prince structured education programme part two ......introduction to part 2 this section of the...

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PRINCE Structured Education Programme Part Two | Physiotherapist Educator Manual

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Introduction to Part 2This section of the manual (Part 2) outlines the exercise sessions of the PRINCE structured education programme and is to be delivered in tandem with the PRINCE educator (Practice Nurse) manual. The PRINCE educator (Physiotherapist) will also be involved in the delivery of the programme for weeks 4, 5 and 6 of the PRINCE educator (Practice Nurse) Manual.

The exercise sessions are typically delivered following the PRINCE educator (Practice Nurse) sessions except in week 3, which are focused exclusively on exercise and in weeks 7 and 8when the PRINCE educator (Practice Nurse) sessions follow the exercise sessions. The duration of the exercise sessions are typically 75 minutes, except in week 1, the introduction, which is 30minutes and week 3 which is 120 minutes

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Session 1: Exercise ProgrammeFacilitator Room Layout TimePRINCE Educators Arrange chairs in semi circle 30 mins

Check ListFor this session you should have the following resources:

• A flip chart & pens;• A3 exercise record board;• DVD of exercise session 1 and PowerPoint session;• Oxygen saturation monitor;• Hand outs for each participant of: - Home exercise diary; - Exercise class record sheet; - In preparation for exercise class… - Borg Scale

Learning OutcomesAt the end of this session participant’s will:• Understand the importance and benefits of regular exercise;• Develop an understanding of the importance of exercise in the management of COPD/Outline of future classes;• Develop personal goals for the programme.

Session Overview

Topic & Duration Content Resources & Activities

• Getting to know participants and setting the focus of the session

• Explain the benefits of exercise for people with COPD

• Flip chart/whiteboard

• Interactive teaching

• Flip chart/whiteboard


• Show PowerPoint “Benefits of exercise” Slide 1 of Session 1

Introduction(5 minutes)

Benefits of Exercise(5 minutes)

Contents

Session 1Exercise programme (duration 30 min) 01








PRINCE Physiotherapist Comments

03

IntroductionExplain to the participants that you are now going to talk to them about exercise and explain the exercise classes on the Pulmonary Rehabilitation Programme. Explain that this is only a brief introduction as they will learn more about exercise and its effects on COPD over the following weeks.

Emphasise with participants that exercise is important to us all and brainstorm with participants to carry out the following activity.

Activity 1.1 Ice BreakerCan you give reasons why exercise is important to your health?

Summarise comments on flip chart and keep the flip chart.

Benefits of exercise Explain that by carrying out exercise regularly participants will maintain the benefits of exercise, however If they stop exercising regularly they will lose the benefits of exercise and will become unfit. Emphasise with participants that when the Pulmonary Rehabilitation Programme is over they should be confident to continue to exercise regularly at home 3-5 days a week for 30 minutes a day.

Now ask participants to carry out the following activity. Contact Sheet

02

• Outline of class exercise sessions and home exercise

• Summary and conclusion

• Flip chart & ‘

• Give handouts of home exercise diary

• Exercise record sheets

• Show A3 exercise record Board

• Show PowerPoint on “Types of exercises” Slide 2 of Session 1

• Show PowerPoint on “Exercise class” Slide 3 of Session 1

• Show power-point “During exercise class…” Slide 4 of Session 1

• Show PowerPoint “For next week’s class please…”

• Give handout on “In preparation for exercise class…” Slide 5 of Session 1

Exercise & COPD 15 minutes)

Closing (5 minutes)

Activity 1.2Ask participants to identify the possible benefits regular exercise may have for people with COPD.

Take feedback, acknowledge and reaffirm participants comments.

Reaffirm and acknowledge with participants the benefits they identified which are similar to those listed.

Exercise and COPDEmphasise with participants that following participation in the PR exercise programme they should find over the coming weeks that they are less breathless carrying out daily activities than they were at the beginning of the Pulmonary Rehabilitation Programme.

Explain to participants that exercise helps to increase the oxygen supply to the lungs. The oxygen is then delivered around the body by the bloodstream. Exercise helps to deliver oxygen more efficiently around the body which in time will make participants feel less breathless.

Explain that exercise will help strengthen the muscles that are working e.g. exercising your arms will make your arms stronger; exercising your legs will make your legs stronger. When your muscles are stronger, you will feel less tired when performing daily tasks and when walking. Exercise will help to increase your exercise endurance meaning that you should be able to walk for a longer distance or time.

Explain that there are different forms of exercise and that these are divided into 4 main types:

• Aerobic - works your heart and lungs;• Endurance - increases your exercise tolerance;• Balance - helps to prevent falls;• Strengthening - makes your muscles stronger.

Benefits of exercise

Regular exercise can • Improve fitness, • Improve muscle strength, • Improve energy levels, • Help you feel better • Improve your quality of life by increasing your ability to carryout daily activities. • Prevent hospital admissions usually caused by exacerbation of COPD.

1 of Session 1

Show Slide 1 of Session 1:

0504

Exercise classesExplain that in the Pulmonary Rehabilitation Programme, participants will be taking part in 7 weekly exercise classes.

Explain that the exercise classes will consist of a gentle warm up, followed by 10 exercises which will be arranged in a circuit. The circuit will be numbered 1 to 10 and there will be a poster at each exercise station. The exercises will consist of arm and leg exercises and a walking circuit. There will be a cool down session at the end. Explain to participants that they will be using weights/bands in the exercise classes to strengthen your muscles, and that when measurements were taken in the assessment we calculated the correct weight for each participant. Explain that each participant will have an exercise plan based on their current level of fitness and strength.

Explain that during the exercise classes participants that will be asked to say how their breathing feels on a scale of 0 – 10.

Explain that we will use the Borg Scale and ask participants to record their score. Explain that we will teach participants how to manage breathing during exercise. Also, during the exercise class, we will record participants heart rate and oxygen saturation level (show participants SaO2 monitor and how it works) so that we know participants normal values.

Show participants the home exercise record sheets and A3 exercise record board that will be used to record the intensity of the exercise and how breathless they are. Explain that we will show them how to fill these in, next week.

Types of exercises

• Aerobic- works your heart and lungs• Endurance- increases your exercise tolerance• Balance- helps to prevent falls• Strengthening- makes your muscles stronger

2 of Session 1


Time Repetitions Weights Borg Hold Steps Steps Resistance (Min) (Number) (Kgs) (1 - 10) (Seconds) (Hi/Lo) (Number (Hi/Med/Lo)

Exercise Class Record Sheet Participant Code: ____________ Session __________ Date____________

Pre-Test; ___________________ HR(BPM) _________ SaO2 (%) _______ BP _______

Post-Test; __________________ HR(BPM) _________ SaO2 (%) _______ BP _______

Exercises

Biceps Curls

Step ups

Arm Circles

Arm Wings

Leg Weights

Wall Press

Sit to Stand

Shoulder Lifts

Wall Squats

Circuit Walk

Pedals

Hold (Sec): Duration of hold in position Repetition

Repitition Times: No of times repeated Resistance:

Kgs: Level of weights used

Steps: Number of steps taken

Resistance: Level of resistance Lo, Med, Hi)

Minutes: Duration of peddling

06 07

Inform participants that as well as the exercise classes, we recommend that they carry out a home exercise programme. This is very important as participants will only really benefit from exercise if they carry it out 3 to 5 times a week. Emphasise that these home exercises will be based on the exercises that they are carrying out in the class. Show participants the home exercise diary.

Closing Thank participants for their input into today’s session. Finally ask participants if they have any queries and clarify same.

Outline that it’s important that they dress appropriately so that they can carry out the exercises more easily. Give participants the handout “In preparation for exercise class….”

Exercise Class

• Gentle Warm up• 10 exercises in a circuit• Exercises - Arm and leg - Walking - Weight bands• Cool down - Personal exercise plan

3 of Session 1


During Exercise Class

• Borg Breathlessness Scale• Recording your heart rate and oxygen• Completing exercise record sheets• Remember home exercise and diary

4 of Session 1


In preparation for exercise class

• Dress in comfortable clothes and supportive footwear• Take your medications as prescribed• Eat a light meal/snack at least 60mins before the class• Bring a bottle of water. It is important not to become dehydrated.• Do not exercise the day before or on the day of the exercise classes

5 of Session 1


Explain that over the coming weeks we will monitor how participants are doing with their goals and their progress. Explain that sometimes they may need to revise goals or set new goals and that is fine.


