1. Cardiac Rehabilitation and Exercise Prescription

2. Objectives
Identify and describe the examination procedures used to evaluate patients with heart disease.
Describe activities that aggravate or relieve edema, pain, or dyspnea in a patient with a compromised cardiovascular system.
Discuss and demonstrate PT interventions specific for individuals with cardiopulmonary and circulatory diseases.
Discuss and demonstrate interventions appropriate for a post-op patient, ie: CABG, angioplasty, transplants.
Identify and describe strategies of intervention during various phases of cardiac rehab.

3. Objectives
Appropriately modify therapeutic intervention as well as activities, positioning, and postures that aggravate or relieve edema, pain, dyspnea, or other symptoms of a patient during a patient-simulated scenario.
Participate in a provide written patient-related instruction to patients, family members, and/or caregivers as a part of discharge planning in collaboration with the supervising physical therapist.
Analyze and interpret patient data and follow goals for cardiac patient.
Perform appropriately under emergency patient conditions.

4. What is Cardiac Rehabilitation?
It is defined as, “all measures used to help cardiac patients return to an active and satisfying life and to prevent re-occurrence of cardiac events”.
Cardiac Rehabilitation includes exercise, education, and social and emotional support.
Rehabilitation can be hospital or home based.

5. Rehabilitation Outcomes and Quality of Life
Improves psychological and physiological well being
Improves quality of life
Lowers hospital re-admission rates
Prevents reoccurrence of future cardiac events
Improves exercise tolerance
Decreases coronary risk factors
Reduces long term mortality
Lowers the risk of death in survivors by 20-25%
Decreases the need for medication

6. Barriers to Rehabilitation
Lack of Knowledge
Poor Motivation
Insufficient understanding
Lower perceived self-efficacy
Forgetfulness
Decreased support from family and care givers
Cost
Poor Patient referral by Nurses and Doctors
Time conflict between work and rehabilitation program

7. Cardiac Exercise Prescription: Indications
Medically stable
Stable angina
CABG
Percutaneous transluminal coronary angioplasty (PTCA)
Compensated CHF
Cardiomyopathy
Heart transplant
Valve/pacemaker insertion
Peripheral arterial disease
CAD

8. Normal Response to Exercise
Must recognize the body's normal response to exercise before we can expect to effectively treat those with cardiovascular compromise
Case Study: Normal Response to Exercise (Finnick)

9. Case Study Discussion: Finnick
Why did HR increase?
What other components of the heart's function increases with exercise?
Why?
Why did Finnick's BP increase? Was this a normal response?
Compare the SBP changes to the DBP changes. Explain the results
What other values are expected to increase with exercise and what do they mean?
What values are expected to decrease with exercise aand what do they mean?

10. Normal Response to Exercise
VO2 CO HR
Systolic BP RR

11. Normal Response to Exercise
Inc or Dec by 10 mmHg
Diastolic BP

12. Normal Response to Exercise
Total Peripheral Resistance

13. Exercise Prescription: Contraindications
Unstable angina
Systolic BP > 200 mm Hg diastolic > 110 mm Hg
Acute illness
Uncontrolled arrhythmias
Uncontrolled sinus tachycardia >100 bpm
Uncompensated CHF
Recent embolism
Thrombophlebitis
Uncontrolled diabetes

14. STOP Exercise Persistent dyspnea Dizziness/confusion Onset of angina
Leg claudication
Excessive fatigue, pallor, cold sweat
Ataxia, incoordination
Bone/joint pain
Nausea/vomiting
Systolic BP that does not rise, or decreases
Systolic BP>200 mmHg, Diastolic BP >110 mmHg
Significant changes in ECG

15. Patient Assessment
Who?
What? (and How?)
When?
Where?
Why?

16. Who to assess?

17. What to assess? Vitals (HR, BP, RR and rhythm, RPE, O2 sats, pulses)
Dyspnea
Auscultation of lungs
Edema
Skin color
Surgical sites
Heart rhythm via EKG if monitored
Pain
Posture
ROM
Strength
Medications and effects

18. Case Study Discussion: Finnick
Why is it important to note in what position Finnick's BP was taken?
Would you expect any difference in the values if his BP were taken with his arm over his head?
Why?
What if his BP was taken while he was lying down? What would you expect then?

