Dr. Dustin Jones // #GeriOnICE // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Dustin Jones shares tips to make HIIT more objective, being diligent with monitoring vital signs, and underdosing high-intensity with medically complex patients when needed.

Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog.

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EPISODE TRANSCRIPTION

INTRODUCTION Hey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the PT on ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account.

DUSTIN JONES Alright folks, welcome to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. My name is Dustin Jones, one of the older adult faculty within the MMOA division. Today we are talking about the top tips to apply high-intensity interval training amongst medical complexity. So I think many of us have been there, right? We're working with that individual that has a whole laundry list of different diagnoses, different medications on board, maybe in a more acute setting. And we know that high intensity interval training is helpful for people. We've seen some literature, we've read some of the research, but what does it actually mean to apply this amongst a very complex situation? All right. So we're going to cover, some key takeaways from a super helpful article that was published last year in 2023 in the Cardiopulmonary Physical Therapy Journal titled, Putting It All Together, An Evidence-Based Guide to High-Intensity Interval Exercise Prescription for Patients with Complex Comorbidities. And I really appreciated the team that wrote this article because it is difficult to navigate, right? Like, we will see some of these headlines of high-intensity interval training proven to be effective in the ICU, for example, or HIT being effective with folks that have recently suffered from a stroke. Some of these things we typically wouldn't associate high-intensity interval training with, but it's been shown to be effective. Now, when we go to apply that, it can be rather intimidating, right? I can speak to this mainly from the home health setting where The trend in home health is that people are getting discharged from more acute settings like the hospital a little too soon, right? So you have these very medically complex individuals in their home with very limited monitoring, medical support if something goes awry, and all the negative thoughts and what coulds, right? What could happen starts to creep into your head, and that can dramatically influence our intervention. Let's talk about three, I've got three main tips for y'all, things that I have learned through mainly mistakes in my career, but then also what this article talks about. One is objectify, two is monitor, three is, I'm gonna save that one for last. BE OBJECTIVE WITH HIGH-INTENSITY TRAINING All right, so the first one, we go to apply high intensity interval training. We need to be objective. Here's what can typically happen. You read an article, you maybe hear a PT on Ice daily show podcast, see a social media post like, all right, I'm going to use this with Betty tomorrow. All right, Betty, we're going to do high intensity interval training. And you're already working on gait training, for example. with Betty and so you're going to be like all right Betty I want you to go fast for 30 seconds and then I want you to walk slow for 30 seconds we're going to do that for a total of 10 minutes right great start I love what you're doing there you got a one-to-one work rest ratio it's already a goal that Betty has to improve her ambulation ability, maybe even distance endurance. Awesome. But what typically happens, right? She goes to do her fast walk. What does that actually look like? Is it fast? Or is it just slightly faster than her normal or a slower walking speed? All that I'm saying here is when, say ambulation, when we aren't objectifying it, when we aren't giving people a number to hit, to look to, to get that real-time feedback loop, they will often undershoot their intensity. This is where the ergometers that many of us have access to can be very, very helpful. A lot of these things are, they're collecting a lot of dust in a lot of clinics, to be honest, right? Like the new step. It's either collecting dust or we're throwing people on there for 20 minutes while you finish your notes or they take a nap, right? We got our recumbent bike. Maybe you have a rower, maybe you have an echo bike, maybe you have a ski in your clinic, but these are functionally all ergometers that are measuring work, they're measuring speed, they're measuring distance traveled. Those are objective metrics that we can use for dosage, that we can use to give people that target to try and hit to make sure you're reaching an intensity. Right, RJ, outpatient, has an Echobike. Echobike, you look at that screen, you've got calories, you've got watts, you've got your revolutions, right? You've got your distance. These are all things that we can use to set a goal to achieve appropriate intensity while we're performing our intervals. So RJ, for example, with the Echobike, it may be watts, right? You may say, pick a number of watts that you're trying to hit. during that 30-second interval and then it's going to be 30 seconds easier, 30 seconds rest for maybe like a total of 10 minutes with someone. Giving them that objective thing to look at is going to be so much more effective than just quote-unquote saying go faster, all right? NuSTEP has the same thing, right? Many of you all have already, I shouldn't say wasted the money, the NuSTEP can be helpful with certain patient populations But my gosh, the price per square foot of a NuStep is absolutely ridiculous. But if you already sunk the money and have one, freaking use it, man. That thing has all kinds of data and information that we can use to really redeem the NuStep, redeem that piece of equipment and achieve a higher intensity. All right? That's the first one. We need to objectify what that high intensity actually looks like. Use ergometers. If you don't have the ergometer, maybe use something like a percentage of a heart rate, for example, some other metrics that we can use to objectify. MONITOR VITALS Speaking of heart rate, number two is going to be monitor. Now, this is what really allows us to apply higher intensity intervals with medically complex individuals, is when we are monitoring Vital signs and signs or symptoms. Vital signs are absolutely huge especially in so many acute settings. Hopefully many of you all are getting them at rest initially, hopefully at least bare minimum at the initial evaluation, right? But when you're working with more acute individuals, you have these complex comorbidities. We need to be checking vitals every visit, but then when we're applying these high intensity intervals, it can be very helpful and advantageous for you to check vitals before, during exercise, and then after to gauge their response. Now I'm not saying check every single vital sign, right? But there's gonna be some pertinent ones based on who you're working with, right? So like if I have someone that is constantly cruising, you know, in the 150s over 90s blood pressure, they're