• Explain the focus of the session

• Explain what exercise intensity is

• Explain and demonstrate how to use the Borg Breathless Scale

• Explain and demonstrate how to control breathing using pursed lip breathing techniques and positions of ease

• Explain the Home Exercise Programme

• Explain how to record the Home Exercise Diary • Explain how to exercise safely

• Establish the exercise circuit

• Demonstration

• Give handout of the “Modified Borg Breathless Scale”

• Demonstration


• Show PowerPoint

“Ways of controlling your breathing”- Slide 1 of Session 2

“Pursed lip breathing technique” - Slide 2 of Session 2

“When practising pursed lip breathing” - Slide 3 of Session 2

• Give handout on “Pursed lip breathing techniques”

• Show PowerPoint on “Positions of ease” - Slide 4 of Session 2

“Description of Posiiotns of Ease” - Slides 5 - 8 of Session 2 (x 4 slides)

“Other Positions of ease” - Slides 9 - 10 of Session 2 (x 2 slides)

• Give handout on “Positions of ease”

• Show PowerPoint of “Home Exercise Programme” - Slide 11 of Session 2 • Give handout “Instructions for completing the home exercise diary”

• Show PowerPoint “Recording your home exercise diary” - Slide 12 of Session 2


Intensity of exercise (5 minutes)

Managing breathlessness(20 minutes)

(10 minutes)

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Session 2: Exercise Programme

Facilitator Room Layout TimePRINCE Educators Flat open space clear of obstacles 75 mins for walking; chairs in a semi circle; clear of walk area

Resources• A3 Borg Breathless Scale for each station; • A3 exercise record board for each station;• Blue tack; • Chairs (one per participant);• Clock with large face; • Cones;• Exercise posters for each station; • Exercise steps (adjustable);• Flip chart and pens; • Non slip mat;• O2 and tubing; • Pedals;• Pedometer; • Pens (Biros);• Pulse oximeter; • Stop watch X2;• Table or stable surface at waist height; • Tape measure;• Therabands; • DVD of Exercise Session 2 Power Point presentations;

Learning OutcomesAt the end of this session participant’s will:

• Know how to use pursed lip breathing and positions of ease when breathless;• Know how to use the Borg breathlessness scale;• Know how to exercise safely at home;• Know how to record exercise in their home exercise diary.

• Hand outs for each participant of: - Modified Borg breathless scale; - Pursed lip breathing technique; - Positions of ease; - Instructions for completing the home exercise diary; - Exercise safety tips; - Home exercise record sheet (one per participant).

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Introduction Explain to participants that today we will begin the exercise classes which will continue for the next 7 weeks and that they will also be taking part in a Home Exercise Programme. Explain to participants that for the Home Exercise Programme they will be provided with a diary to record the exercises and walking that they will be doing at home. Explain to participants that we will discuss the Home Exercise Programme in more detail later.

Emphasise that to achieve any benefits from exercise it is very important to remember exercise should be carried out regularly. Outline that it is recommended that everyone should exercise for at least 30 minutes a day, 3-5 days a week.

Intensity of exercise Help participants understand that when they exercise it is important to exercise at the correct intensity, otherwise they will not achieve the benefits of exercise. Explain that a good way of knowing that they are exercising at the correct intensity is by measuring how breathless they are. This is done by rating breathing on a scale of 0 to 10. This is called the modified Borg Breathlessness Scale (Borg Scale). Emphasise that they need to measure their breathlessness before, during and after exercise.

Now show participants the poster of the Modified Borg Scale explaining that the scale is from 0 to 10, where: 0 = No breathlessness and 10 = Maximum breathlessness. Give handout of the Modified Borg Scale to all participants.

Nothing at all

Very, very slight(just noticeable)

Very slight

Slight

Moderate

Somewhat severe

Severe

Very severe

Very, very severe(almost maximal)

Maximal

Instructions for Borg Breathlessness Scale

“This is a scale that asks you to rate the difficulty of your breathing. It starts at number 0 where your breathing is causing you no difficulty at all and progresses through to number 10 where your breathing difficulty is maximal”. How much difficulty is your breathing causing you right now?

0

0.5

12345678

9

10

Modified Borg Breathlessness Scale

10 11

Exercise timetable

Duration Topic Content

• Warm-up

• Exercise circuit

• Walk/marching on spot swinging arms side stepping

• Measuring 1-2 on the Borg scale

• Each participant (depending on ability) to carry out 5 reps of each of the following activities: - Arms pull backward with theraband; - Shoulder flexion; - Trunk rotation; - Calf stretches; - Hamstring stretches.

• Each participants (depending on ability) to walk

for 3 mins around cones (measure distance) Use pedometer (record steps) Measuring 4 on the Borg Scale

• Legs:- Leg weights; - Step ups; - Sit to stand; - Wall squats;- Pedals.

• Arms:- Biceps curls; - Arm circles;- Arm wings; - Wall press;- Shoulder lifts.

(5 minutes)

20 minutes

• Show PowerPoint “Completing your home exercises” - Slide 13 of Session 2 Show PowerPoint “You should stop exercising if you experience any of the following” - Slides 14 - 15 of Session 2 (x 2 slides)

Show PowerPoint “Exercising safety tips X 2 slides” - Slide 16 - 17 of Session 2 (x 2 slides)

• Give handout on “Exercise safety tips”

• Show PowerPoint on “Exercise Class (practical) Session 2” - Slide 18 of Session 2

Cool-down

• Each participant to carry out 1-3 sets 8-10 reps body weight (as time allows)

• Measuring 3 on the Borg Scale

• Walk 5 minutes 1-2 Borg Scale

5 minutes

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Ask participants to carry out the following activity.

Activity 2.1 Ask participants to identify their level of breathlessness by choosing the number closest to how their breathing feels at this moment. Check with participants that they understand how to use the scale.

Outline that when people exercise they are working their muscles and body harder than when resting. Emphasise that when exercising, the heart rate increases, people often sweat and breathing becomes harder – emphasise that they are not to worry when these things happen as these are all normal responses to exercise.

Emphasise with participants that its important they try to keep exercising until they feel moderate breathlessness i.e. that their breathing has increased to a level 4 on the Borg Breathlessness Scale and therefore they should feel a noticeable increase in breathlessness before they stop exercising.

Managing breathlessness Explain to participants that we are now going to talk about ways of controlling their breathing and ways of managing breathlessness when exercising or doing any activity that makes them breathless. Explain that in Week 4, we will again discuss managing breathlessness in more detail.

Controlling Your BreathingThere are a number of ways participants can control their breathing and allow more air to enter their lungs. These are:• Pursed lip breathing technique;• Diaphragmatic breathing technique (abdominal breathing) - which will be covered in week 4• Positions of Ease.

Pursed lip breathingExplain to participants that when you breathe out through pursed lips, you are creating a pressure of air which can help to keep the airways of the lungs open.

Acknowledge that some participants may already know how to do this technique but as it is one of the most important ways of reducing shortness of breath, we will practice how to use it nowGive participants the “Pursed lip breathing” handout and guide participants through the technique.

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Ways of controlling your breathing

• Pursed Lip Breathing technique• Diaphragmatic Breathing technique (Abdominal Breathing) -which will be covered in week 4.• Positions of Ease

1 of Session 2


Lip Breathing Technique• Relax your shoulders and upper chest. If able, place hand on abdomen.• Close your mouth.• Breath in slowly through your nose over two seconds.• Do not take a deep breath while breathing in• Purse your lips as if you were going to whistle• Breath out slowly through your pursed lips over 4 seconds. feel your abdomen fall away from your hand as you breath out

Encourage participants that they should perform pursed lip breathing until breathing feels better. Emphasise that it’s important that they practice this technique several times a day, suggest that they choose times to practice that are easy to remember, for example, after meals. Explain to participants that they should use pursed lip breathing when they do anything that makes them feel short of breath, such as climbing stairs, bathing, housework or at night if they become breathless. (American lung association of Washington, 2005)

When Practicing Pursed Lip Breathing

Remind participant that when they are using pursed lip breathing that they need to: • Keep the breathing quiet and relaxed;• Try to “breathe” at a normal rhythm;• Take normal size breaths and don’t hold the breath for too long;• Concentrate most on breathing out for the count of 4.

Purse Lip Breathing technique

• Relax your shoulders and upper chest. If able, place hand on abdomen.

Close your mouth.Breathe in slowly through your nose over 2 seconds.

Do not take a deep breath while breathing in.

Purse your lips as if you were going to whistle.

Breathe out slowly through your pursed lips over 4 seconds. Feel your abdomen fall away from your hand as you breathe out.

2 of Session 2


Explain that some people with COPD do not breathe through the nose but through the mouth, and that this is fine. But that people who do this need to focus on exhaling through pursed lips and using more time to breathe out than to breathe in.

Positions of ease

Outline to participants that there are several body positions that they can use to help them breath more easily when they are breathless. These are:

• Relaxed sitting;• Forward lean sitting;• Forward lean standing;• Relaxed standing;• High side lying.

Explain that by adopting one of these positions, they are assisting the diaphragm to change position so that it moves upwards and forwards to help with inspiration (breathing in). Emphasise that it’s important that they do not tense up but keep their shoulders and neck relaxed; do not grip or push down with their hands as this will make the work of breathing harder.

Give participants the handouts on the “Positions of ease” and then guide them through relaxed sitting and forward lean standing.

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Relax your shoulders and upper chest. If able, place hand on abdomen.

Close your mouth.Breathe in slowly through your nose over 2 seconds.

Do not take a deep breath while breathing in.

Purse your lips as if you were going to whistle.

Breathe out slowly through your pursed lips over 4 seconds. Feel your abdomen fall away from your hand as you breathe out.

Pursed lip breaking key steps

Place a tick in the box if this technique is performed correctly

14

When practising pursed lip breathing

• Keep breathing quiet and relaxed• Try to “breathe” at a normal rhythm• Take normal size breaths and don’t hold the breath for too long.• Concentrate most on breathing out for the count of 4.