19. Before Treatment
HR 75 bpm
BP 200/95
What decisions do you make?

20. How to assess? Outcome measures and tools
Pulse ox
Borg Scale
Dyspnea Scale
BMI
Patient journals
Questionnaires
METs
ETT – Exercise Tolerance Test
Swan-Ganz catheter
EKG
Heart catheterization
Echocardiogram
Re-hospitalization data

21. Dyspnea Scale

22. Exercise Tolerance Test (ETT)
Or “Graded Exercise Test” (GXT)
Determines safe aerobic exercise levels without symptoms
Sets the level of exercise just below the onset of symptoms
Pt. exercises thru increasing levels of workload
Example: Bruce protocol p. 608
Use of 12 lead EKG and face mask
Gathers info on perfusion, rhythm, and conduction changes
Read as either positive or negative
Goals:
1. Detects presence of ischemia
2. Determines functional aerobic capacity

23. ETT Results
Point was reached where O2 demands of myocardium exceeded supply
O2 supply was adequate for the needs of the myocardium

24. Exercise Tolerance Testing
Testing Modes
Treadmill or cycle ergometry (UE)
Step tests
Max or Submax
Age adjusted HR max (220 – age)
THR or THRR
Karvonen’s formula
Continuous
Progresses steadily in 2-3 minute stages
Discontinuous
Allows rest between stages

25. Metabolic Equivalents (METs)
Measurement of estimated energy expenditure
Oxygen cost of the body to do activity
Measured in L/min; kcal; ml O2/kg/min
One MET = basic O2 requirement at rest
Five METs = 5x the O2 requirement needed at rest
VO2: Oxygen consumption of the body
VO2 max: Maximal O2 consumption
O’Sullivan: p. 558; ScoreBuilders p. 246

26. METs 3-4 METs, when continuous, can promote endurance
5 METs required to safely resume most daily activities
How many METs?
How many METs?

27. MET chart 2-3 METs: 2 mph walking, bartending, auto repair, bowling
4-5 METs: 3.5 mph walking, scrubbing floors, raking leaves, table tennis, doubles tennis
6-7 METs: 5 mph walking, splitting wood, water skiing, swimming, square dancing
8-9 METs: 5.5 mph running, vigorous basketball
10+ METs: 6 mph running, competitive handball, competitive swimming (>40 yds/min)
See book for more examples, p. 558

28. Results of ETT
How do you use the results to determine treatment parameters?

29. When to assess?
BEFORE
exercise
DURING
AFTER

30. Where to assess?
Wherever the rehab is being performed

31. Why to assess?
Safety
Documentation
Outcomes
Progression
Reimbursement

32. Exercise prescription
Four Variables

33. Exercise - Demonstrate
Aerobic
Anaerobic
Resistive
Maximal
Submaximal

34. Exercise Prescription Variables
I. Type (Mode)
II. Intensity
III. Duration
IV. Frequency

35. I. Mode (Type) Aerobic LE activity (treadmill)
Aerobic UE activity (UE ergometer)
Aerobic activities (high inter-individual variability)
Swimming, dancing, cross country skiing
Resistive exercise (typically 40% of max contraction)

36. II. Intensity
Selected as a percentage of the functional capacity determined on the ETT, within 40% - 85%
Use a combination of HR, RPE, and METs (VO2) to determine training intensities and to assess pt’s response to treatment

37. Heart Rate % of HR max determined by ETT or other methods
HR might not be the best indicator of exercise intensity
Beta blockers or Calcium channel blockers affect HR’s ability to rise during exercise
Pacemakers with limited HR elevation with exercise
UE work, Valsalva, or isometrics may affect HR and BP

38. Rating of Perceived Exertion
Original Borg Scale (6-20)
RPE of (fairly light) equates to 45-50% of HR range
RPE of (somewhat hard) equates to 60% of HR range
RPE of 16 (hard) equates to 85% of HR range
Must allow pt to become familiar with the scale to learn how to use it
Not all pts will be able to accurately use it
Very important with pts where HR would not be accurate

39. Original Borg Scale

40. Modified Borg Scale

41. METs
A measurement of the oxygen requirements for the level of activity performed

42. How is intensity determined?

43. III. Duration 5-10 min Warm Up and Cool Downs
Conditioning phase: 15 – 60 min
Average time is 20 – 30 min for moderate intensity
May require short bouts spaced throughout the day
Increase duration before increasing intensity

44. IV. Frequency Dependent on duration and intensity
Lower intensity and lower duration would pair with greater frequency
Average: 3-5 sessions per week for moderate work (>5 METs)
Daily or multiple daily sessions for low intensity work (<5 METs)

45. 4 Variables of Exercise?

