolyte imbalance and hyperthyroidism
9
Q
What is the range of moderate intensity for a treadmill and bike in terms of speed?
A
Treadmill: 3.0-4.5mph
Cycling: 9-15 mph
10
Q
Briefly outline the methods and results from Mandsager (2018) in the JAMA journal and the 2 main findings
A
Method: 122 007 patients with a median follow up of 8.4 years
Result:
1) Top 2.5% 5 fold all-cause mortality vs. bottom 25%
2) Below vs. Above: 41% CRF, 41% Smoking, 40% Diabetes - Risk Adjusted decreases in all cause mortality
11
Q
Briefly outline the methods and the main results from the paper “Physical fitness and activity as a separate heart disease risk factor: a met-analysis” Williams 2001 - Medicine and Science
A
- Method: Meta-analysis in 23 cohorts (16 activity, 7 fitness)
1) Physical fitness about 65% relative risk reduction and physical activity 25% at the top end
2) Significant difference between the two at all quartiles
12
Q
What signs and symptoms immediately require medical referral?
A
1) Pain
2) Dyspnea
3) Dizziness
4) Orthopnea
5) Edema
6) Palpitations
7) Intermittent claudication
13
Q
What two situations is medical clearance needed?
A
1) Known CV, metabolic and renal disease with no previous activity
2) Any signs and symptoms suggestive or CV, metabolic or renal disease with or without previous PA
14
Q
How should a exercise programme start for someone with no exercise history?
A
Light to moderate exercise intensity
15
Q
Based on HRR, RPE and effort - define light activity
A
30-39% HRR, RPE 9-11, Barely noticeable increase in breathing
16
Q
Based on HRR, RPE and effort - define moderate activity
A
40-59% HRR, 12-13 RPE, Noticeable increase in HR and breathing
17
Q
Based on HRR, RPE and effort - define vigorous activity
A
> 60% HRR, >14 RPE, substantial increases in hear rate
18
Q
What is the equation for heart rate reserve
A
HRR = Maximum Heart Rate - Resting Heart
= Heart Rate Reserve
(Heart rate reserve x training %) + resting heart rate = Intensity
19
Q
What 8 criteria would identify patients who require a specialist intervention if one is met?
A
1) LVEF <40%
2) Survivor of cardiac arrest
3) MI or Cardiac Surgery with post-intervention ischemia
4) Abnormal hemodynamics with exercise
5) Exercise intolerance symptoms <5.0 METs
6) Significant silent ischemia (>2mm depression)
7) Functional capacity <5.0 METs
20
Q
What are the 8 risk factors for CVD?
A
1) Age: >45 Men, >55 Women
2) Family history
3) Cigarette smoking
4) Physical inactivity
5) Obesity (BMI: >30 kg/m2, WC >40 inch M or >38 inch W)
6) Blood pressure: >130/>80 (Either)
7) Dyslipidaemia: LDL>130 mg/dL, <50 mg.dL HDL
8) Blood glucose >100 mg.dL (fasting value)
HbA1C >5.7%
21
Q
Where is waist circumference measured from
A
Above the belly button but below the ribs - narrowest point
22
Q
What 8 elements should be included when providing informed consent
A
1) Informed of programme
2) Purpose of test
3) Risks
4) Responsibilities
5) Benefits to be expected
6) Inquiries
7) Statement of confidentiality
8) Freedom of consent
23
Q
What 7 elements does a comprehensive fitness evaluation
A
1) Informed consent,
2) Preparticipation health screening
3) Resting measures
4) Circumference and body composition
5) Measurements CRF,
6) Measurement muscular fitness
7) Measurement of flexibility
24
Q
What intensity must heart rate be maintained at for the Astrand 6 minute cycle/arm test
A
125-170 bpm
25
What is average fitness on a cycle ergometer test for a 60-69 year old male?
22.4 ml/kg/min
26
How does VO2 peak decrease with age?
10-15% per decade
27
How does VO2 peak differ with gender?
20-30% lower for age standardized rates in women
28
How should flexibility be measured?
Goniometer: Lay flat on a bench or sat in chair and measure angle
29
Describe the time up and go test
Sit in a chair, get up and walk around a cone 3 metres away. Come back and sit back down
30
What stances are performed on a Berg Balance Test and how
Eyes closed
1) Feet side by side
2) Non-dominant foot
3) Tandem stance
4) Same positions on foam pad
31
What score is considered normal and of increased fall risk on the timed up and go test?
Normal: <10 seconds
Falls risk: >12 seconds
32
What 7 tests outline the senior fitness test and how long does it take to complete?
30 minutes
1) 30s chair stand
2) 30s arm curl (5/8lb DB)
3) Timed up and go
4) 6 minute walk
5) 2 minute step test
6) Back scratch
7) Sit and reach test
33
What score is considered poor on the senior fitness test?
Bottom 25% percentile for age based norms
34
What is a good assessment of muscular power?
1) How quickly you can do a set number of sit-to-stands
35
How is aerobic exercise progressed?
1) 5-10 minutes -> Every 1-2 weeks - Over 4-6 weeks
2) Gradually taper up over 4-8 months+
36
What are the resistance training recommendations for strength and hypertrophy?
1) 60-70% 1RM for 8-12 repetitions
2) 40% sufficient in novice
3) 70-80% 1RM, 8-12 repetitions best
37
What are the recommendations for power training?
1) 0-60% 1RM for lower body
2) 30-60% 1RM for upper body
3) 1-3 sets trying to move weight as quickly as possible
38
What are 4 goals of outpatient cardiac and cancer rehabilitation
1) Implement PA routine
2) Supervision to detect change in clinical status
3) Return to vocational and avocational activity
4) Optimise other lifestyle and medication factors
39
What are the 13 contraindications for cardiac rehabilitation
1) Unstable angina
2) Uncontrolled hypertension
3) Orthostatic hypotension
4) Aortic stenosis
5) Uncontrolled arrhythmia
6) Sinus tachycardia >120bpm
7) Uncompensated HF
8) Active pericarditis or myocarditis
9) Recent embolism
10) Systemic illness or fever
11) Uncontrolled diabetes
12) Severe psychological disorder
12) Metabolic disorder: Hypokalemia, Hyperkalemia, Hypovalemia
13) Severe psychological disorder
40
How might the type of resistance exercise be adapted in PAD patients?
