The utility of boxing for cardiac prehabilitation

Abstract

A 56-year-old man with end-stage heart failure performed a 4-week, symptom-limited, progressive inpatient cardiac prehabilitation program while confined to the cardiovascular intensive care unit awaiting heart transplantation. Mobility was limited by an acute gout flare and multiple central venous access lines. He received a tailored prescription of intermittent boxing, supervised hallway ambulation, stair training, and golfing on a putting green on four consecutive weekdays and was encouraged to mobilize with nursing on the remaining days. The patient progressed and by the last week demonstrated increased activity tolerance. He had a successful transplant after 40 days in the intensive care unit and was discharged with stamina sufficient to participate in outpatient cardiac rehabilitation, demonstrating the value, safety, and feasibility of an individualized inpatient cardiac prehabilitation program for patients with advanced cardiac disease medically confined to the intensive care unit.

“Prehabilitation” seeks to optimize physical functionality prior to surgery to minimize the negative effects of deconditioning and muscular decline.^1–3 Many patients at greatest risk for deconditioning during the weeks leading up to surgery also face the greatest barriers—physical and logistical—to conventional exercise training methods.⁴ For such patients, individual exercise prescriptions need to be developed and adapted to the particular needs of the patient’s clinical condition and physical setting.

CASE DESCRIPTION

A 56-year-old man with end-stage heart failure awaiting transplantation participated in a 4-week inpatient cardiac prehabilitation (ICP) program (outlined in Table 1) during his 40-day stay in the cardiovascular intensive care unit. He was on milrinone 0.375 to 0.75 mcg/kg/min and dobutamine 2 to 5 mcg/kg/min with an indwelling pulmonary artery catheter via the right internal jugular vein that prevented independent mobilization. Additionally, an acute left leg gout flare limited walking or prolonged standing. He initially refused ambulation or use of the restorator bike due to pain; therefore, a symptom-limited, intermittent boxing protocol was implemented to promote bilateral upper-extremity strength, endurance, and core stability (Figure 1).

Table 1.

Detailed schedule of inpatient cardiac prehabilitation exercise sessions^a

Week	Day 1				Day 2				Day 3				Day 4
	Box (min)	RB (min)	Amb (ft)	Other	Box (min)	RB (min)	Amb (ft)	Other	Box (min)	RB (min)	Amb (ft)	Other	Box (min)	RB (min)	Amb (ft)	Other
1	10	2b			10	2b			10	2b			10	2b
2	15	2b	1000		15	2b	1000		15	2b	1000		15	2b	1000
3			1500	Golf 5 min	(S) 15	2		Stairs: 1/2 flight			1500	Golf 5 min	(S) 15	2		Stairs 1 flight
4	25	2b	2000	Golf 5 min	25	2b	2000	Stairs: 2 flights	25	2b	2000	Golf 5 min	25	2b	2000	Golf 5 min

^aWeek 1 Day 1, seated through exercise; Week 1 Days 2 and 3 and Week 2 Days 1 and 2, standing with seated rest break; Week 1 Day 4, Week 2 Days 3 and 4, and Week 4, standing throughout exercise.

^bNoninvasive blood pressure check.

Amb indicates ambulation; RB, rest break; (S) shadow boxing.

Figure 1.

The patient performing sport-specific exercise while awaiting heart transplant in the cardiovascular intensive care unit.

The patient tolerated this exercise well and agreed to progress to hallway ambulation after four exercise sessions. He shared his historic apprehension of his home stairs due to his self-reported debility, and stair training in the hallway was incorporated during the third week of his ICP program. Care was taken to ensure patient safety by continuous observation of telemetry, blood pressure response, oxygen, vascular access lines, and patient-reported symptoms. On the third week, an unrelated central line–associated bloodstream infection required removal of the pulmonary artery catheter and peripherally inserted central catheter, requiring bridging with redundant peripheral intravenous lines. These caused the patient irritation and prevented the use of boxing gloves; therefore, shadow boxing (nonresisted, controlled “boxing the air”) was implemented in addition to ambulation and stair training. As the patient is an avid golfer, his son had buoyed his spirits by challenging him to a golf tournament upon hospital discharge. Therefore, a small 10-foot putting green, putter, and golf ball were placed at the bedside for the patient to practice (Figure 1). The patient was limited by nonsustained ventricular arrhythmias that resolved with rest and required frequent rest breaks, but remained stable and asymptomatic throughout exercise sessions with no countershocks or antitachycardia therapies from his internal cardiac defibrillator.

Throughout this program, the patient increased his tolerance for activity from 10 min of one seated activity to 45 min of standing and ambulatory activity. Although no metabolic testing was performed, the patient was able to increase his sustained exercise tolerance from an estimated 3.5 METs (walking, leisurely pace on a flat surface) to 6 METs (light-intensity boxing). On day 40, the patient was successfully transplanted and discharged home on the fifth postoperative day with endurance sufficient to begin a phase II cardiac rehabilitation program immediately.

DISCUSSION

The progressive deconditioning and decline in muscular strength, endurance, and functional capacity that occurs with short- and long-term immobility⁵ is associated with loss of independence, frailty, poor outcomes, and negative psychosocial effects that persist despite heart transplantation.⁶ Prehabilitation programs in the outpatient setting for patients listed for transplant suggest such programs can achieve significant improvements in aerobic capacity and postoperative outcomes.^7,8 For example, increasing patients’ aerobic capacity by even 1 MET reduces their all-cause and cardiovascular mortality by up to 34%.⁹ Evidence regarding similarly structured programs for heart transplant candidates in the acute care setting is lacking. In the inpatient setting, ambulation and chair-sitting is often prescribed¹⁰ but is ineffective in staving off the negative effects of restricted mobility due to staffing availability, medical therapy, acuity of the patient,¹¹ lack of equipment, or fear of overloading a compromised heart.¹²

We have previously reported success with customized, symptom-limited cardiac rehabilitation programs for individuals needing to return to physically demanding jobs^13,14 or athletic routines^15,16 after cardiac surgery, which inspired the design of the customized program described in this case, but there were several new barriers to surmount in implementing this program, including the patient’s tenuous cardiovascular status and the multiple lines that had to be monitored and secured to avoid pulling, snagging, or displacement. Any excess visible line was secured by the patient’s nurse prior to exercise, and the dressing was evaluated before and after exercise per the hospital infection-prevention protocol. Additionally, the patient sanitized his hands with the hospital’s liquid hand sanitizer, donned disposable, one-time-use, elbow-length nitrile medical gloves, and utilized appropriately sized boxing gloves. Boxing gloves were cleaned with hospital-approved antiseptic wipes and allowed to dry completely before and after use.

The patient’s tolerance of progressive, customized training during his 40 days in the cardiovascular intensive care unit awaiting heart transplant, and his readiness for cardiac rehabilitation when discharged 5 days posttransplant, illustrate the benefits that accrue when individualized ICP programs are deployed to reduce the negative atrophic effects of prolonged hospitalization. Initiation of ICP as able, despite medical acuity, may help both surgically and medically managed patients maintain or recover physical independence prior to enrollment in a phase II cardiac rehabilitation program at discharge.