Dr.
Luh Kamiati, SpKFR
Bagian Ilmu Kedokteran Fisik dan Rehabilitasi
FK .UNUD/ SMF.Rehabilitasi Medik,RSUP Sanglah,
Denpasar
DEFINITIONS:
Cardiac Rehabilitation is a multidisciplinary
program of education and exercise
established to assist individuals with heart
disease in achieving optimal physical,
psychological, and functional status within the
limits of their disease
Cardiac rehabilitation
is the process by which patients with cardiac
disease, in partnership with a multidisciplinary
team of health professionals, are encouraged
and supported to achieve and maintain
optimal physical and psychosocial health.
The involvement of partners, other family
members, and carers is also important.
Cardiac Rehabilitation Program
consist of :
Primary preventions
Focus on the reduction of cardiac risk factors :
- education, ideally started in schools with parental support
- physical activity ( decrease obesity, lower SBP, modifies
lipid profiles )
- should begin in childhood
- in order to establish helthy behavior patterns of life
Secondary prevention
-
include all of the features of primary prevention programs
decreases second cardiac event
lowers mortality post-MI
improve hypertension and Diabetes management
GOALS OF THE CARDIOVASCULAR
REHABILITATION
To prevent the harmful effects of prolonged
immobilization.
To develop cardiovascular fitness after acut illness
To maximize exercise tolerance and ADL performance
To control risk factors for coronary artery disease (CAD)
To provide guidelines for safe activities and work
To help patiens cope with perceived stressor
To improve quality of life
through program : - education
- behavior modification
- secondary prevention and exercise-- to resume
activities of normal life without significant cardiacsymptom
Candidates for Cardiac
Rehabilitation
Myocardial Infarction
Post CABG
Post coronary angioplasty
Post valve replacement
Postvalvuloplasty
Post surgical congenital cardiac
Post cardiac transplatation
Compensated CHF / Cardiomyopathy
Chronic stable angina
Risk Factor CAD
Contra Indication Exercise
Heart rate increase > 50 / minute
BP systolic > 210 mmHg, Diastolic > 110 mmHg
Unstable angina
Heart failure acute
Uncontrolled arrhytmias
Moderate / severe aortic stenosis
Decompensated CHF
Acute systemic illness/ fever
Active pericarditis/myocarditis
Embolism
Thrombophlebhitis acute
Resting ST diplacement > 3 mm
Uncontrolled diabetes
Coronary Artery Disease ( CAD )
Risk Factors
Reversible risks :
Sedentary lifestyle
Cigarette smoking
Hypertension
Low HDL cholesterol ( < 0.9
mmol/L [35 mg / DL ] )
Hypercholesterolemia ( >
5.20 mmol/L [200 mg / DL ])
High lipoprotein A
Abdominal obesity
Hypertriglyceridemia ( >2.8
mmol/L [250 mg / DL] )
Hyperinsulinemia
Diabetes mellitus
Irreversible risks :
Age
Male gender
Family history of premature
CAD ( before age 55 in a
parent or sibling )
Past history of CAD
Past history of occlusive
peripheral vascular disease
Past history of
cerebrovascular disease
Outcome Cardiovascular
Rehab
Decreased length of hospital stay.
More rapid and complete resumption of usual
activities
Increased self confident
Fewer readmission
Less psychological distress
Improve quality of life
MYOCARD INFARCT ( MI )
Post MI Rehabilitation
Classic model as first described by Wenger et al
:
Phase I (acute phase)
Phase II (convalescent phase)
Phase III
(training phase)
Phase IV
(maintenance phase)
Phase I :
Acute Phase Rehabilitation
Immediately following the MI up to discharge :
Early mobilization to prevent complication of
prolonged immobilization
Alleviation of anxiety and depression
Establish modifiable risk factor reduction
strategies
Prescription and education with guidelines for
activity and work after discharge
Phase II :
Convalescent Phase
Its done at home
Rehabilitation
Continues the program started in phase I
until the myocardial scar has matured :
To achieve cardiovascular conditioning and
fitness via aerobic exercise
To achieve control modifiable risk factors
using physical activity,psychosocial and
pharmacologic interventions and lifestyle
changes
To an early return to work
Phase III
The Training Phase
Usually starts after 4 6 weeks
Conditioning exercise program and education
Phase IV
The Maintenance phase
To keeping the aerobic conditioning gains
Be taught risk-factor modifications
CARDIOMYOPATHY
the most common cardiomyopathies are
the dilated and hypertrophic varieties.
Careful exercise training may result in
sufficient peripheral cardivascular and
musculoskeletal adaptation for there to be
significant improvement in effort tolerance.
Can transform a totally dependent person
into one capable of independent self-care
and even of training for a sedentary job.