46. Progression When HR is lower than target range
When RPE is lower than previous
When symptoms of ischemia do not appear
Increase duration first, then intensity
Rate of progression depends on age, health, functional capacity, goals, and preferences

47. Reduce Activity/Exercise
Acute illness
Acute injury
Increase in edema, unstable angina
Change in medications
Environmental stressors (heat, cold, humidity, smoke, pollution)

48. Cardiac Rehab Candidates
Post Myocardial Infarction
Post Cardiac Surgery

49. Phase I: Cardiac Rehab
In-Patient Cardiac Rehab

50. Inpatient Cardiac rehab
Length of stay commonly 3-5 days for uncomplicated MI
4 goals of therapy
Activity guidelines (3-5 METs at D/C)
Exercise guidelines
Patient and family education
HEP

51. 1. Activity Guidelines
Initiate early return to independent ADLs (after 24 hours or until pt is stable for 24 hours)
Counteract effects of bedrest
Reduce anxiety and depression
Provide medical surveillance
Provide enough stamina to go home

52. 2. Exercise guidelines - MI
First 24 hours: bedrest, bed mobility, ankle pumps, breathing exercise (1-1.5 METs)
Once stable for 24 hours: sit EOB, sit OOB x 30 min several times a day, LE exercise (1.5-2 METs)
Gradual increase in ambulation up to 5 min., several times a day (2-2.5 METs)
ADLs, selected arm and leg exercises, progressive ambulation up to 10 min, several times a day (2.5 – 4 METs)
Activity needs for home – stairs (Up to 5 METs)
RPE in light range (HR increase 10 – 20 bpm), constant monitoring of vital signs and pt response

53. Exercise Guidelines – Post PTCA
May ambulate at comfortable pace following surgery
Avoid aerobic training for 2 weeks post-op
Exercise prescription to be based on post-op ETT results
Often progress faster than MI patients

54. Exercise Guidelines – Post CABG
Sternal or intercostal incision
Sternal precautions for 4-6 weeks
LE incision
Address soft tissue impairments
Address posture and scapular retraction
UE ROM if cleared by MD
Energy conservation

55. 3. Pt and family education
Modification of risk factor profile
treatment of hyperlipidemia
smoking cessation
treatment of hypertension
control of diabetes
regular exercise
dietary changes

56. Pt and family education
Behavior modification
stress management at home
stress management at work
creation of hobbies - time out
conflict resolution skills

57. Pt and family education
Improve understanding of cardiac disease
Empower pt to gain control of disease via modifications
Teach self-monitoring procedures
Teach general activity guidelines, pacing, energy conservation
CPR

58. 4. HEP
Low-risk patient may be safe candidates for unsupervised exercise at home
Gradually increase ambulation time (goal min 1-2x/day at 4-6 weeks post MI)
UE and LE mobility exercises
Assist pt in planning out the day alternating between activity and rest
Elderly homebound pts may benefit from home cardiac rehab program
Patients should be skilled in self-monitoring procedures

59. Carl 56 yo, married with three teenage girls
Business owner, travels 2-3x/month
Weighs 200 lb, BMI of 30, often resorts to a fast food diet
Admitted to hospital 2 days ago with acute chest pain
Diagnosed with MI, stable, evaluated by PT this morning, BP at rest was 130/80
Transferred to sit EOB with min assist
Goals by discharge:
Patient and family education
Indpt in ADLs
Ambulate 100’ with SBG A
I with HEP

60. Phase II
Outpatient cardiac rehabilitation

61. Exercise goals and outcomes
Improve functional capacity
Progress toward full return to ADLs, hobbies and work activities
Risk-factor modification, counseling for lifestyle changes
Encourage activity pacing, energy conservation; stress importance of taking proper rest periods

62. Exercise guidelines
Frequency: 36 visits allowed by payers (3x/wk x 12 wks)
Duration: minutes (5-10 min of warm-up and cool down)
Mode: walking and/or cycle/arm ergometer and strength training
Intensity: Submaximal, or determined by ETT data

63. Exercise guidelines: con’t
Strength training
begin at 3 weeks cardiac rehab, 5 weeks post MI, 8wks post CABG
Begin with bands and light weights (1-3 lbs)
Progress to moderate loads, reps

64. Benefits of Phase II
Beneficial for pt at risk for arrhythmias, angina and other complications with exercise
Availability of ECG monitoring, trained personnel and emergency support
Group camaraderie and support
Pts gradually taken off continuous monitoring to self monitor
D/C: 5 METs needed for daily activities; 9 METs recommended

65. Adelle 62 yo s/p CABG 6 weeks ago, Hx of HTN
(+) ETT with symptoms of ischemia at 5 METs
Resting BP 125/83, controlled with Lopressor (a beta blocker)
Head Baker at Publix
Lives alone, has 2 sons that live out of state, smokes
PT eval showed low endurance, decreased strength, and forward posture
Goals in 12 weeks (asymptomatic):
Patient education
Increase endurance to ambulate 60 min at RPE of 12-13
Increase strength to 4/5 overall to lift and carry groceries and household objects
I in HEP

66. Phase III
Community exercise programs

67. Exercise goals Improve functional capacity
Promote self-regulation of exercise programs
Promote life-long commitment to risk-factor modification

68. Exercise guidelines
Located in community centers, YMCA or clinical facilities
Entry level: 5 METS, clinically stable angina, medically controlled arrhythmias during exercise
Progress from supervised to self-regulation of exercise
Progression to 50-80% of functional capacity 3-4 times/week, 45 minutes or more per session
Regular medical check-ups and periodic ETT generally required
D/C 6-12 months