Focus on lower limbs if time limited
41
What 3 adverse responses to inpatient exercise require termination
1) DBP >110 mmHg
2) SBP >10 mmHg drop with increasing workload
3) Exercise intolerance
42
What are the 6 key signs and symptoms of exercise intolerance?
1) Chest pain
2) Dizziness
3) Shortness of breath
4) Palpitations
5) Weakness
6) Excess fatigue
43
What are the four exercise training considerations in a stroke patient?
1) Avoid Valsalva Maneuverer
2) Treadmill starts slow (0.8mph) and harness provided
3) No age predicted calculations
4) Affective issues: Memory, Mood, Confusion
44
What are the resistance training FIIT principles for a stroke patient?
F: 2 non-consecutive days
I: 50-75% 1RM
T: 1-3 sets : 8-15 reps
T: Safest exercises
45
How might stroke exercise be adapted to stroke patients wanting to return to work?
Assess patients physical environment and design prescription specific to his work demands
46
What 4 elements should be considered when designing a exercise programme for a CVD patient?
1) Ischemic threshold
2) Musculoskeletal limitation
3) Cognitive impairment
4) Exercise capacity
47
What 6 strategies can improve enrolment to Prehab or CV referral?
1) Automatic referral
2) Inpatient liaison
3) Home-based option
4) Flexible hours
5) Appointment pre-discharge
6) Audit referral system
48
What 3 avenues are there for setting goals in CR?
1) Premorbid activity level
2) Vocational and avocational goals
3) Personal health and fitness goals
49
What are the aerobic FIIT principles for HF patients?
F: 3-5 days
I: 40-50% HRR, progress to 70-80%
T: 20-60 minutes/day
T: Large rhythmic movements
50
What are the aerobic FIIT principles in outpatient CR
F: 3-5 days/weeK
I: 40-80% HRR, RPE 12-16
T: 20-60 minutes/day
T: Large rhythmic muscle
51
What two main reasons heart failure patients have a low anaerobic threshold?
1) Vasodilation of large and small vessels reduced limiting blood flow
2) Limited oxidative capacity in musculature due to smaller muscle and mitochondrial dysfunction
52
How does inflammation in heart failure and cancer affect mitochondrial function?
Ischemic conditions release pro-inflammatory cytokines that disrupt oxidative phosphorylation
53
What are the aerobic FIIT recommendations for PAD?
F: 3-5 days
I: 40-59% HRR, Moderate pain (3-4/10)
T: 30-45 mins/day progress to 60 in 12 weeks
T: Weight bearing (free-or treadmill walking) intermittent exercise with seated rest when moderate pain is reached.
54
What is a slow rate of intensity progression on a bike or treadmill test?
0.5 to 2 METs every 2-3 minutes
55
What HIIT protocol did Wisloff (2007) use in the circulation Journal and what was the result?
- 30s-4 minute work, 85%-90% HRR, 1-3 minute at 50-70% HRR
- 48% in stable HF symptoms
56
What medications considerations are there in CV patients
Beta blocker: Attenuated heart rate response
Diuretic: Hypotension - Monitor for dizziness and educate on hydration
57
What are the resistance training FIIT principles in HF patients?
F: 1-2 days
I: 40% 1RM, 50% 1RM lower body. Increase to 70% 1RM over weeks to months
T: 1-2 sets, 10-15 reps - major muscle groups
T: Weight machine, dumbbells, elastic bands, and/or bodyweight
58
What are the guidelines for COPD patients in from the Global Initiative for COPD patients in determining severity?
All: FEV1/FVC <0.7
Mild: >80% age predicted
Moderate: 50-80% age predicted
Severe: 30-80% age predicted
Very severe: <30% age predicted
59
What is the minimum clinical important difference on a 6MWT
30 metres
60
What specific test termination criteria is there is COPD patients for CPET
<80% peripheral capillary oxygen desaturation (SPO2)
61
How does exercise intensity defer between mild and moderate to severe COPD?
- Mild COPD can use healthy adult guidelines
- Moderate to Severe <60% peak work rate
62
What 3 exercise training considerations are there in COPD patients?
1) Interval training for symptoms
2) Moderate breathlessness (3-6 Dyspnoea scale considered)
3) HIIT: Ventilatory limitation at peak exercise co-incides with significant metabolic reserves
4) Flexibility exercise for thoracic mobility and lung function
63
What should oxygen saturation be maintained above in COPD and how can it be helped?
- 88-92%
- Bronchodilation techniques
- Pursed lip breathing
- Supplemental oxygen
64
What are the 3 types of inhaler and name the brand and medical name for each
1) Short acting beta-agonists: Albuterol (Ventolin)
2) Long-acting beta-agonists: Formoterol (Forail)
3) Long-acting muscarinic antagonists: Umeclidinium (Incruse Elipta)
65
What are the risks with short-acting inhalers before exercise?
Tachycardia and Palpitations if used in too high a dose
66
What are the aerobic FIIT principles for COPD patients
F: 3-5
I: 50-80% peak work rate of 4-6 BORG CR10 scale
T: 20-60 minutes at mod to high intensity.
T: Common aerobic activity
67
What are the resistance training FIIT principles for COPD patients?
F: 2+
I: Strength 60-70% 1RM, >80% 1RM for experienced. Endurance <50% 1RM
T: 2-4 sets, 8-12 repetitions (Strength) -
2 or less sets 15-20 repetitions (Endurance)
T: Weight machines, Free weight, or body weight exercises
68
What are the 5 exercise testing considerations in patients with Arthritis?
1) Acute inflammation - no test
2) Cycle/Arm ergometer
3) Warm-up
4) BORG CR10 for pain measure
5) Neural inhibition due to pain limits maximal strength
69
What are the FIIT recommendations for aerobic exercise in individuals with arthritis?