3 of Session 2


Positions of Ease

• Relaxed sitting• Forward lean sitting• Forward lean standing• Relaxed standing• High side lying

4 of Session 2


Descriptions of positions of ease (a) Relaxed sitting• Sit on a chair, feet on the ground, relax your shoulders and upper chest.• Place hand on upper abdomen, just below lower ribs.• As you slowly breathe in for 2 seconds, feel your upper abdomen and lower ribs rise.• As you slowly breathe out for 4 seconds, feel your abdomen fall away from your hand.

5 of Session 2

Show Slide 5 of Session 2

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Descriptions of positions of ease • Sit on a chair leaning forward, rest forearms on knees, feet on the ground, relax your shoulders and upper chest.• Slowly breathe in for 2 seconds, be aware of your upper abdomen and lower ribs rising.• Slowly breathe out for 4 seconds, be aware of your abdomen and lower ribs falling back into original position.

6 of Session 2

Forward lean sitting • Sit on a chair, leaning forward. Have table in front with 2 pillows placed on it.• Rest your head and arms on the pillows.• Slowly breathe in for 2 seconds, be aware of your upper abdomen and • lower ribs rising.• Slowly breathe out for 4 seconds, be aware of your abdomen and lower ribs falling back into original position.

7 of Session 2

Forward lean standing • When standing, lean body forward from your hips and rest elbows on a window ledge or similar support.• Keep your shoulders and upper chest relaxed.• Slowly breathe in for 2 seconds, be aware of your upper abdomen and lower ribs rising.• Slowly breathe out for 4 seconds, be aware of your abdomen and lower ribs falling back into original position.

8 of Session 2

Now ask participants to carry out the following activity.

Activity 2.2 Ask participants to practice the relaxed sitting and forward lean standing techniques. Monitor participants performance and give positive feedback.

Now guide participants through the remaining positions.

Other Positions of Ease • Relaxed Standing When standing, place your back against a wall or similar support and lean forward, with your arms relaxed by your sides.• Keep your shoulders and upper chest relaxed.• Slowly breathe in for 2 seconds, be aware of your upper abdomen and lower ribs rising.• Slowly breathe out for 4 seconds, be aware of your abdomen and lower ribs falling back into original position.

9 of Session 2

High Side Lying • Lie on your side in bed, with 3-4 pillows under your head and shoulders.• Lean forward, keep shoulders and upper chest relaxed. • Slowly breathe in for 2 seconds, be aware of your upper abdomen and lower ribs rising.• Slowly breathe out for 4 seconds, be aware of your abdomen and lower ribs falling back into original position.

10 of Session 2



Positions of ease (handout)

a) Relaxed sitting: • Sit on a chair, feet on the ground, relax your shoulders and upper chest;• Place hand on upper abdomen, just below lower ribs;• As you slowly breathe in for 2 seconds, feel your upper abdomen and lower ribs rise;• As you slowly breathe out for 4 seconds, feel your abdomen fall away from your hand.

(b) Relaxed sitting:• Sit on a chair leaning forward; rest forearms on knees, feet on the ground, relax your shoulders and upper chest;• Slowly breathe in for 2 seconds, be aware of your upper abdomen and lower ribs rising;• Slowly breathe out for 4 seconds, be aware of your abdomen and lower ribs falling back into original position. (image on next page)




(e) Relaxed standing:• When standing, place your back against a wall or similar support and lean forward, with your arms relaxed by your sides;• Keep your shoulders and upper chest relaxed;• Slowly breathe in for 2 seconds, be aware of your upper abdomen and lower ribs rising;• Slowly breathe out for 4 seconds, be aware of your abdomen and lower ribs falling back into original position.

(f) High side lying:• Lie on your side in bed, with 3-4 pillows under your head and shoulders;• Lean forward, keep shoulders and upper chest relaxed;• Slowly breathe in for 2 seconds, be aware of your upper abdomen and lower ribs rising;• Slowly breathe out for 4 seconds, be aware of your abdomen and lower ribs falling back into original position.

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(c) Forward lean sitting:• Sit on a chair, leaning forward. Have table in front with 2 pillows placed on it;• Rest your head and arms on the pillows;• Slowly breathe in for 2 seconds, be aware of your upper abdomen and lower ribs rising;• Slowly breathe out for 4 seconds, be aware of your abdomen and lower ribs falling back into original position.

(d) Forward lean standing:• When standing, lean body forward from your hips and rest elbows on a window ledge or similar support;• Keep your shoulders and upper chest relaxed;• Slowly breathe in for 2 seconds, be aware of your upper abdomen and lower ribs rising;• Slowly breathe out for 4 seconds, be aware of your abdomen and lower ribs falling back into original position.

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2120

Home exercise programme Explain to participants that the aim of the home exercise programme is to build up a pattern of regular exercise to achieve health benefits. Each week they will receive a programme of exercises to carry out at home and that these exercises will be based on the exercises practiced in the exercise class they do each week within the PR programme.

Home exercise programme

Explain to participants: • The exercises will include aerobic exercises to make their heart and lungs fitter and strengthening exercises for their arms and legs, to make it easier to carry out daily tasks;• The duration of the home exercises should build up to 30 minutes, 3-5 times a week;• If they are unable to perform the exercises in one session, it is okay to divide the exercise session over the day, for example, 10 minutes of exercise, three times a day will give you an accumulated total of 30 minutes of exercise for that day;• In addition to the strengthening exercises they will begin a walking programme, starting with a short time interval and increasing as able to 30 minutes. Explain again that it is okay to divide the walking time over the day, for example, walk for 10 minutes, 3 times a day, to achieve 30 minutes of walking a day;• Over the weeks, they should aim to increase the length of time they can walk. Once they can walk for 30 minutes without stopping for a rest, they can start to increase the speed they walk at. This will keep a high level of exercise intensity to help increase their fitness level.

Home exercise programme • The exercises will include aerobic exercises to make the heart and lungs fitter and strengthening exercises for arms and legs, to make it easier to carry out daily tasks.• The duration of the home exercises should build up to 30 minutes, 3-5 times a week. • If unable to perform the exercises in one session, it is okay to divide the exercise session over the day, for example, 10 minutes of exercise, three times a day will give an accumulated total of 30 minutes of exercise for that day.• In addition to the strengthening exercises begin a walking programme, starting with a short time interval and increasing as able to 30 minutes. It is okay to divide the walking time over the day, for example, walk for 10 minutes, 3 times a day, to achieve 30 minutes of walking a day. • Over the weeks, aim to increase the length of time you can walk for. Once you can walk for 30 minutes without stopping for a rest, you can start to increase the speed you walk at. This will keep a high level of exercise intensity to help increase fitness level.

11 of Session 2


Recording exercise in your exercise diaryIn this section you will emphasise with participants that it’s really important that they record the exercise activities that they do at home in their home exercise diary. Explain that this will allow them to see how they are progressing and will also allow you to prescribe the correct exercises and the weight for your strengthening exercises. For example once each person can perform 3 sets of 15 repetitions of an activity easily, the weight will be increased after reassessment.Give participants the following handout of instructions for completing their home exercise diary.

Instructions for completing the home exercise diaryEach day: • Record you’re walking time for exercise and distance (if known). Record, also the resting time taken between walks;• Record the exercise intensity of your walking by using the Borg Scale;• Record the number of sets and repetitions of exercises. You will be prescribed the correct amount of repetitions and sets in your exercise class;• Record how many rests you take during exercise and how long they are. Try to decrease the amount and length of rests as you become fitter;• Record that you have carried out a warm up and cool down session.

Remind participants to: • Exercise at an intensity of 4 on the Borg breathlessness scale;• Enjoy yourself when exercising. Exercise should not be a chore and to think of the benefits that regular exercise can bring;• Read the “Exercise safety tips” handout before exercising;• Bring your exercise diary to class, so that progress can be monitored

Recording your home exercise diary

Each day • Record you’re walking time for exercise and distance (if known). Record, also the resting time taken between walks. • Record the exercise intensity of your walking by using the Borg Scale• Record the number of sets and repetitions of exercises. You will be prescribed the correct amount of repetitions and sets in your exercise class. • Record how many rests you take during exercise and how long they are for. Try to decrease the amount and length of rests as you become fitter.• Record that you have carried out a warm up and cool down session

12 of Session 2

ShowSlide 12 of Session 2:

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Now give participants the “exercise safety tips” handout and guide participants through it.

Emphasise with participants that it’s important to know when to stop exercising. Tell participants to stop if they feel any of the following:

You should stop exercising if you experience any of the following:

• Chest pain or tightness;• Palpitations – irregular and fast heart rate associated with shortness of breath;• Nausea or dizziness;• Cold or clammy;• Increased wheezing;• Pain in joints or muscles;• Extreme tiredness;• Severe headache.

Emphasise that they should stop exercising, sit down, perform pursed lip breathing, and adopt a position of ease. Emphasise that if the symptoms persist longer than 10 minutes or become worse, they should contact their GP or practice nurse.

