Healthy Mom, Healthy Family (Exercising with Multiple Morbidities)

Abstract

A patient with asthma, Type II diabetes, hypertension and obesity presented with right lower limb cellulitis. Multiple surgeries were performed and she was left with two large wounds medially and laterally extending from her ankle up to her mid-calf region, a stiff ankle and an oedematous foot. It was initially presumed that this was the type of patient that would not be very physically active and that she would be difficult to motivate to participate in regular exercise. This assumption was completely incorrect. Once this patient understood the clear health benefits of physical activity to each of her different conditions and realized that being healthy would keep her out of hospital and with her children, she did not need any other input and was able to successfully push herself to exercise harder as the program progressed with marked results.

Introduction

First impressions and judgement of a patient’s motivation to exercise can often be incorrect. A patient’s internal motivation can come from many different areas rather than one specific source.

Case Presentation

Mrs. X was a 46 year old female patient presenting with right lower limb cellulitis. She underwent four incision and drainage surgeries and was transferred for rehabilitation two weeks later. She had multiple co-morbidities such as obesity (BMI = 30), asthma, Type II diabetes and hypertension.

Medication

She used an inhaler as needed, was on a sliding scale for insulin injection and was on medical treatment for her blood pressure.

She had a myocardial infarction in 2011 but no complications or complaints since that time.

Tests and investigations

Doppler of right lower limb – Nil of note

Social History

Married with five children. She lives in a four room house with electricity and running water and a toilet outside the house. She is the sole breadwinner of the family and her work entails walking to a school our hour from her home to sell food.

Clinical presentation

• Mental state: Alert and responsive
• Chest: Clear
• Blood Pressure: 140/80, Pulse 90 and Respiratory rate: 20
• Wound on medical and lateral side of ankle extending 15cm up leg
• ROM: Full except for Right ankle 0° – 91°
• Muscle strength: Grade V except for right ankle Grade III
• Oedematous right foot – pitting
• The patient was independently mobile with a pair of elbow crutches and also independent in all ADLs
• Endurance was fair

Management and Outcomes

The care plan was to increase her physical activity levels gradually, introduce strength exercises as well as endurance training2.

Patient’s fitness was assessed using a modified 2 minute step in place test as her ankle and mobility with elbow crutches made other tests difficult to implement. She was unable to reach the recommended tape height due to difficulty weight bearing on her right ankle so the height was lowered to a more comfortable level. She was able to achieve a score of 80.

Exercise plan

A daily3 walking exercise program was introduced. The distance and speed of walking was adjusted over the 2.5 weeks of treatment4 and stairs and ramps were included1. By the end of the 2.5 weeks, she was exercising for 30 minutes 5 days per week3. Warm up of marching5 on the spot as comfort allowed. Strengthening exercises5 of the upper limb1 were done using 2 kg’s, then 3 kg weight. Exercises included Bicep curls, elbow extension 20 reps, 2 sets (increased form 1 set initially). The quads bench for quadriceps and hamstring strengthening exercises1, 5 instead of squats and lunges due to the patients stiff ankle. Hip abduction with ankle weights was done in side lying. The patient was given two 2 kg ankle weights to use at home. The strengthening program was done 2 – 3 times per week1. All weights added were low so as not to add too much stress with regards to her blood pressure and were only added after her blood pressure was stable for 2-3 days.

A motivational interview was done with the patient, she easily identified where exercise could be added to her day, and she was even able to come up with a solution for making her own weights for her upper limb exercise program at home. She was determined to continue and was keen to include her husband and children in the program.

Outcome – Before starting the exercise program the patients systolic blood pressure would regularly spike to 140 – 150. After 3- 4 days of the walking program the patient’s blood pressure stabilized and for 2 weeks, she maintained a systolic pressure of 110 – 120. Her fasting GM’s were initially spiking between 15 – 20 mmol. This was always corrected prior to exercise. Post exercise, her GM’s was more stable maintaining a level of between 7 – 10 mmol. There was also a self-report from the patient regarding the fact that she hadn’t needed to use her pump and that she usually needed to use it in the type of weather we had been having. Her modified score for her modified step in place test was raised from 80 – 120. Her level of breathlessness went from a level 2 to a level 1.

Discussion

This patient was seen to be a difficult patent to start and exercise program with as she was obese and had >2 co-morbidities, however once starting the exercise program with the patient. She quickly responded to the exercise and the health benefits were clear. She was able to feel and see the benefits and became well motivated internally. She had many reasons for changing her habits as she needed to care for her family and was unable to do so in hospital. She also saw the need to include and motivate her family to participate in the exercises with her. Even in her low income setting, she easily came up with a solution for adding her own weights by taking empty 2l bottles of water or soda and fill them with sand. So, given the right motivation and at the right time, patients may only need minimal advice and input to change their own lives.