F: 3-5 day/week
I: Moderate to vigorous (40-80% HRR) as tolerated
T: 150 minutes moderate or 75 minutes vigorous or equivalent combination in bouts of 10 minutes or more
T: Low joint stress such as walking, cycling, swimming or aquatic exercise
70
What are the FIIT recommendations for resistance exercise in individual’s with arthritis
F: 2-3
I: 60-80% 1RM or 50-60% 1RM in those unaccustomed
T: Healthy adults values: 8-12 repetitions, 1-3 sets for all major muscle groups
T: Machine, free weight, resistance bands, tubing, body weight
71
What are the 5 exercise training implications for individual's with arthritis?
1) Improve CRF without joint pain
2) Start with movement of 5 minutes or less in some
3) Flexibility training enhances ROM and counteracts negative effects of arthritis
4) Balance training as individuals at increased falls risk
5) 5-10 min warm-up and cooldown critical for reducing pain
72
Outline how balance training might take place?
Balance training (pain, coordination, protective reflex, proprioception) as individuals at increased falls risk including static (standing on one foot) and dynamic (walking, changing direction, stepping over obstacles)
73
Why is resistance training important for individuals with arthritis?
Reduces chronic pain through local (enhanced dynamic stability, attenuated joint forces) and systemic changes (decreased inflammation, elevated endogenous opioids)
74
What are 5 special considerations for arthritis patients?
1) Acute flare up = No exercise
2) Education: DOMs vs. Joint pain
3) Replace exercises for pain
4) Exercise during pain med peak
5) Appropriate shoes
6) Functional exercises (balance)
75
What are some example of functional exercises that may help with neuromuscular control and improve balance?
Sit-to-stand, Step-ups, Stair-climbing, Carrying to improve neuromuscular control, balance, and enhanced ability to perform ADLs
76
Name exercises that improve neuromuscular control
Balance: Single-leg balance with eyes open/closed
Single-leg balance on a foam pad or unstable surface
Single-leg deadlifts
Lunges: Forward lunges
Reverse lunges
Lateral lunges
Curtsy lunges
Gait training: Walking lunges
High knees
Butt kicks
Grapevine steps
Functional squats:
Bodyweight squats
Squats with medicine ball toss
Split squats
Pistol squats (advanced)
Core exercises:
Planks (front, side, and variations)
Bird-dog exercise
Pallof presses
Russian twists
77
What are the diagnostic criteria for pre diabetes and diabetes mellitus?
Normal: HbA1C: 5.7-% (38 mmol) FPG: 100-mg.dL
Diabetes: HbA1C: 6.5+ (48 mmol) FPG: 126 mg.dL
Pre diabetes: HbA1C: 5.8-6.4% FPG: 100-125 mg.dL
78
What is a exercise testing consideration in patient with T2DM
Silent ischemia often goes unnoticed
79
Briefly outline the methods and 2 key results from Young (2014) in the Journal of Sports Medicine
Method: Systematic review of 12 trials
Results: Equal when individual exercise intervention but best when combined
80
What is vigorous intensity particularly important in this population?
Vigorous intensity - CRF particularly tied to good outcomes in this population
81
What are 3 exercise training considerations are important in patients with diabetes?
1) Increased risk tendinopathy so progress slowly - frequency last
2) Limited mobility due to glycation of collagen
3) Increase resistance only after exceeding target rep number
82
What 2 exercise methods can regulate blood glucose in patients with DM?
1) Resistance training prior to aerobic training
2) Vigorous exercise in short bouts
83
What 4 neuropathies need managing in patients with diabetes?
1) Retinopathy: Increased work of Virteous haemorrhage
2) Autonomic neuropathy: Chronotropic incompetence and Anhydrosis
3) Peripheral neuropathy: Dodgey feet
4) Nephropathy: Low fitness
84
Name 3 methods to reduce post-exercise hypoglycaemia in patients take insulin?
1) Long acting insulin
2) Increase carb intake
3) Blood glucose monitoring
85
What is the cut off value for hypoglycaemia and what would this mean for exercise?
<70 mg.dL - no exercise until rectified
86
What are 3 moderate and 3 severe symptoms of hypoglycaemia?
Moderate: Abnormal Sweating, Anxiety, Shakiness
Severe: Headache, Confusion, Visual Disturbance
87
How might thermoregulation be effect in diabetic patients?
1) Polyuria secondary to hyperglycaemia compromises thermoregulation
2) Autonomic neuropathy - unable to sweat
88
What is considered severe hyperglycaemia and what does this mean for exercise?
a) >250 mg.dL
b) Only moderate exercise - postpone if ketones present
89
What are the high cut-off values for LDL-C, HDL-C and Triglycerides
LDL-C: <100 / >160 mg.dL
HDL-C: <40 / <50 mg.dL
Triglycerides: <150 / >200 mg.dL
90
How might the quantity of exercise differ in dylipidemia?
a) Maximise caloric expenditure --> Up to 250-300 minutes/week
91
What is considered a moderate and vigorous weight lifting intensity based on 1 rep max in the 8-10 rep range?
a) 50-69% Moderate
b) 70-85% Vigorous
92
What is a safety consideration for a patient on Statin Therapy and what should be done?
Myalgia: Muscle weakness and Injury: Severe muscle injury - contact healthcare provider
93
What is the definition of hypertension?
- SBP >130 mmHg
- DBP >80 mmHg
Two reading on two separate days
94
What 6 lifestyles are recommended for hypertension?
1) Smoking cessation
2) Moderate alcohol consumption
3) Weight managements
4) Habitual PA
5) Reduced salt intake
6) Overall healthy diet
95
What are 3 exercise testing considerations for individuals with hypertension?
1) Medical BP management until <140 / 80 for testing and training
2) Anti-hypertensive medications need to be considered if prescribing (vasodilation)
3) Diuretic therapy increases false positive test result
96
What are the stages of hypertension?
Elevated: 120-129 / 80
Stage 1: 130-139 / 80-89
Stage 2: 140+ / 90+
Hypertensive crisis: 180+ / 120+
97
What is the most common ACE-Inhibitor and a potential issue faced during exercise?
Lisonpril: Sudden drop in BP - Cool down slowly
98
What 3 things does the ACSM position stand say exercise can do for hypertension?
1) Reduced SBP (7 mmHg) and DBP (5 mmHg)
2) Reduces SBP at submax workloads
3) Regression of cardiac wall thickness and left ventricular mass
99
What are the FIIT principles for aerobic exercise in patients with hypertension?