Completing your home exercises

Remember:• Exercise at an intensity of 4 on the Borg Breathlessness Scale• Enjoy yourself when exercising. Exercise should not be a chore and to think of the benefits that regular exercise can bring. .• Read the Exercise Safety Tips handout before exercising• Bring your exercise diary to class, so that progress can be monitored

13 of Session 2



• Chest pain or tightness• Palpitations – irregular and fast heart rate associated with shortness of breath• Nausea or dizziness• Cold or clammy • Increasingly wheezy• Pain in joints or muscles• Extreme tiredness• Severe headache 14 of Session 2


You should stop exercising contd:

• Sit down, • Perform pursed lip breathing, • Adopt a position of ease • If the symptoms persist longer than 10 minutes or become worse, contact your GP or practice nurse.

15 of Session 2

ShowSlide 15 of Session 2:

Exercising safety tips

Exercising safety tips• Wear comfortable clothing and supportive footwear;• When walking outside bring your mobile phone or inform someone, and wear reflective clothing in dark weather;• Take medications as prescribed; • Bring a bottle of water to prevent dehydration;• Ensure that you have eaten at least one hour before exercise;• Make sure that you have a safe environment;• Do not exercise the day before or the day of the PR exercise classes;• Always warm up for 5 minutes before exercise and cool down for 5 minutes after exercise. For this activity, your breathlessness should measure 1 to 2 on the Borg Scale;• Do not carry out strengthening exercises of the same muscle groups (e.g. arms or legs/both) two days in a row. There must be a day of rest to help the muscles recover and to prevent injury;• Do not add or increase weights – this will be done in your exercise class on assessment;• Take rest periods when you exercise as needed. This should be guided by measuring your breathlessness on the Borg Scale. Record how many rests and how long they are for. Try to decrease the amount and length of these rests as you become fitter;• Remember when you are breathless use pursed lip breathing, positions of ease and diaphragmatic breathing techniques (these will be covered in Week 4).

Exercising Safety Tips

• Wear comfortable clothing and supportive footwear• When walking outside bring your mobile phone or inform someone, and wear reflective clothing in dark weather• Take medications as prescribed • Bring a bottle of water to prevent dehydration• Ensure that you have eaten at least one hour before exercise• Make sure that you have a safe environment.• Do not exercise the day before or the day of the PR exercise classes.• Always warm up for 5 minutes before exercise and cool down for 5 minutes after exercise. For this activity, your breathlessness should measure 1 to 2 on the Borg.

16 of Session 2


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Next commence the exercise class as outlined in the timetable at the start of this session. The following is the list of exercises participants will complete in all the exercise classes. Following reassessment each week the number and intensity of the exercises undertaken by each participant will be reviewed.

Weekly class exercises

Warm Up ExercisesArms pull backward:• Sitting or standing, with back straight. Keep elbows straight and arms at shoulder level in front of the body;• Separate arms to the side, as far as possible;• Hold for ____ seconds;• Slowly return to the starting position;• Repeat ___times for each arm (add weights as prescribed).

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Guidelines for PRINCE physiotherapist re: pedals & step-ups:

• Pedals - use first with participants who cannot perform wall squats and then for the other participants depending on time;• In sitting, adjust resistance on pedals and inform participant to pedal for time at circuit station e.g. 3 minutes;• Remember that some participants will need assistance with step-ups for safety reasons;• Progress step-ups for participants by increasing the height of the step when they can easily exercise for 3 minutes on the low step.

Exercise class (Practical) (Session 2) (75minutes)

Establish the exercise class circuit and explain to participants that there are:• 10 stations that each participant needs to exercise at;• Each station takes 3 minutes;• Each participant needs to record how breathless they are after completing the station on the Borg Scale;• Each participant needs to record the number of repetitions they have done at each station.

Exercising Safety Tips contd

• Do not carry out strengthening exercises of the same muscle groups (e.g. arms or legs/both) two days in a row. There must be a day of rest to help the muscles recover and to prevent injury.• Do not add or increase weights – this will be done in your exercise class on assessment.• Take rest periods, when you exercise, as needed. This should be guided by measuring your breathlessness on the Borg Scale. Record how many rests and how long they are for. Try to decrease the amount and length of these rests as you become fitter.• Remember when you are breathless use pursed lip breathing, positions of ease and diaphragmatic breathing techniques (these will be covered in Week 4)

17 of Session 2


Exercise class (Practical) Session 2

• There are 10 stations that each participant needs to exercise at, • Each station takes 3 minutes, • Each participant needs to record how breathless they are after completing the station on The Borg Scale, • Each participant needs to record the number of repetitions they have done at each station

18 of Session 2

Show Slide 18of Session 2:

Trunk rotation: • Stand with back straight and feet shoulder width apart; • Cross arms across your chest (see picture);• Turn upper body and head to look over right shoulder as far as you can go; • Keep feet in the same place;• Hold for ____ seconds;• Slowly return to the starting position;• Repeat ___times to the right and left.

Class ExercisesBiceps curls:• Sitting or standing, with back straight; • Slowly return to the starting position;• Lift your hand up to your shoulder, bending the elbow; • Repeat ___times for each arm (add weights as prescribed).• Hold for ____ seconds;

2726

Calf stretches:• Stand a little more than an arm length away from a wall;• Keeping back and hips straight, place hands on the wall;• Keep elbows straight;• Bring right leg forward, bending at the knee;• Keep left leg straight and keep left heel on the ground;• Push gently into the wall;• Feel a stretch on your left calf;• Hold for ____ seconds;• Slowly return to the starting position;• Repeat on Right leg;• Repeat ___times each leg.

Hamstring stretch:• In standing position, feet shoulder width apart;• Bring right leg forward, keep knee straight;• Bend right foot towards the ceiling, keeping heel on the ground;• Gently bend left knee, so that it is in line with left 2nd toe;• Hold for____seconds;• Repeat on left leg;• Repeat_____times each leg.

29

Wall press:• Stand a little more than an arm length away from a wall;• Keeping back and hips straight, place hands on the wall, Keep elbows straight;• Push into the wall through your shoulders;• Be conscious of keeping your shoulder blades against your rib cage;• Hold for ____ seconds; • Slowly return to the starting position;• Repeat ___times.

Arm circles:• Sitting or standing, with back straight. Keep elbows straight and arms at shoulder level out to the side of the body;• Start moving your arms in small circles gradually increasing to large circles;• Repeat ___times for each arm (add weights as prescribed).

Arm wings:• Sitting or standing, with back straight;• Keep elbows straight, lift arms out to the side and up, as far as possible;• Hold for ____ seconds;• Slowly return to the starting position;• Repeat ___ times for each arm (add weights as prescribed).

Shoulder lifts:• Sitting or standing, with back straight; • Keep elbow straight, lift 1 arm up in front, followed by the other, as far as possible;• Hold for ____ seconds;• Slowly return to the starting position;• Repeat ___times for each arm (add weights as prescribed).

28

Wall squat:• Standing with your back to the wall, feet shoulder width apart and back straight;• Slowly bend your knees so you slide down the wall. Keep your knees hip width apart (Both knees go over the second toe, respectively);• Hold this position for ___seconds;• Repeat ___times.

Step-ups:• Standing beside a step and holding onto a stable surface for balance;• Slowly step up onto the step with foot A;• Bring the foot B up onto the step also;• Slowly step back down with foot B;• Return foot A to the floor;• Repeat ___times for each foot (add weights as prescribed).

3130

Leg weights:• Sitting in a hard chair, with back straight; • Hold for ____ seconds;• Keep your toes pointing towards the ceiling; • Slowly return to the starting position;• Straighten your knee as far as possible; • Repeat ___times for each leg (add weights as prescribed).

Sit-to-stand:• Sitting on a chair, with feet flat on the floor shoulder width apart;• Lean forward, bringing your nose over your toes;• Slowly stand up using your hands as little as possible;• When standing, stand up straight and take a deep breath in;• Repeat_____times.

Stand-to-sit: • Standing in front of a chair;• Move backwards until you can feel the chair at the back of your knees;• Slowly lower yourself down into the chair using your hands as little as possible;• Repeat ___times.

33



For this session you should have the following resources:

• A3 Borg Breathless Scale for each station; • A3 exercise record board for each station;• Blue tack; • Chairs (one per participant);• Clock with large face; • Cones;• Exercise posters for each station; • Exercise steps (adjustable);• Flip chart and pens; • Non slip mat;• O2 and tubing; • Pedals;• Pedometer; • Pens (Biros);• Pulse oximeter; • Stop watch X2;• Table or stable surface at waist height; • Tape measure;• Therabands; • Weights:• DVD of Exercise Session 3 - adjustable for ankles; PowerPoint presentations. - dumbbells for arms;


• Understand the benefits of a warm-up and cool-down;• Understand the importance of aerobic and progressive strengthening exercises;• Know how to progress strengthening exercises;• Apply safety precautions associated with progressive strengthening exercises and balance exercises;• Receive feedback on how home exercises are progressing.

32

Exercise timetable


• Warm-up

• Exercise circuit (Includes prescribed individual arm/leg weights)

Cool-down



• Each participant (depending on ability) to carry out 5 reps of each of the following activities: - Arms pull backward with theraband; - Shoulder flexion; - Trunk rotation; - Calf stretches; - Hamstring stretches.