pretty hypertensive. It's not managed terribly well. They sometimes have some symptoms, but a lot of times it's asymptomatic. I'm going to be checking blood pressure pretty regularly. I'll also be checking their heart rate as well. And I can do that during, and before, during, and after an interval. That's where these ergometers can be really helpful. Like a new step, for example, when I program that interval, they're working hard, but then they have that rest. That rest is when we check our vitals. I'll support their arm, get a manual blood pressure reading, and you're going to be able to gauge their response and make sure that you're in a safe zone, right? And the way we like to think about these zones is we like to think about them as traffic lights. So there's a red light in terms of things that you may see where we're going to stop exercise and a yellow light where we're going to be cautious but proceed and then green is just full send. We go into those in our Level 2 course, related to resting vitals, exercise vitals, signs and symptoms as well, related to high-intensity interval training. But for our purposes here, we want to monitor during, so you'll have a good idea of how they're responding. Another one is if someone has some type of cardiopulmonary issue, then a pulse ox can be really helpful, looking at oxygen saturation. We can see their response, make sure we're good to go, and we can adjust our dosage based on that. when we're able to monitor those vital signs it's going to give you an objective view of what's actually happening and I don't know about y'all but here's what typically happens with me is I may throw someone on a new step for example a recumbent bike and we're doing high intensity interval training and I know they've got some cardiopulmonary issues on board, some things that I'm somewhat concerned about, and I literally tell them to go hard. I may give them, you know, hit this number of watts during these hard intervals, and I literally am closing my eyes, crossing my fingers, praying to the rehabilitation gods that something bad doesn't happen. But if we're able to monitor and get that objective information, you can rest assured that you're giving that person exactly what they need, and it is safe. UNDERDOSE THE HIGH-INTENSITY FOR MEDICALLY COMPLEX PATIENTS Alright, so first we need to objectify it, second we need to be able to monitor it, and then third and the counterintuitive one, but it's the reality when we're going to apply high-intensity interval training amongst medical complexity, is that we need to underdose. I hate to say it y'all, but we need to underdose. Oftentimes, I'm not gonna say always, but oftentimes these folks are have a lot on board, right? And from the medical side, but then also from the psychological side, you take someone that has been given the diagnosis of heart failure and imagine what that feels like, right? You may have some perspective of what that actually means, a prognosis of that and what people can continue to do with a diagnosis like that. But there's so many individuals that will get these seven syllable medical diagnoses and they literally view it as a death sentence and they're actively falling apart right in front of your eyes. And that is not necessarily the case. There's a lot of psychological damage as well as physical damage along with these medical complexities. And it can be very advantageous when you introduce something novel and new like high intensity interval training to do it in a very approachable manner. This is where I am typically when I'm introducing I may use something like a subjective report, like an RPE, a rating of perceived exertion. That goes against the first thing I said, right? I told you you need to objectify it, but maybe initially, we want them to be a little bit more in the driver's seat and give them that RPE. You may say, I want you to go hard, I want you to go fast, I want you to go at a seven out of 10, RPE of 10 is your all-out effort, right? Initially, I think that is helpful. But we don't want to stay there because most of the time, people's true high intensity doesn't necessarily match up with their perception of high intensity. And that's where we need to be objective to calibrate that. But initially, I think under dosage, self-report can be very, very helpful. We also need to consider what these high-intensity intervals can do to people outside of our session, right? I learned this the hard way way too many times in home health, where we'd have this epic session. We'd be gone for about 20, 25 minutes, high-intensity intervals, you know, doing steps or ambulation, and then we do some transfer training. I'd take them, walk them out to their mailbox and back. They haven't seen the sunshine in weeks. Man, it was an epic session. And then I come back in a few days. What has that person done since that session? Nothing, right? They weren't able to do their laundry. They weren't able to do any tasks around their home. they were laid up because I absolutely gas them. And so we want to be able to leave gas in the tank for many of these individuals to be able to do things that are really important to them like ADLs, like IADLs, maybe a certain social function, right? And so when we start with that under dosage, you will be able to tweak and progress without impacting the rest of their life too much. which is really important. Many of you all may not have experienced that, right? I think many of you all probably did MRF, right? Memorial Day, high volume, you're working real hard for, you know, 40, 50, 60 minutes, maybe more if you're me, right? How'd you feel after that, right? Many of you all, myself included, were absolutely wiped and that's what a 10-minute session can do for some of these individuals. SUMMARY So, We may want to introduce it in an underdosed manner, see how they respond, make it approachable, and then gradually progress it from there. Then we start to objectify it, give them that target for, I want you to hit this many watts, for example, or this many revolutions per minute. And then we continue to monitor their vitals before, during and after those intervals, and you've got a potent cocktail that can really influence people's functional capacity, but then also the disease process that they are suffering from, and most importantly, it can be safe. All right, let me know your thoughts. Let me know any tips that you have from applying high-intensity interval training amongst medical complexity. I would love to hear from the folks in the ICU, in acute care, in skilled nursing facilities, in acute rehab, where you're dealing with a lot of medical complexity. Love to hear from you all. Drop in the chat on this Instagram video, or if you're watching on YouTube, if you're listening on the podcast, we're grateful for you listening. Hop on social media, and I'd love to hear your take as well. Hope this was helpful. I'll also put the citation for the article, the really helpful article, in the comments on Instagram as well. All right, hope you all have a lovely rest of your Wednesday. Go crush it, and I'll talk to you soon.

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