F: 5-7/days/week
I: 40-59% HRR or 12-13 or 6-20 scale
T: >30 minutes of continuous or accumulated exercise
T: Prolonged rhythmic activity focusing on major muscle groups
100
What are the FITT principles for resistance exercise in patients with hypertension?
F: 2-3 days/week or more
I: 60-70% 1RM progressing to 80%, 40-50% 1RM progressing for novice or older exercisers
T: 2-4 sets, of 8-12 repetitions or each of the major muscle groups per session to total 20 minutes or more with rest days interspersed
T: Resistance, machines, free weight, resistance bands, and/or functional body weight exercises
101
What are the exercise considerations for patients with hypertesion
1) Moderate: Benefit to Risk
2) Valsalva manoeuvre
3) Exercise below 220 systolic and 105 diastolic
4) Progression should be gradual particularly intensity
102
What is the metabolic syndrome criteria?
3 or more of the following
1) WC
2) T2DM
3) Dyslipidaemia
4) Blood pressure
103
What does the IDF recommend as a recommendations for weight loss and what level produces maintained improvement?
5-10% weight loss in 1 years
3-5% maintained weight loss
104
Why is exercise important for weight loss and when might it's effect be reduced?
- Exercise and diet produce extra 3kg loss
- Benefit lost with severe deficit
105
What does the ACSM state about exercising for weight loss?
>150 minutes/week result in moderate loss (2-3kg)
225-420 significant (5-7.5 kg)
106
What are 3 exercise testing considerations for someone who is overweight or obese?
1) Leg or arm ergometry in severely obese
2) Equipment must be calibrated
3) Appropriate cuff size
107
What is a poor score for usual gait speed
<0.8 m/s
108
What are the FIIT principles for aerobic exercise in older adults?
F: >5 days/week moderate intensity, >3days a week vigorous intensity or a combination of the two
I: 0-10 scale. 5-6 for moderate intensity and 7-8 for vigorous intensity
T: 30 min/day moderate, 20-30 min/day vigorous or combination of the two
T: Any activity that does impose excessive orthopaedic stress
109
What are the FIIT principles for resistance exercise in older adults?
F: >2 days/week
I: Progressive from light intensity 40-50% 1RM, to 60-80% 1RM or 5-6 or 7-8 RPE scale
T: 8-10 exercises involving major muscle groups, >1 set of 10-15 repetitions for beginners. progress to 1-3 sets for 8-12 repetitions for each exercise
Power training: 6-10 repetitions with high velocity
T: Progressive or power weight training if weight-bearing calisthenics, stair climbing, or other strengthening activities that use major muscles
110
Name the PD warrior exercises you may use in PD and with older adults
Sky reach, Scarf Snatch, Overhead ball throw, Banded side steps, Over the river, Tah Dahs
111
What are the 7 nutritional considerations that should be made in the pre-operative setting
1) Micronutrients: Support immune function
2) Calories: Anabolic stat/Energy
3) Protein: Anabolism
4) Hydration for blood pressure and glucose
5) Body fat - maintenance
6) Omega-3 anti-inflammatory effects
112
What is the impact of anaesthetic?
- Impairs insulin signalling: Muscle loss and Increased blood glucose
113
When would you refer someone for nutritional support?
- PG-SGA: >9 or >5
- BMI <18.5 ml/kg/min
- 10-15% unintentional weight loos in previous 6 months
- Anyone who has significant reduction in appetite
114
What are the protein and calorie requirements in the pre-operative setting?
a) 1.2-1.5 kg/day in typical patients
b) 1.5-2.0 kg/day with significant wasting
c) 25-30 kcal/day
115
Name 6 indicators of malnutrition
1) BMI <18.5 kg/min2
2) Energy intake: <25-30 kcal/kg/day
3) Handgrip strength <30kg men, <20kg women
4) Gait speed below 0.8m/s or other functional impairment
5) 10% 6 months +, 5% 3-6 months
116
How might meals be structured in pre-op setting?
30g intake, 3 times/day with additional 20g supplement
117
What 6 benefits does Prehab before the operation
1) Improved fitness
2) Improved patient experience
3) Improved fatigue
4) Improved frailty
5) Active involvement
6) Set expectations
118
What 3 benefits does Prehab have in the peri-treatment setting
1) Improved tolerance to treatment
2) Reduced complications/side effects
3) Improved quality of life
119
What 4 benefits does exercise have post-operatively?
1) Reduced length of stay
2) Reduced complications
3) Reduce contact with primary care
4) Reduced burn on carers
120
What 5 long-term benefits does Prehab have?
1) Reduced risk of recurrence
2) Improved survival
3) Return to life roles (QOL)
4) Reduced impact of late effects (fatigue/incontinence)
5) Sustained lifestyle change
121
What is the definition of cancer Prehabilitation?
“A process on the cancer continuum of care that occurs between the time of cancer diagnosis and the beginning of acute treatment and includes physical and psychological assessment that establish a baseline level, identify impairments, and provide interventions that promote physical and psychological health to reduce the incidence and/or severity of future impairments”
122
Outline the methods from Jensen (2014) Scandinavian Journal of Urologyand the results
Method:
- 107 patients - prospective randomized controlled trial
- Aerobic and strength 2 weeks before surgery
Results:
- Improved mobilisation and ability to perform daily activities 3 weeks post
- No change in LOS or post-op complications
123
What did Minella do and find (2017) in the paper titled "Multimodal prehabilitation improves functional capacity before and after colorectal surgery for cancer: a five-year research experience"
Method:
- 185 participants performing trimodal prehabilitation vs. rehab only
- Changes in 6MWD before surgery, at four and eight weeks were compared between groups.
Result: 6MWD 17.0 vs. -8.8 and 6 weeks follow up
124
What did Silver and Baima find when looking at Prehabilitation in orthopaedic conditions?
1) Increases functional capacity
2) Improves quality of life
3) Decreases depression
4) Reduces hospital length of stay
5) Increases physical fitness
6) Reduce complications
7) Less costly per patients then standard care
125
What are the issues with hypertension and diabetes in cancer patients?