• Each participants (depending on ability) to walk

for 3 mins around cones (measure distance) Use pedometer (record steps) Measuring 4 on the Borg Scale

• Legs:- Leg weights;- Step ups; - Sit to stand;- Wall squats;- Pedals.

• Arms:- Biceps curls;- Arm circles;- Arm wings;- Wall press;- Shoulder lifts.

• Each participant (depending on ability) to carry out 3 sets, 8-10 reps prescribed weights for biceps curl and leg weights


• Walk 5 minutes 1-2 Borg Scale

5 minutes

50 minutes

5 minutes

3534


• Review Home Exercise Programme & diaries

• Explain the benefits of warm up and cool down

• Explain the specific content of this exercise session

• Explain the benefits of walking and different ways of making it a “fun” event

• Review goal setting in relation to exercise

• Explain the aim of strengthening exercises and the need for progressive strengthening exercises and how these will be prescribed


• Group work

• Show PowerPoint “Warm up & cool down sessions are important as they will...” Slide1 of Session 3

• Show PowerPoint “Exercise” class (Practical) Session 2


• Group activities

• Show PowerPoint “Walking Exercises” Slides 2 - 3 (x 2 slides)


• Show PowerPoint “Progressive strengthening exercises” - Slide 4 - 7 of Session 3 (x 4 slides)

• Show PowerPoint “Exercise class (Practical) Session 3” - Slide 8 of Session 3


Warm up &cool down (10 minutes)

Walking exercises (10 minutes)

Progressive strengthening exercisesPrescribing weights (20 minutes)

37

Introduction Welcome the participants back to their second exercise class and thank them for showing commitment and motivation to improve their lifestyle and management of COPD.

To elicit feedback on participants performance of the home exercise activities carry out the following activity with participants.

Activity 3.1 Ask participants to work in pairs to share their achievements with each others in terms of the amount and type of exercise that they carried out in their Home Exercise Programme. Then ask participants to list what they found easy and why: and what they found difficult and why? Take feedback

Activity 3.2 Still working in pairs, ask participants to look again at what they found difficult last week and discuss what they will do to make it easier for next week. Take feedback and acknowledge and reaffirm participants positive strategies for overcoming difficulties

Ask the Participants if they have any questions and clarify same.

Warm up and cool downIn this session you will explain to participants about the importance of warm up and to cool down sessions before and after engaging in any exercise activity.

Warm upExplain to participants that a warm up session before exercise will increase the oxygen supply throughout the body and increase the blood supply to the muscles and to the lungs, making it easier to carry out exercise. It will also make the muscles more flexible and decrease the risk of injury.

A warm up session comprises of a 5 minute walk, at a Borg intensity of 1-2, and gentle stretchesof the arms and legs. Explain that these will be practised in the PR exercise class.

Cool downEmphasise that a cool down session after exercise will allow the heart rate and breathing to return to normal. It will also allow the body’s temperature to return to normal. A cool down session comprises of a 3-5 minute walk, breathing control, and gentle stretches. Explain to participants that these will be practised in the PR exercise class.

Explain a warm up and cool down session will:

• Improve exercise performance;• Decrease the risk of injury;• Reduce muscle soreness;

36

Warm up and cool down sessions are important as they will:

• Improve exercise performance• Decrease the risk of injury• Reduce muscle soreness

1 of Session 3


Prior to beginning the exercise class remind participants to exercise at their own pace but to try and achieve an exercise intensity of 4 on the Borg Scale. Ask participants to inform you if they feel unwell during the exercise session. Explain to participants that we will be recording their oxygen saturation and heart rate on the exercise record sheet at the start of the class, after the walking circuit or if someone feels unwell.

Notes for PRINCE Physiotherapist

Remember that the aim of the exercise programme is to increase exercise tolerance. Thereforethe focus should be on the progressive nature of the exercises i.e. increasing distance covered and length of time walked rather than speed. The higher the intensity the participant exercises at the bigger the improvement will be. However, high intensity exercising may be limited by breathlessness. Try to ensure that participants avoid excessive breathlessness as they may become adverse to exercise training.

Walking exerciseExplain to participants that walking can improve their heart and lung function, exercise endurance and quality of life. Explain that walking doesn’t have to mean an exercise session; it can be fun like walking with friends and family, walking to the shop, or walking up and down a corridor. Explain that if they are walking up and down a corridor/hall, to count how many lengths walked and try and improve as able. Remind participants that it is important to walk at the correct pace, not to start off walking too quickly, to avoid breathlessness and aim to walk a little further each week.

Remind participants to keep a record of the time/distance walked before taking a rest break or the number of rest breaks taken when walking for 30 minutes. Emphasise participants need to walk at an exercise intensity of 4 on the Borg Scale. Explain to participants that there are other options to increase exercise endurance such as dancing, exercise bike/cycling.

Explain to participants that when they are walking up stairs, it is easier to practice bringing both feet up onto a step at a time and progressing that way. Another technique is breathing in when climbing up one step and breathing out when climbing up the next step. This will help to reduce breathlessness.

Activity 3.3 Remind participants that with the PRINCE educator in session 1 we looked at setting personal goals. Now ask participants to think about their personal goals for exercising and what they need to do to achieve those goals.

Take feedback and acknowledge and reaffirm participants positive strategies.

Explain that an exercise goal could be to walk to the shop and back without rests.

Help participants understand that short bursts of walking exercise (interval training) are as effective as prolonged exercise sessions (continuous training). Often people with COPD find ‘short burst’ exercising easier.

Emphasise that ideally at the end of the 7 weeks exercise sessions, they should be able to see an improvement in the distance they can walk with most participants being able to walk for up to 30 minutes.

Explain that Participants should aim to increase the length of time they can exercise for and decrease the rest time in between walks.

38 39

Progressive strengthening exercises

Explain to participants that progressive strengthening exercises increase muscle strength and mass thereby improving the ability to carry things, to move about and to carry out housework/work more easily. Explain that in this week’s session once a participant can perform 3 sets of 8-10 repetitions of an exercise easily in one go, then the exercise will be progressed by increasing the weight or increasing the number of sets. Inform participants that this is the weight that they will be using in the exercise class and that they will be carrying out 3 sets of 8-10 repetitions.

Note for PRINCE PhysiotherapistOnly prescribe weights in session 3, so that each participant has time to become familiar with the exercise protocol and the correct body position for the exercise. It is essential that the participant can perform all the exercises correctly, to decrease the risk of injury.

Once a participant can perform 3 sets of 8-10 repetitions of an exercise easily in one go, then the exercise can be progressed by increasing the weight or increasing the number of sets. This will be done by finding the repetition max. This is the maximum weight the participant can lift for 10 repetitions comfortably.

E.g. Leg weights: 3 sets of 8-10 repetitions – body weight Leg weights: 3 sets of 8-10 reps with __kg (or a suitable weight)

Explain to participants that all the strengthening exercises can be done on one day, but if they find this difficult, they can break the exercises up by performing arm exercises one day and leg exercises another day. Emphasise however that it is important to allow at least one day of rest between repeated strengthening exercises for the same muscle group, so as to avoid injury/ overtraining.

For example explain to participants that if they do all the strengthening exercises on Monday (arms and legs) then take a rest from all strengthening exercises on Tuesday. But they can still carry out the aerobic exercises on the Tuesday, but return to strengthening on Wednesday. However, if they do only arm strengthening on Monday, then they can do the leg strengthening on Tuesday.

Explain that in order to achieve increased muscle strength, the correct number of repetitions for each exercise must be completed and an exercise of 3 sets of 8 – 10 repetitions must be performed in one go. Emphasise that performing one set in the morning, one in the afternoon and the last set in the evening is not effective for muscle strengthening.

Outline to participants that the strengthening exercises can be performed seated or standing, whichever is the most comfortable position.

Walking exercise

• Walking can improve heart and lung function, exercise endurance and quality of life. • It can be fun like walking with friends and family, walking to the shop, or walking up and down a corridor. • If walking up and down a corridor/hall, count how many lengths walked and try and improve as able. • It is important to walk at the correct pace, not to start off walking too quickly and aim to walk a little further each week.• Keep a record of the time/distance walked before taking a rest break or the number of rest breaks taken when walking for 30 minutes. • Walk at an exercise intensity of 4 on the Borg Scale. • Other options - increase exercise endurance through dancing, or cycling.

2 of Session 3


Walking contd.

• Short bursts of walking exercise (interval training) are as effective as prolonged exercise sessions (continuous training). Often people with COPD find ‘short burst’ exercising easier. • At the end of the 7 weeks exercise sessions, you should be able to see an improvement in the distance you can walk and most of you should be able to walk for up to 30 minutes.• You should aim to increase the length of time you can exercise for and decrease the rest time in between walks.

3 of Session 3


4140

Guidelines for PRINCE physiotherapist re: pedals & step-ups• Pedals - use first with participants who cannot perform wall squats and then for the other participants depending on time;• In sitting, adjust resistance on pedals and inform participant to pedal for time at circuit station e.g. 3 minutes;• Remember that some participants will need assistance with step-ups for safety reasons;• Progress step-ups for participants by increasing the height of the step when they can easily exercise for 3 minutes on the low step.