Exercise capacity may not correlate
with left ventricular function in the
individual patient
The special needs of patient with
cardiomyopathies include strict medical
management of congestive failure and
arrhythmias ( need long-term
anticoagulation in dilated
cardimyopathy )
Only low-intensity exercise should be
undertaken by patients with
hypertropic cardiomyopathy because
of the increased risk of sudden death
CHF Rehabilitation
EFFECT EXERCISE:
Improvement exercise tolerance
Improvement cardiopulmonary function
Reduce patient symptoms
Guideline for Exercise in
CHF
Aerobic exercise
Intensity
: sub maximal
Duration
: 20 45 min
Frequency
: 2 5 X/week
Prolonged warm ups and cool downs
Avoided isometric exercise
GUIDELINE FOR GRADUATED ACTIVITY AFTER DISMISSAL
FROM THE HOSPITAL AFTER A MYOCARDIAL INFARCTION
table 21 5, Sinaki M , Basic Clinical Rehabilitation Medicine,St.Louis,
Mosby, 1993
ACTIVITY
METs
mL 02. kg-1
.min -1
Kcal / min
(70 kg person
)
WEEK 1
Any light activity that can be done
while sitting
Walking, 1 2 mph , on level
Stationary cycling , minimal
resistance
Light household work
dishes or meal
preparation ( alternate with
rest periods )
dusting
sweeping
Personal hygiene
shaving
showering
dressing
1.5 - 3
5 - 11
2-4
GUIDELINE FOR GRADUATED ACTIVITY AFTER DISMISSAL
FROM THE HOSPITAL AFTER A MYOCARDIAL INFARCTION
ACTIVITY
METs
mL 02. kg-1
.min -1
Kcal / min
(70 kg person
)
WEEK 2
Increased social activity
playing cards at home
visiting neighbors
card riding
Walking, 2 - 4 mph , on level
Stationary cycling , slight resistance
increased household work
bed making
ironing
minor appliance repair
bench work
supervising farm work
11 - 14
4-5
GUIDELINE FOR GRADUATED ACTIVITY AFTER DISMISSAL
FROM THE HOSPITAL AFTER A MYOCARDIAL INFARCTION
ACTIVITY
METs
mL 02. kg-1
.min -1
Kcal / min
(70 kg person
)
WEEK 3
Driving with another driver present
Household work, vaccuming
Resumption of sexual intercourse
Social activity
movies
church
conceds
walking, 3 4 mph
Stationary cycling , slight resistance
Lifting , 10 15 lb
14 - 15
5-6
GUIDELINE FOR GRADUATED ACTIVITY AFTER DISMISSAL
FROM THE HOSPITAL AFTER A MYOCARDIAL INFARCTION
tabel 21 5, Sinaki M, Basic Clinical Rehabilitation Medicine, St.Louis,
Mosby,1993
ACTIVITY
METs
mL 02. kg-1
.min -1
Kcal / min
(70 kg person
)
WEEK 4
Potential return to part-time work
Driving alone
Light gardening
Pitch and pull golfing
Social group activities
club meetings
parties
dancing
grocery shopping ( no heavy lifting )
walking, stationary cycling
<6
18 21
6-7
Phases of Cardiac
Rehabilitation
Table 21-3. Sinaki M, Basic Clinical Rehabilitation Medicine, St. Louis, Mosby,
1993
Phase
Type of Program
Duration
inpatient
days
Outpatient, immediate interval after
hospitalization
2 12 weeks
Late recovery period
Minimum of 9
months beyond
phase 2
Maintenance program
indefinite
Mayo Clinic Inpatient Physical Activity Protocol
for Cardiac Rehabilitation
Table 21.4, Sinaki M, Basic Clinical Rehabilitation Medicine, St. Louis, Mosby, 1993
Days of Program
Sta
ge
6Day
Plan
9Day
Plan
12Day
Plan
Use bedside commode. Begin physical
therapy range of-motion exercises to
each extremity. Sit at side of bed for 5 to
10 minutes
Sit in chair for 5 to 15 minutes twice daily.
Begin education program at bedside.
Continue physical therapy describe above
Sit in chair for up to 30 minutes twice
daily. Continue physical therapy describe
above
Activity Schedule
Mayo Clinic Inpatient Physical Activity Protocol
for Cardiac Rehabilitation
Table 21.4, Sinaki M, Basic Clinical Rehabilitation Medicine, St. Louis, Mosby, 1993
Days of Program
Sta
ge
2
6-Day
Plan
9Day
Plan
12Day
Plan
Move to step-down area. Bathe above
waist, shave, and comb hair. Begin selfexercise program supervised by physical
therapist. Sit in chair for 60 to 120
minutes twice daily.
continue self-exercise program supervised
by physical therapist. Begin ambulation
with physical therapist . Sit in chair for 90
150 minutes twice daily. Begin attending
education classes and discussion groups
Take wheelchair shower and use bathroom
ad lib. Continue physical therapy as
Activity Schedule
Mayo Clinic Inpatient Physical Activity Protocol
for Cardiac Rehabilitation
Table 21.4, Sinaki M, Basic Clinical Rehabilitation Medicine, St. Louis, Mosby, 1993
Days of Program
Sta
ge
6Day
Plan
9Day
Plan
12Day
Plan
Activity Schedule
Move to general cardiovacular ward . Dress
in street clothes if desire. Be up and
around room as tolerated. Begin climbing
stairs with physical therapist.
11
Take predismissal graded-exercise test.
Continue physical therapy as described
above. Take standing shower.
12
Receive final intructions before going
home
BORG PERCEIVED EXERTION SCALE
Table 21-6, Sinaki M, Basic Clinical Rehabilitation Medicine, St.Louis, Mosby,
1993
SCALE
EXERTION
6
7
Very, very light
8
9
Very light
10
11
12
Fairly light
13
14
Somewhat hand
15
16
hard
17
18
Very hard
19
20
Very, very hard