1) Delayed wound healing
2) Impaired immune function
3) Increased risk of kidney dysfunction, respiratory events, and cardiovascular events
126
What was found by Thomas and Goldsmith (2016) in the cardiovascular thoracic journal and outline the methods
Method:
- Multimodal prehabilitation including respiratory exercise
- 42 patients with dyspnea for lung resection
Results:
- Postoperative complication rate 5.3% vs 37.5% and mean length of hospital stay 8.7 days vs 10.3.
127
What did Dunne and Colleagues (2016) find in the British Journal of Medicine and outline how they found it?
Method:
4-week (12 sessions) high-intensity cycle, interval training programme in patients undergoing elective liver resection for colorectal liver metastases.
Results: Improvements in anaerobic threshold (+1·5 ml per kg per min) peak VO2 (+2·0 ml per kg per min) and O2 pulse.
- SF-36 increased 95%
128
Identify 6 research gaps in the Prehab evidence
1) What is the best practice in prehabilitation
2) What is the Macmillan model for prehab
3) Who and who should fund prehab
4) Evidence of outcomes for each intervention not just PA
5) Who is best placed to provide prehab, who can realistically provide prehab
6) What are the potential cost saving that can be made
129
What are 8 core soft-skills a exercise professional needs when working with patients?
1) Be encouraging
2) Friendly
3) Knowledgeable
4) Good communication skills
5) Be genuinely proud of patients
6) Supportive of progressive (new ideas)
7) Show empathy
8) Don’t push patients too hard can lead to disengagement
130
What 10 things does Macmillan suggest as beneficial psychological interventions?
1) Hydrotherapy
2) Body image
3) Mindfulness
4) Tai Chi
5) Motivation interviewing
6) Art and music therapy
7) Social coping
8) Behaviour change development
9) Sleep hygiene
10) Healthy conversation
131
What did the systematic review from Pouvels (2014) in the international journal of surgery titled: Pre-Operative exercise for elective abdominal surgery
Method: 6 studies
Result: Improvement in physical fitness across most and chest physio reduces pulmonary complications
132
What did Tismopoulou (2014) find regarding "Psychological intervention in Prehab"
Method: 7 studies
Result:
- Interventions did not affect traditional surgical outcomes
- Psych interventions positively affected patients’ immunologic function.
133
What was found in the Belfast Physio study and how did they find it?
Method: 18-month pilot study starting in 2015 funded by Prostate Cancer UK who treated 131 men.
Result: Improvement in incontinence: 50% were performing the pelvic floor exercises incorrectly
134
What are the 3 key principles of prehabilitation?
1) For all
2) Person-centred
3) Process on the continuum of care
135
What 4 steps of prehab lead to better improvement then standard care?
1) Greater supervision with more professional involvement
2) Greater motivation and engagement
3) Better compliance
4) Improved outcomes and patient experience
136
What did the Southampton study titled Patients experience of exercise and cancer. Informing WESFIT Pilot Patient Involvement Report Feedback to participants (2017) show
1) Joint-decision making essential
2) Patients like fitness monitoring score
3) Need support for safe return to exercise
137
What are the 3 stages of core recovery and the exercises involved?
1) Engage: 5 days post - Long squeeze/Quick flicks
2) Activate: 3-6 weeks - Knee rolls - Seated knee lifts - Bridge
3) Strengthen: 6 weeks + - Bridge with leg lift- Bridge with Pillow balls squeeze - Bird dog
138
Outline the four main stage of cancer rehabilitation
1) Preventative (Prehab)
2) Restorative (Rehab) - Return to pre-illness
3) Supportive: Aim to limit functional loss on treatment
4) Palliative: Reduce complications and symptom management
139
What did the Macmillan cancer report titled: “What motivates people with cancer to get active? Understanding the motivations and barrier to physical activity in people living with cancer (2015)” show
1) Individual drivers
2) Social network
3) Physical symptoms
4) Physical environment
140
What is the issue with anaemia and what's foods can you eat to help?
- Increases need for pre-operative transfusion
- Significant fatigue and cardiac complications
- Legumes, Shellfish/Fish, Red Meat, and Spinach, Turkey
141
What are 3 breathing exercise recommendations?
1) Focus Breathing
2) Diaphragmatic Breathing
3) Pursed lip breathing
142
What was found in the London PREPARE programme?
1) Reduced LOS from 12 to 8 days
2) Prevented deterioration during neo-adjuvant (pre/post-op)
3) Reduced post-op complications
4) Physical capacity 4.6-5.1 METs
5) Reduced incidence pneumonia 60% to 29%
6) Improved self-confidence
143
What elements are always, often, and sometimes seen in the current prehabilitation services?
Always: Physical activity
Often: Dietary support
Some-times: Anaemia management, Smoking cessation/Alcohol reduction, Respiratory exercises, Lymphoedema management, Medication and comorbidities review
144
What are the 4 interventions outlined by the European Journal of Nutrition Metabolism for cancer patients?
1) Nutrition counselling
2) Oral nutrition supplements
3) Artificial nutrition
4) Drug therapy
145
What are four key elements first outlined in the Macmillan guidelines
1) Promotes healthy behaviour
2) Less vulnerable to side effects
3) Interventions are safe and welcomed
4) Prehabilitation sits in broader context of rehab
146
What are the 8 benefits of prehabilitation?
1) Reduce length of stay
2) Improve cardiorespiratory fitness
3) Enhance recovery following treatment
4) Improve nutritional status
5) Reduce post treatment complications
6) Improve aspects of neuro-cognitive function
7) Provide a teachable moment to enable smoking and alcohol cessation
8) Enhance quality of life
147
What are the governing bodies involved in principles and guidance for prehabilitation in people with cancer?
1) National institute of health research: Nutrition and cancer collaboration
2) Royal college of anaesthetists
3) Macmillan
148
What are the 4 key underlying themes in prehabilitation
1) Underpins whole pathways
2) MDTs need prehab representation
3) PPCP's - Includes screening/assessment to identify needs and tailor intervention
4) Interventions should start as early as possible
149
What 3 things does the document say about screening?
1) Should occur as early as possible
2) Uses validated tools
3) Aligned to holistic needs assessment - including psychological risk factors, physical fitness, and nutrition
150
What does screening help us do in Prehab?