69. Edwin 78 yo s/p angioplasty 16 weeks ago D/C’ed from PT 4 weeks ago
Lives with wife of 49 years
Hx of hyperlipidemia, HTN, non-smoker
Avid golfer, 5 days a week prior to procedure
BP 128/75
D/C report states I with ADLs and community ambulation
Strength 4/5 overall
Tolerated treadmill for 20 min at 5 mph
Personal goal: to return to golfing at the club

70. CHF (Marty)

71. CHF Criteria for exercise Medically stable
Exercise capacity >3 METS
Exercise training
Prolonged Warm up and cool down
Low intensities (40-60%)
Increase duration as tolerated
Maintain HR below 115 bpm
Monitor RPE: fairly light
Avoid isometrics
May include light resistance

72. Classes of Congestive Heart Failure
Class I:
Mild; no symptoms up to 6.5 METs
Class II:
Mild; dyspnea, fatigue, angina with activity at 4.5 METs
Class III:
Moderate; limited up to 3 METs by dyspnea, fatigue, angina
Class IV:
Severe; symptoms present even at rest; 1.5 METs cause discomfort

73. Cardiac Transplant

74. Cardiac transplant Present with:
Exercise intolerance due to extended inactivity
Side effects from immunosuppressive drug therapy: hyperlipidemia, hypertension, obesity, diabetes, leg cramps
Decreased LE strength
Increased fracture risk from long-term corticosteriod use

75. Cardiac Transplant
HR alone is not an appropriate measure of exercise intensity (heart is denervated).
Use RPE, METS, dyspnea scale, BP
Use longer periods of warm-up and cool-down because the physiological responses to exercise and recovery take longer

76. Pacemakers

77. Pacemakers Should know setting for HR limit Use RPE
ST segment changes may be common
Avoid UE aerobic or strengthening exercises initially after implant
Electromagnetic signals may cause devices to fire or slow down or speed up

78. Diabetes

79. Diabetes
Poorly controlled blood glucose, CV disease, renal disease, neuropathy, peripheral vascular disease and ulceration and/or autonomic dysfunction
Exercise testing
May need to use submaximal ETT
With PVD and peripheral neuropathy, may need to use arm UBE
Exercise training
Exercise prescription (40-60% functional capacity)
Monitor for signs of hypoglycemia (shaking, dizzy, HA, sweating)
Proper footwear important
Jogging/jarring activities contraindicated

80. Pulmonary Disease Intensity:
Training effect is achieved with 60-95% of VO2 max when spaced with rest periods
Use of warm up and cool down (5-15 min)
Emphasize controlled breathing
Use of a THR range
Pts will reach ventilator limit before their cardiovascular limit
May be able to work at top end of THR range
Dyspnea scale
Exercise at moderate to severe level on the scale (3 – 6)
RPE

81. Pulmonary Disease Mode: Varies Duration:
Within THR at least min, continuous or with rest breaks
Increase duration first when progressing
Shorten rest breaks
Frequency:
3-5x/wk if min of exercise can be achieved
Increase frequency if duration is shorter or for patient with low functional abilities

82. Pulmonary Disease Stretching Posture Strength Training
Increase resistance with aerobic exercise
Weight training
Progression:
Increase intensity once 20 minutes of continued activity is tolerated

83. Pulmonary Disease Patient education
Symptom recognition, self management, airway clearance techniques, pacing
HEP
Use of an exercise log and journal

84. Effects of cardiac rehab
Decreased HR at rest and during exercise
Increase stroke volume
Increase myocardial oxygen supply
Improved respiratory capacity during exercise
Improved functional capacity of exercising muscles
Reduced body fat, weight reduction
Decrease serum lipoproteins
Improved glucose tolerance
Improved coagulability
Improved measures of psychological status

85. Objectives
Identify and describe the examination procedures used to evaluate patients with heart disease.
Describe activities that aggravate or relieve edema, pain, or dyspnea in a patient with a compromised cardiovascular system.
Discuss and demonstrate PT interventions specific for individuals with cardiopulmonary and circulatory diseases.
Discuss and demonstrate interventions appropriate for a post-op patient, ie: CABG, angioplasty, transplants.
Identify and describe strategies of intervention during various phases of cardiac rehab.

86. Objectives
Appropriately modify therapeutic intervention as well as activities, positioning, and postures that aggravate or relieve edema, pain, dyspnea, or other symptoms of a patient during a patient-simulated scenario.
Participate in a provide written patient-related instruction to patients, family members, and/or caregivers as a part of discharge planning in collaboration with the supervising physical therapist.
Analyze and interpret patient data and follow goals for cardiac patient.
Perform appropriately under emergency patient conditions.