Exercise class (practical) (Session 3) Remind participants to exercise at their own pace but to try and achieve an exercise intensity of 4 on the Borg Scale. Ask participants to inform you if they feel unwell during the exercise session. Explain to participants that we will be recording their oxygen saturation and heart rate on the exercise record sheet at the start of the class, after the walking circuit or if someone feels unwell.

Emphasise with participants that they:• Do not increase weights unless told to do so by the PRINCE physiotherapist;• Do not exercise on the day before or day of the exercise class;• Always leave at least one day of rest in between doing strengthening exercises for the same muscle groups to avoid fatigue and injury.

Establish the exercise class circuit as in exercise session 2 and remind participants that there are: • 10 stations that each participant needs to exercise at; • Each station takes 3 minutes;• Each participant needs to record how breathless they are after completing the station on The Borg Scale;• Each participant needs to record the number of repetitions they have done at each station.

Next commence the exercise class as outlined in the timetable at the start of this session. The types of exercises are the same as that listed in exercise session two. Following reassessment each week the number and intensity of the exercises undertaken by each participant will be reviewed.


• Increase’s muscle strength and mass thereby improving your ability to do normal daily activities• In this week’s session once you can perform 3 sets of 8 -10 repetitions of an exercise easily in one go, then the exercise will be progressed by increasing the weight or increasing the number of sets. • Strengthening exercises can be performed seated or standing, whichever is the most comfortable position.

4 of Session 3



• This is the weight that you will be using in the exercise class and you will be carrying out 3 sets of 8-10 repetitions. in order to achieve in creased muscle strength, that the correct number of repetitions for each exercise must be completed and an exercise of 3 sets of 8 – 10 repetitions must be performed in one go. Emphasise that performing one set in the morning, one in the afternoon and the last set in the evening is not effective for muscle strengthening.

5 of Session 3


Progressive strengthening exercises contd.

• In order to achieve increased muscle strength, the correct number of repetitions for each exercise must be completed and an exercise of 3 sets of 8 – 10 repetitions must be performed in one go. • Performing one set in the morning, one in the afternoon and the last set in the evening is not effective for muscle strengthening.• The strengthening exercises can be performed seated or standing, whichever is the most comfortable position.

6 of Session 3


Progressive strengthening exercises contd.

• All the strengthening exercises can be done on one day, but if you find this difficult, you can break the exercises up by performing arm exercises one day and leg exercises another day. • However it is important to allow at least one day of rest between repeated strengthening exercises for the same muscle group, so as to avoid injury or overtraining.

7 of Session 3


Exercise class (Practical) Session 3

• Exercise at you own pace but to try and achieve an exercise intensity of 3 on the Borg scale. • Please let us know if you feel unwell during the exercise session. • Do not increase the weights unless told to do so by the PRINCE physiotherapist• Do not exercise on the day before or day of the exercise class.• Always leave at least one day of rest in between doing strengthening exercises for the same muscle groups to avoid fatigue and injury.

8 of Session 3


42




• A3 Borg Breathless Scale for each station; • A3 exercise record board for each station;• Blue tack; • Chairs (one per participant);• Clock with large face; • Cones;• Exercise posters for each station; • Exercise steps (adjustable);• Flip chart and pens; • Non slip mat;• O2 and tubing; • Pedals;• Pedometer; • Pens (Biros);• Pulse oximeter; • Stop watch X2;• Table or stable surface at waist height; • Tape measure;• Therabands; • Weights:• DVD of Exercise Session 4 - adjustable for ankles; PowerPoint presentations. - dumbbells for arms;


• Understand the importance of stretching exercises;• Receive feedback on how home exercises are progressing

43

Introduction Welcome and thank participants for attending. Ask participants how they got on with their home exercises last week and if they recorded their activities in their home diary. Find out if anyone; had any difficulties; felt any benefits for example if they could walk further. Ask participants if they have any queries and clarify same.

Emphasise home exercise is essential to their success with this programme

Stretching ExercisesStretchingExplain to participants that people, who are often breathless or cough a lot, can develop a curve in their upper spine. Explain to participants that flexibility exercises and stretching can help to prevent this from happening. However, emphasise that exercising alone is not enough to prevent this; they also need to be conscious of their posture and regularly check to make sure they are not ‘stooping’.

Explain to participants that they can ‘cue’ themselves to help remember not to ‘stoop’. For example, every time they see a tap, imagine they are ‘opening out their chest’ and draw their shoulders back.

Remind participants to exercise at their own pace but to try and achieve an exercise intensity of 4 on the Borg Scale. Ask participants to inform you if they feel unwell during the exercise session. Explain that we will be recording their oxygen saturation and heart rate on the exercise record sheet at the start of the class, after the walking circuit or if someone feels unwell.

Guidelines for PRINCE Physiotherapist re: pedals & step-ups• Pedals - use first with participants who cannot perform wall squats and then for the other participants depending on time;• In sitting, adjust resistance on pedals and inform participant to pedal for time at circuit station e.g. 3 minutes;• Remember that some participants will need assistance with step-ups for safety reasons;• Progress step-ups for participants by increasing the height of the step when they can easily exercise for 3 minutes on the low step;

45



• Explain the benefits of stretching exercises


• Group work


• Show PowerPoint “Stretching” - Slide 1 of Session 4


Stretching exercises (10 minutes)

Exercise timetable


• Warm-up


Cool-down



• Each participant (depending on ability) to carry the following activities: - Arms pull backward with theraband; - Shoulder flexion; - Trunk rotation; - Calf stretches; - Hamstring stretches.

• Each participants (depending on ability) to walk for 3 mins around cones (measure distance) Use pedometer (record steps) Measuring 4 on the Borg Scale



• Each participant (depending on ability) to carry out 3 sets 8 -10 reps prescribed weights for biceps curl and leg weights • Measuring 4 on the Borg Scale

• Walk 5 minutes (1-2 Borg Scale)

5 minutes

45 minutes (Each participant to do 3 mins at each station)

5 minutes

44

Stretching

• People, who are often breathless or cough a lot, can develop a curve in their upper spine. • Flexibility exercises and stretching can help to prevent this from happening. • However, exercising alone is not enough to prevent this; you also need to be conscious of your posture and regularly check to make sure that you are not ‘stooping’. • You can ‘cue’ yourself to help remember not to ‘stoop’. For example, every time they see a tap, imagine they are ‘opening out their chest’ and draw their shoulders back.

1 of Session 4





• A3 Borg Breathless Scale for each station; • A3 exercise record board for each station;• Blue tack; • Chairs (one per participant);• Clock with large face; • Cones;• Exercise posters for each station; • Exercise steps (adjustable);• Flip chart and pens; • Non slip mat;• O2 and tubing; • Pedals;• Pedometer; • Pens (Biros);• Pulse oximeter; • Stop watch X2;• Table or stable surface at waist height; • Tape measure;• Therabands; • Weights: - (adjustable for ankles); - dumbbells for arms;


• Understand medications and exercise/medications and risk of falls;• Receive feedback on how home exercises are progressing.



• Review the use of medications when exercising


• Group work



Medications and exercise (10 minutes)

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Exercise class (practical) (Session 4) Establish the exercise class circuit as in exercise session 2 and remind participants that there are: • 10 stations that each participant needs to exercise at;• Each station takes 3 minutes;• Each participant needs to record how breathless they are after completing the station on the Borg Scale; • Each participant needs to record the number of repetitions they have done at each station.


Medications and exerciseExplain to participants that correctly timing their exercise regimen around taking their medication can often make exercising a little easier. Explain that exercising half an hour after they have taken their bronchodilator can decrease breathlessness or exercising half an hour after taking pain killers can make exercising easier. Emphasise that they should not exercise after taking medications as that can cause them to become drowsy or tired.

Explain to participants that some side effects of some medications can result in a greater risk of falling and bone fractures. Explain that exercise can improve balance; muscle and bone strength and decrease the risk of falling. Remind participants that they should not exercise if they feel dizzy or light headed, but to sit and wait a few minutes to see if this resolves. Emphasise that if the symptoms persist longer than 10 minutes or become worse, they should contact their GP or practice nurse.

Remind participants to exercise at their own pace but to try and achieve an exercise intensity of 4 on the Borg Scale. Ask participants to inform you if they feel unwell during the exercise session. Explain that we will be recording their oxygen saturation and heart rate on the exercise record sheet at the start of the class, after the walking circuit or if someone feels unwell.

Exercise class (practical) (Session 5)Establish the exercise class circuit as in exercise session 2 and remind participants that there are: • 10 stations that each participant needs to exercise at;• Each station takes 3 minutes;• Each participant needs to record how breathless they are after completing the station on The Borg Scale; • Each participant needs to record the number of repetitions they have done at each station.


49

Exercise timetable


• Warm-up


Cool-down







• Each participant (depending on ability) to carry out 3 sets 8 -10 reps prescribed weights for biceps curl and leg weights


5 minutes


2 minutes

Introduction Welcome and thank participants for attending. Ask participants how they got on with their home exercises last week and if they recorded their activities in their home diary. Find out if anyone had any difficulties/felt any benefits; for example if they could walk further. Ask participants if they have any queries and clarify same.