Screening
- Identifies individual's at high risk of peri-operative complications
- Screening helps determine eligibility for prehabilitation programs and guides the selection of appropriate assessment tools.
- Helps triage patients and prioritize those who are most likely to benefit from prehabilitation interventions.
151
What is the importance of assessment interventions in patients with cancer?
- Informs the individualised prescription of exercise, nutrition, and psychological interventions
152
What methods are used in cancer screening?
Standardized screening tools:
- Questionnaires, or checklists to assess patients’ risk factors, functional capacity, health history, and psychosocial well-being.
153
What is the importance of outcome assessments in Prehab?
- Gather information about patients’ baseline physical fitness, functional capacity, health status, and treatment needs to inform the development of personalized exercise prescriptions and care plans.
154
Outline Universal, Targeted and Specialist Interventions
Universal: Applicable to anyone with cancer. Sign-post, advised on self-management (physical or psychological), self monitored.
Targeted: Long term condition. Adherence monitored. Prescribed exercise, nutrition, and psychological intervention and behaviour change support
Specialist: Complex needs, Complex Treatment, Severe Impairment. Prescribed exercise, nutrition, psychological interventions. Adherence and effectiveness monitored
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How should services be developed
1) Pathways need to be efficient and timely
2) Patients, carers, wider network (friends) supported to engage with Prehab
3) Services delivering Prehab should be co-designed
156
What does the HNA identify and what does it include?
1) Highlights most important issues for a individual
2) Includes physical concerns, practical concerns, emotional concerns, family or relationship concerns, spiritual concerns, information or support.
157
What does the Macmillan document say about quality assurance?
1) Implementation and effectiveness should be audited as part of quality assurance and improvement framework
2) Standard screening, assessment, adherence, efficacy, experience and outcome measures should be defined and used consistently within this framework.
158
What does the document say about leadership and education?
1) Communicate the importance of prehabilitation through
leadership and advocacy.
2) Prehabilitation should be incorporated into undergraduate and postgraduate training programmes
159
What does the Macmillan doc for professional say about developing the evidence based?
1) Prehab underpinned evidence including discovery science (observational data), experimental data, population science quality assurance data.
2) Evidence should be carefully, critically and systematically appraised in the context of current experience so safe and effective guidance that minimises risk and harm.
160
What are the 9 action plan points made in the prehabilitation document?
1) Integrate prehabilitation into clinical pathway
2) Share personalised prehabilitation care plans
3) Develop 'community of practice' to share expertise
4) CIMPSA and BASES to develop accreditation
5) Standardised outcomes measures
6) Include relevant data in national audit
7) Conduct gap analysis of evidence
8) Pursue prehab research agenda
9) Purse health economic evaluation
161
What 4 features of the NHS England long-term plan does Prehab align with?
1) Personalised care
2) Screening and early diagnosis
3) Tackling health inequalities
4) Maximising value
162
What are the 10 side effects of chemotherapy?
1) Nausea and Vomiting
2) Fatigue
3) Hair loss
4) Bone marrow suppression (low white blood cells, anaemia (low red blood cells) and bleeding and bruising (low platelet counts)
5) Mouth sores (eating is difficult)
6) Increased or decreased appetite
7) Neuropathy (numbness, tingling, weakness, pain (hands and feed peripheral neuropathy)
8) Constipation and diarrhea
9) Skin changes - dryness, itching, rash, increased sensitivity to sunlight
10) Cognitive impairment
163
What are the 12 side effects of radiotherapy?
1) Skin changes
2) Fatigue
3) Nausea and vomiting
4) Difficulty swallowing
5) Mouth and throat problems
6) Shortness of breath
7) Change in taste
8) Breathing difficulties
9) Swelling (edema)
10) Change in bowel habits
11) Urinary problems
12) Sexual side effects
164
By what 3 methods does exercise improve respiratory efficiency?
1) Increased capillarisation
2) Increased inspiratory muscle strength
3) Increased elasticity of lung tissue
165
What are the 4 side effects of immunotherapy treatment?
1) Fatigue
2) Skin reactions
3) Flu-like symptoms
4) Gastro-intestinal issues
166
What is the lactate threshold and what intensity of exercise does it occur?
- Onset of blood lactate accumulation: 2.0-4.0 mmol per litre occurring at 60-95% VO2 max (trained vs. untrained)
167
How does exercise intensity relate to adherence?
- Reduced in individuals just starting for the first time
- Moderate by previous behaviour
- 45-55% HRR new exerciser, 65-75% experienced
168
What does the social cognitive theory state about exercise behaviour?
Personal, Environmental, and Behavioural factors determine adherence
169
What are the four sources of self-efficacy and the strategies used to increase?
1) Mastery experiences
2) Vicarious experience
3) Verbal Persuasion
4) Physiological feedback
170
How are each of the strategies for self-efficacy increased?
ME: Log behaviour, Progress gradually, Realistic goals
VE: Use videos, Group exercise leaders, Show success stories
VP: Encouragement, Discuss skills
PF: Educate on symptoms, Music
171
Outline the 5 stages of change in the transtheoretical model of behaviour change?
1) Pre-contemplation: No intention be active
2) Contemplation: Active in next 6 months
3) Preparation: Active in the next 30 days
4) Action: Active less than 6 months
5) Maintenance: Active more than 6 months
172
What are the constructs of the HBM and what strategies it is made up of?
1) Perceived susceptibility
2) Perceived severity
3) Perceived benefits
4) Perceived barriers
5) Cues to action
6) Self-efficacy
173
What are the three aspects of the self-determination theory?
1) Autonomy
2) Competence
3) Relatedness
174
What are 8 strategies for behaviour change
1) Self-monitoring
2) Goal setting (SMART)
3) Reinforcement
4) Social support
5) Affect regulation
6) Relapse prevention
7) Group leader effectiveness
8) TTM stages
175
What are the four areas of social support?
a) Instrumental
b) Emotional
c) Informational
d) Companionship
e) Validation
176
What are the stages of problem solving?
A) Identify
B) Brainstorm
C) Select strategy
D) Analyse
177
Outline the process of MI
1) Express empathy
2) Explore discrepancy
3) Roll with resistance
4) Build self-efficacy
178
What are the four techniques of MI?
1) Reflective listening
2) Open-ended questions
3) Affirmations
4) Summarization
179
What was found in the After Breast Cancer Pooling Project (2012)
- 25% Mortality decrease
- 22% Increase (<1.5 MET hours)
- 35% Pooled risk reduction
180
Outline the methods and results from Sweegers and Colleagues (2018)
Method: 28 RCT - UBMS, LBMS, LBMF, CRF
Results: >60 minutes (RT), 3x/week (RT), supervised all
181
What did Freidenreich 2016 find in the clinical cancer research journal
Result: 26 Prospective cohort studies showed 37% pooled risk reduction for cancer specific mortality for breast, colon, and prostate cancer
182
Outline the 8 stages in physical activity assessment for cancer survivors?
1) Prior activity
2) Clinical evaluation
3) Barriers
4) Disease status
5) Review of symptoms
6) Assessment of contributing factors
7) Assessment of comorbidities
8) Determine risk level of adverse event
183
What did Cormie (2017) find in the paper, impact of exercise on cancer mortality, recurrence, and treatment related adverse events
100 studies showed fewer/less severe adverse effects, improved bone mineral density, improved psych distress (anxiety/depression), improved quality of life
184
What are the resistance training FIIT principles for cancer patients?
F: 2-3 days
I: 60-80% 1RM or allow for 6-15 repetitions.
T: >1 set >8 repetitions set
T: 8-10 exercises
185
What are some ongoing clinical trials in cancer research and briefly describe the methods?
UK CHALLENGE Trial: Supervised 3 year multi-centre programme of exercise aiming to achieve 10-27 MET hour/week. Colon patients who have completed routine treatment.
INTERVAL-GAP4 Trial: High-intensity aerobic and resistance exercise routine over 12-months in 6 centres for metastatic prostate cancer.
186
What is the blood cell count cut off values for exercise in cancer patients?
Red blood cell <10 mg/dL
Absolute neutrophil count <1000 cells per decilitre
Platelets - 50,000-100,000 per microliter
187
What are your top strengths?
1) Team player:
- Mark Wilke
- Clinical team
2) Attention to detail:
- Medical history, Motivational interviewing
- Roger Ma Fat
- Macmillan guidelines
3) Passionate:
- Masters degree in CEP
- Evidence in Prehab
- Enthusiastic
188
What are your biggest weaknesses
1) Public speaking:
- Trying to correct presenting at Greater Manchester conference
2) Struggle to say no to patients
- Effective time management
- Time blocking now on outlook calendar impacting time management
189
Why should we hire you?
- Prehabilitation
- Patient centred care
- Academic role
- Taken part in research
- Multi-disciplinary team working
- Passionate - just getting started
- Proven experience and enthusiasm
190
Why are you interested in this role?
- Two years working in Prehab
- Physical and psychological impact
- NHS long term plan - it's the future
- Team actively expanding
- Huge trust serving 2.5 million
- Surgical rates doubled from 12.8% to 29.9* in you pilot review - getting results
- Macmillan principles
- Further professional development
- Lead exercise physiologist
191
Tell me about yourself?
1) Cancer exercise specialist and Clinical Exercise Physiology MSc
2) 4 years delivering intervention to long-term conditions
3) 2 years prehabilitation
4) 400 patients - Motivational interviewing, designing exercise prescriptions, and research
6) EXTRA-Meso study
7) Targeted practitioner education programme - programme extended
8) Hope to continue work at Barts
192
Why do you want to work for Barts?
- Serve over 2.5 million people
- Hepato-novel-pancreato billary clinical - working alongside anaethetists
- Value collaboration - see as one it's core values
- Opportunity for professional development and learn new skills
- Surgical rate doubled between 2015 -2020 - clearly a forward looking team like myself
- Not just a tickbox
- Hope to take on a lead role
193
What hospitals make up Barts?
1) St Bartholomew’s hospital
2) The Royal London Hospital
3) Mile End Hospital
4) Whipps cross hospital
5) Newham hospital
194
What is meant by audit activities and do you have any experience with audit?
- Audit activities aim to evaluate, monitor, and improving the quality, effectiveness, and outcomes of healthcare services.
- Central health record system - ReferAll
- Collected data on time it took for patients to undergo first session - 8 days instead of 7
- Increased from 3 to 2 working days with 2 in Stockport
- Now see patients in a average of 5 days
195
Describe a time you were adaptable/flexible to accommodate a patient?
S: Patient was functional severely impaired - Vivienne Forrester
T: Get her exercising without having the seated area available and without using any exercise equipment
A: Liaised with front desk to see if they had any space available in hall or studio which they did.
R: Able to use studio undertaking a seated exercise routine - we now meet in the studio once a week for a ad hoc session following her radiotherapy treatment and she is carrying out same routine from home once a week - progressed from 10 minutes to 15 minutes with mixture of functional strength exercise.
196
Why do you want to work for the NHS?
- Multidisciplinary collaboration
- NHS long term plan looking at prevention
- Make biggest difference
197
What are the 6 NHS values and when have you demonstrated one of them in your work?
1) Respect and dignity
2) Commitment to quality of care
3) Compassion
4) Improving lives
5) Working together for patients
6) And everyone counts
198
Can you provide me a example of when you showed a commitment to quality of care?
S: Mr Bond: Skeptical, Medical History, 3 opinions
T: T: Undertook motivational interviewing - sat in the cafe - identified what he wants - just wants to be able to walk half a mile with her wife at her wife’s speed - 320 metres in 6 minutes - 1.9 mph
A: Treadmill protocol - 1 minute easy to 30 second interval - increased hard interval over time. Breathing exercises
R: Walk with wife - 320 metres to 410 metres on the 6 minute walk test. Oxygen sats maintained above 95% compared to 90% before - RPE 4 vs. 7
199
Can you tell me about a time you responded to advice from a colleague or manager that improved the service you delivered?
S: I remember when I first started the role I invited a dietician and physiotherapist from the hospital to come view the session I put on to help increase awareness of the scheme we were delivering. I was working with a patient with Parkinson’s disease which I didn’t really know about
- Complex movements promoting new neural connection are best
- Scarf snatch, Sky reach, Medicine ball throw, Over the river
A: For the patients rehab stage - following radiotherapy treatment I incorporated the timed up and go test and she showed a 4 second improvement from 9 to 13 seconds
R: I now use this programme with patients suffering with some patients suffering with balance issues or lacking functional mobility
200
Can you describe a time you displayed collaborative working?