48

51



• What to do if an exacerbations of their COPD occurs during exercise and afterward


• Group work


• Show PowerPoint “Exercise Advice during exacerbations of COPD” – Slides 1-2 of Session 6 (x 2 slides)


Exercise & exacerbations of COPD (10 minutes)

Exercise timetable


• Warm-up


Cool-down





• Legs:- Leg weights; - Step ups; - Sit to stand; - Wall squats;- Pedals.

• Arms:- Biceps curls; - Arm circles;- Arm wings; - Wall press;- Shoulder lifts.



• Walk 5 minutes (1-2 Borg Scale)

5 minutes


5 minutes

50




• A3 Borg Breathless Scale for each station; • A3 exercise record board for each station;• Blue tack; • Chairs (one per participant);• Clock with large face; • Cones;• Exercise posters for each station; • Exercise steps (adjustable);• Flip chart and pens; • Non slip mat;• O2 and tubing; • Pedals;• Pedometer; • Pens (Biros);• Pulse oximeter; • Stop watch X2;• Table or stable surface at waist height; • Tape measure;• Therabands; • Weights:• DVD of exercise Session 6 - adjustable for ankles; PowerPoint presentations. - dumbbells for arms;


• Understand how to adjust exercises during an exacerbation of COPD;• Receive feedback on how home exercises are progressing

53

Emphasise with participants that they: • Should not exercise if they are short of breath;• Should not exercise if they have a temperature or feel dizzy;• Should avoid exercising in hot or cold weather.

Remind participants to exercise at their own pace but to try and achieve an exercise intensity of 4 on the Borg Scale. Ask participants to inform you if they feel unwell during the exercise session. Explain to participants that we will be recording their oxygen saturation and heart rate on the exercise record sheet at the start of the class, after the walking circuit or if someone feels unwell.

Exercise class (Practical) (Session 6) Establish the exercise class circuit and remind participants that there are: • 10 stations that each participant needs to exercise at;• Each station takes 3 minutes;• Each participant needs to record how breathless they are after completing the station on The Borg Scale;• Each participant needs to record the number of repetitions they have done at each station.


52

Introduction Welcome and thank participants for attending. Ask participants how they got on with their home exercises last week and if they recorded their activities in their home diary. Find out if anyone; had any difficulties; felt any benefits for example if they could walk further. Ask participants if they have any queries and clarify same.

Exercise and exacerbations of COPD This session focuses on helping participants to manage their breathing when exercising and an exacerbation of their COPD occurs.

Emphasise with participants that if an exacerbation occurs they should:

• Stop exercising temporarily until symptoms have improved;• Decrease the intensity of their exercise i.e. do not use weights; reduce sets or repetitions, reduce walking time/distance, avoid walking up hills; • Take extra rests/rest days;• Use controlled coughing techniques, the Huff coughing technique, pursed lip breathing, diaphragmatic breathing and positions of ease.

Explain to participants that following an exacerbation they must consult with their GP or physiotherapist first, before resuming their exercise programme, as their ability to exercise and their fitness levels may have dropped.

Emphasise that it is important to resume regular exercise as soon as they are well again. This can help to speed up their recovery and decrease the risk of developing another exacerbation. Emphasise that it is important that the exercise is built up gradually.

Exercise Advice during exacerbations of COPD

• Stop exercising temporarily until symptoms have improved• Decrease the intensity of the exercise i.e. do not use weights; reduce sets or repetitions, reduce walking time/distance, avoid walking up hills • Take extra rests/rest days• Use controlled coughing techniques, the Huff coughing technique, purse lip breathing, diaphragmatic breathing and positions of ease

1 of Session 6


Exercise Advice during exacerbations of COPD contd.

• Following an exacerbation you must consult with your physiotherapist or GP first, before resuming the exercise programme, as your ability to exercise and your fitness levels may have dropped.• It is important to gradually resume regular exercise as soon as you are well again. This can help to speed up recovery and decrease the risk of developing another exacerbation.

2 of Session 6


You should also avoid exercising

• If you are short of breath.• Have a temperature or feel dizzy• The weather is too hot or too cold

3 of Session 6


54 55




• A3 Borg Breathless Scale for each station; • A3 exercise record board for each station;• Blue tack; • Chairs (one per participant);• Clock with large face; • Cones;• Exercise posters for each station; • Exercise steps (adjustable);• Flip chart and pens; • Non slip mat;• O2 and tubing; • Pedals;• Pedometer; • Pens (Biros);• Pulse oximeter; • Stop watch X2;• Table or stable surface at waist height; • Tape measure;• Therabands; • Weights:• DVD of exercise Session 7 - adjustable for ankles; PowerPoint presentations. - dumbbells for arms;


• Understand the benefits of exercise in reducing stress;• Be able to minimise exercise related stress;• Be aware of exercises which can help to reduce stress;• Receive feedback on how home exercises are progressing.

56 57



• Understanding how exercise can reduce stress and that exercise should not become a stressful activity


• Group work


• Show PowerPoint “Exercise & Stress” – Slide 1-3 of Session 7


Exercise & stress (10 minutes)

Exercise timetable


• Warm-up










5 minutes


Cool-down • Walk 4 minutes (1-2 Borg Scale)5 minutes

Introduction Ask participants how they got on with their home exercises last week and if they recorded their activities in their home diary. Find out if anyone had any difficulties/felt any benefits; for example if they could walk further. Remind participants to pace themselves during exercise.

Encourage participants to keep expanding their exercise regimen as able, e.g. take shorter rests, exercise for longer, and achieve more sets of arm and leg exercises.

Exercise and stress This session focuses on helping participants understand how exercise can reduce stress and that exercise itself should not become a stressful activity.

Explain to participants that exercise reduces stress by: • Releasing chemicals from the brain into the blood stream called endorphins which increase feelings of well being and good mood. This decreases the feelings of depression and anxiety;• Decreasing high blood pressure and cardiovascular risk e.g. high cholesterol;• Reducing built up tension; • Helping people to sleep better;• Increasing confidence;• Increasing energy levels, to cope better with stressful situations;• Helping people feel more peaceful and calm.

Explain that going for a peaceful walk can sometimes help to decrease stress and give a person time alone, or walking with someone can give the time to discuss what is making a person feel stressed. Exercises such as yoga, Tai chi, or getting a massage, may also help to decrease stress.

Emphasise exercise should not be stressful. It should be enjoyable, so if it is making anyone anxious or stressed they should try to change some aspects of their exercise regimen to suit their lifestyle, for example, choose an exercise that you enjoy, exercise with a friend, choose a time of day that suits them – some people exercise better in the mornings, whereas other people exercise better in the evenings. Emphasise that they should not feel guilty if they miss a day, but don’t give up! It is important that they start exercising as soon as possible again to maintain health benefits.

Exercise & Stress

Exercise reduces stress by • Releasing chemicals from the brain into the blood stream called endorphins which increase feelings of well being and good mood. This decreases the feelings of depression and anxiety.• Decreasing high blood pressure and cardiovascular risk e.g. high cholesterol.• Reducing built up tension. • Helping people to sleep better.• Increasing confidence.• Increasing energy levels, to cope better with stressful situations.• Helping people feel more peaceful and calm.

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Remind participants that they decide - when, where, and how they want to exercise. Encourage participants to feel proud of their achievements and commitment to exercise – remind participants that every time they exercise they have done something positive for themselves and for their health.

Remind participants that breathlessness is a common symptom of COPD and of exercising, therefore, try not to become stressed or anxious if they become breathless. Emphasise that if they do become anxious or stressed, to use diaphragmatic breathing and or pursed lip breathing and to try performing some of the relaxation techniques which will be covered in the next session to help decrease their stress levels

Remind participants to exercise at their own pace but to try and achieve an exercise intensity of 4 on the Borg Scale. Ask participants to inform you if they feel unwell during the exercise session. Explain to participants that we will be recording their oxygen saturation and heart rate on the exercise record sheet at the start of the class, after the walking circuit or if someone feels unwell.

Exercise & Stress contd.

• Exercise should be enjoyable, not stressful so if it is making you anxious or stressed you should try to change some aspects of your exercise regimen to suit you lifestyle, for example, choose an exercise that you enjoy, exercise with a friend, choose a time of day that suits them – some people exercise better in the mornings, whereas other people exercise better in the evenings.• Do not feel guilty if you miss a day, but don’t give up! It is important to resume your exercising regime the next day or as soon as possible

2 of Session 7


Exercise & Stress contd.

• You decide - when, where, and how you want to exercise. • Every time you exercise you have done something positive for yourself and for your health.• Remember breathlessness is a common symptom of COPD and of exercising, therefore, try not to become stressed or anxious if you become breathless.• If you do become anxious or stressed, use diaphragmatic breathing and or pursed lip breathing and to try performing some of the relaxation techniques which will be covered in the next session to help decrease stress levels.

3 of Session 7


Guidelines for PRINCE Physiotherapist re: pedals & step-ups• Pedals - use first with participants who cannot perform wall squats and then for the other participants depending on time;• In sitting, adjust resistance on pedals and inform participant to pedal for time at circuit station e.g. 3 minutes;• Remember that some participants will need assistance with step-ups for safety reasons;• Progress step-ups for participants by increasing the height of the step when they can easily exercise for 3 minutes on the low step.