S: Mark Wilke - Stage l - Echo - Severe depression and loss of appetite - 10-15% ejection fraction - stopped taking medication due to feeling unwell
T: Have programme that was safe
A: Completed screening but postponed any assessment - liase with psychologist Pod - liase with dietician faye - requested results of CPET
R: Cardio-pulmonary exercise test to help guide his 40%-60% of his heart rate reserve
- Cognitive behavioural therapy, Oral nutrition supplements
R: 40m improvement 6MWT from baseline to pre-op, weight stabilised, gym twice a week - currently recovering from a lobectomy
201
Name a time you gave time and energy to developing relationships within and outside your own team?
1) Dietician and Physiotherapist - Increased referrals - Great advice given to me
2) Phil bowers - Physical pathway in Wythenshawe meeting - about 3 groups missing but made effort to attend - led to us setting up of the wellbeing Wednesday session - liased with a lady in the meeting called Rachel and came and saw the sessions to see if suitable - now I refer patients into this session from our service enabling patients to achieve two sessions a week instead of 1
202
Can you provide me a example of when you showed respect and dignity in your work?
S: Fatima - Spoke to her - Spoke to Son - Identified problem - Wearing hijab - Recognised issue when asking to put blood pressure cuff on - Son explained to me not permissible.
T: Cultural beliefs - Got female GP referral instructor from the other room to take blood pressure- Evidence of supervised sessions - I collaborated closely with a female exercise instructor
A: Ensure correct prescription (HIIT protocol) and Resistance training regime - Targeted arm due to low fitness with Anaerobic threshold of 11 ml/kg/min - 4 weeks leading into operation - Home Programme as well
T: Taught her to carry out 6 MWT which she delivered to the patient - Improved AT by 1.5 and 6MWT by 50 metres
R: Carried this plan into rehab where she has now moved into community based exercise including a women’s only gym session at Abraham moss after undertaking no exercise pre-diagnosis
203
Can you tell me a time when you demonstrated the NHS value improving lives?
S: In my role as Prehabilitation exercise physiologist - Mrs Burns - 12 week rehab - 60m improvements - incident of slipping and hurting herself of lat pulldown
T: To meet the NHS value improving lives, I needed to insure that these fitness gains were maintained or improved upon for long term but not in my sessions as I needed to move her on
A: I liaised with a local exercise instructor - Racheal who runs a wellbeing Wednesday session that offers a transitional point for patients to continue or start exercising who are possibly not yet comfortable with attending a gym independently. I made her aware of her fitness level and provided a programme for her to look at long term.
R: Mrs Burns now attends these sessions once a week and keep me updated on her progress saying she is thoroughly enjoying and has even brought her friend denise along. In conjunction with this - she is still completing the home exercise booklet we provided twice a week and going out for regular walks as we advised. This approach shows my commitment to improving long term health in line with Macmillan guidelines.
204
Can you describe a time where you made a mistake, owned up to it and learnt from it
S: I had a supervised gym session consisting of 12 individuals undertaking rehabilitation - taking time with other patient - very fit individual wanted help - not observing - sprinted
T: Developed pre-syncope symptoms - lied down on back with feet up measuring his heart rate - got him a water.
- Told my manager who told me not to worry and gave me some advice having everyone do the aerobic exercise at the same time
R: I now have all my patients unless specific reasons for not doing so to start with aerobic exercises. Each session I ensure to explain thoroughly the reason for a warm-up and a cooldown and why this must absolutely must be completed at the prescribed intensity - if they want to do something different let me know. No syncope issues since.
205
Describe a time you have been equitable
- Denise
S: Fibromyalgia and chornic fatigue syndrome unable to travel and attend supervised
T: Design programme factoring in her physical needs - RPE 3 - 3 minute bouts separated with 3 minutes rest RPE 2/3 seated
A: Home based contact - twice a week calling on her on days session prescribed so she gets the verbal element everyone else has
R: 30 metre improvement in the 6MWT from baseline to pre-op
206
Can you show me a time you showed compassionate care
S: May Macdonald - severely depressed had tried all kinds of medication over her lifetime
T: Offered her encouragement and emphasised and listened to her - emphasised with how strong she was for coming her - took time to understand the need to
A: Offered support knowing exercise would help her symptoms of fatigue - also referred her to a psychiatrist - very keen to come to the gym
R: She has since regressed quite severlely but she always lets me know what a great job I'm doing - despite regressing EQ-5D stage dropped from a 5 to a 2 - have sent her a home exercise programme she is currently carrying and sent a band which I will review on Monday
207
Tell me a time when you met the NHS value “everyone counts”?
S: Denise - Fibromyalgia - Home exercise - Followed up call for same contact - 40 metre improvement in 6 mintue walk score - self efficacy scale 2 to 8 - "I'm doing more than most now aren't I!"
208
Give me a example of a time when you made improvements in your service?
S: Previous masters degree in Clinical Exercise Physiology found a confidence interval of 35 bpm for heart rate estimations, RER- 1.0-1.44m, Lactate 4 to 17nm. Are team who are all abit older then me were not really aware of this data and we were told to use 220-age as estimation of max - particularly bad for older adults
T: Improve the prescription of patients in are service
A: Delivered a presentation outlining this and the benefits of cardio-pulmonary exercise testing and how we can use the data to identify exercise intensity - graphically showed v-slope method. Showed tanaka method as better heart rate training estimation
R: Since delivering this in my first year. 6MWT test scores have improved 24 metres from baseline to pre-assessment and other staff members are either using the V-slope method or better predictive equation improving the service we run.
209
Can you tell me about a time you responded to feedback from a patient to improve the service?
Mrs Heighway lobectomy supervised gym session - Monday not good because bank holidays - you work from home?
T: Switch sessions speak with boss to a Thursday
A: Spoke manager about changing switched centre to Romiley on Thursday - home session on Monday
R: All the team have now moved the bank holiday monday to tuesday session where the leisure centres have had availability