Exercise class (Practical) (Session 7) Establish the exercise class circuit as in exercise session 2 and remind participants that there are: • 10 stations that each participant needs to exercise at; • Each station takes 3 minutes;• Each participant needs to record how breathless they are after completing the station on The Borg Scale;• Each participant needs to record the number of repetitions they have done at each station;• Ask Participants to inform you if they feel unwell during the exercise session.


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• Explaining the importance of and benefits to maintaining their exercise regime

• Review how to exercise safely


• Group work


• Show PowerPoint “Long term exercise maintenance” – Slide 1 of Session 8

• Show PowerPoint “When exercising at home…” – Slide 2 of Session 8

• Show PowerPoint “Tips for maintaining long term exercise” – Slides 3-4 of Session 8 (x 2 slides)

• Give handout on “Tips for main taining long term exercise”

• Group work Show PowerPoint on “You should stop exercising if you feel any of the following” -Slides 5-6 of Session 8 (x 3 slides)

• Show PowerPoint “More Tips for maintaining long term exercise” – Slide 7 of Session 8


Long-term exercise maintenance (15 minutes)

Exercise timetable


• Warm-up • Walk/marching on spot swinging arms side stepping



5 minutes

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• A3 Borg Breathless Scale for each station; • A3 exercise record board for each station;• Blue tack; • Chairs (one per participant);• Clock with large face; • Cones;• Exercise posters for each station; • Exercise steps (adjustable);• Flip chart and pens; • Non slip mat;• O2 and tubing; • Pedals;• Pedometer; • Pens (Biros);• Pulse oximeter; • Stop watch X2;• Table or stable surface at waist height; • Tape measure;• Therabands; • Weights:• DVD of exercise Session 8 - adjustable for ankles; PowerPoint presentations; - dumbbells for arms;• Handouts for each participant of “Tips for maintaining long term exercise”.


• Understand the necessity of regular, continued exercise;• Understand how to keep achieving gains from exercise;• Learn ways to maintain exercise in their lifestyles;• Be able to use the home exercise handout as a resource for independent exercising;• Receive feedback on how home exercises are progressing.

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• Each participant (depending on ability) to carry out 3 sets 15 reps prescribed weights for biceps curl and leg weights


Cool-down • Walk 5 minutes (1-2 Borg Scale)5 minutes

Introduction Congratulate participants on their attendance, participation and commitment to the exercise programme over the past 8 weeks.

Ask participants how they got on with their home exercises last week and if they recorded their activities in their home diary. Find out if anyone; had any difficulties/felt any benefits; for example if they could walk further. Remind participants to pace themselves during exercise.

Long-term exercise maintenanceThis session focuses on the fact that over the past 8 weeks participants have been gradually building up their exercise activities and exercise should now be a part of their daily life. The need to encourage participants to continue with their home exercise activities now that the programme is finished must be emphasised.

Explain to participants the importance of continuing their exercise regimen of walking and arm and leg strengthening exercises once the programme has ended. Remind participants, that in order, to maintain the beneficial effects of exercise, e.g. increased muscle strength, increased exercise endurance, increased fitness levels, increased energy levels and increased feeling of well being, they must continue to exercise regularly, 30 minutes, 3 – 5 times and a week. Emphasise that exercising should be specific to each person, and should be continued along the same lines as the supervised exercise programme.



Explain to participants that when exercising at home they should:

• Walk for 30 - 40 minutes 3 - 5 times per week. Explain that this can be a number of short walks or one long walk as long as it adds up to the required length of time i.e. 30-40 minutes 3-5 times per week;• Perform strengthening exercises: 3 sets of 10-15 repetitions of arm exercises and leg exercises 3 times per week;• Keep monitoring their exercise ability and to progress the exercises and walking, in the same way as during the exercise programme, that is depending on your ability. Remind participants that we will be following up on their progress over the next 18 months. Explain that the details of the follow up programme will be explained in the next session today.

Give participants the handout on “Tips for maintaining long term exercise” and guide them through it.

Tips for maintaining long term exercise:• Choose an exercise you enjoy e.g. walking, aqua aerobics, aerobic class, gym, table tennis etc;• Make time for exercise, pencil it in your diary/calendar, 30 minutes 3 to 5 days a week – this is your time to gain health benefits;• Exercise with a friend/group some days. Exercising with a friend or group can be very motivational and you are more committed to exercise;

Long-term Exercise Maintenance

• In order, to maintain the beneficial effects of exercise, - increased muscle strength, - increased exercise endurance, - increased fitness levels, - increased energy levels a - increased feeling of well being, • You must continue to exercise regularly, 30 minutes, 3 – 5 times and a week. • exercising is specific to each person, and should be continued along the same lines as the supervised exercise programme.

1 of Session 8


When exercising at home

• Walk for 30-40 minutes 3-5 times per week. This can be a number of short walks or one long walk as long as it adds up to the required length of time i.e. 30-40 minutes 3-5 times per week.• Perform strengthening exercises: 3 sets of 10-15 repetitions of arm exercises and leg exercises 3 times per week.• Keep monitoring your exercise ability and progress the exercises and walking, in the same way as during the exercise programme.

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Activity 8.1 Ask Participants to list the symptoms that would alert them to stop exercising?

Take feedback and acknowledge and reaffirm participants positive strategies

Expected answers should include the following:

• Chest pain or tightness;• Palpitations – irregular and fast heart rate associated with shortness of breath;• Nausea or dizziness;• Cold or clammy;• Increased wheezing;• Pain in joints or muscles;• Extreme tiredness;• Severe headache.

Reaffirm and acknowledge with participants the symptoms they identified which are similar to those listed in this list.

Remind participants that they should stop exercising, sit down, and perform some of the helpful breathing strategies that they have learnt over the past number of weeks for example pursed lip breathing, diaphragmatic breathing, control coughing technique, and adopt a position of ease. Emphasise that if the symptoms persist longer than 10 minutes or become worse, they should contact their GP or practice nurse.

• Choose a time of day that suits you;• Do not feel disappointed, if you are unable to exercise as you had planned due to unforeseen reasons. Just return to your exercise plan the next day. Don’t give up;• Set your exercise goals, what you want to achieve from exercise e.g. walk half a mile without stopping, walk 5 times for 30 minutes in a week;• Keep an exercise diary. This is a good way of tracking your progress and for motivating you to keep up your levels of fitness gained through exercise;• Remember exercise makes you feel good about yourself and improves your confidence levels as well as all the health benefits mentioned earlier.

Exercising safelyExplain to participants that we will now take a few minutes to recap on the importance of exercising safely as discussed in exercise session 2.

Brain storm with participants to carry out the following activity.

Tips for Maintaining Long Term Exercise

• Choose an exercise you enjoy e.g. walking, aqua aerobics, aerobic class, gym, table tennis, etc.• Make time for exercise, pencil it in your diary/calendar, 30 minutes 3 to 5 days a week – this is your time to gain health benefits.• Exercise with a friend/group some days. Exercising with a friend or group can be very motivational and you are more committed to exercise.• Choose a time of day that suits you.• Do not feel disappointed, if you are unable to exercise as you had planned due to unforeseen reasons. Just return to your exercise plan the next day. Don’t give up!

3 of Session 8


Tips for Maintaining Long Term Exercise contd.

• Set your exercise goals re what you want to achieve from exercise e.g. walk half a mile without stopping, walk 5 times for 30 minutes in a week.• Keep an exercise diary. This is a good way of tracking your progress and for motivating you to keep up your levels of fitness gained through exercise.• Remember exercise makes you feel good about yourself and improves your confidence levels as well as all the health benefits mentioned earlier.

4 of Session 8



• Chest pain or tightness• Palpitations – irregular and fast heart rate associated with shortness of breath• Nausea or dizziness• Cold or clammy • Increasingly wheezy• Pain in joints or muscles• Extreme tiredness• Severe headache

5 of Session 8


You should stop exercising contd:

• Sit down, • Perform pursed lip breathing, • Adopt a position of ease • If the symptoms persist longer than 10 minutes or become worse, contact your GP or practice nurse.

6 of Session 8


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PRINCE Physiotherapist Comments

Session 1:

Explain to participants that they should reduce their exercise intensity/walking, if their exercise programme has been interrupted for a few days (e.g. due to illness, bad weather) and then gradually progress the exercises again.

Explain to participants that the advice and educational handouts that they have received during the programme should have all they need to know on how to keep exercising independently in the future. However, inform participants that if they have any questions to please contact you or the practice nurse at ________________.

Exercise class (practical) (Session 8) Establish the exercise class circuit as in exercise session 2 and remind participants that there are: • 10 stations that each participant needs to exercise at; • Each station takes 3 minutes;• Each participant needs to record how breathless they are after completing the station on The Borg Scale;• Each participant needs to record the number of repetitions they have done at each station.


More Tips for Maintaining Long Term Exercise contd.

• You should reduce your exercise intensity/walking, if your exercise programme has been interrupted for a few days (e.g. due to illness, bad weather) and then gradually progress the exercises again. • The advice and educational handouts that you have received during the programme should have all you need to know on how to keep exercising independently in the future. • If you have any questions to please contact you or the practice nurse at ________________.

7 of Session 8


Session 2: Session 3:

Session 8:

prince structured education programme part two ......introduction to part 2 this section of the...

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