Introduction

•“CR is a multidisciplinary program, individually

tailored, given through accurate diagnosis,
education to patient & family, emotional
support (behavioural changes)and exercise
training to achieve optimal physical,
psychological & functional status of cardiac
patient or person at risk of cardiac disease”
Cardiac rehabilitations services are
comprehensive, long-term programs involving :
• Education of patient & family in the recognition, prevention and treatment
of cardiovascular disease
• Assessment of Risk stratification
• Reduction or modification of risk factors
Nutritional counseling
Management of lipid levels, hypertension, weight and diabetes
Smoking cessation
• Dealing with psychological factors that influence recovery from heart disease
• Structured progressive physical activity, either in a Rehabilitation setting or
home program (Exercise Prescription)
• Vocational counselling
Members of Cardiac Rehabilitation team:
• Patient
• Physician-Medical Director
• Cardiologist
• Exercise physiologist
• Physical Therapist
• Nursing staff
• Dietitien
• Psychologist
• Medical Social Worker (MSW)
• Vocational Counsellor
• Occupational Therapist
• Pharmacist
Goals:
• To prevent the harmful effects of prolonged bed rest when a
patient is hospitalized with heart disease
• To develop cardiovascular fitness with an emphasis on
optimal ability for employment & Leisure
• To promote risk modification and secondary prevention of
cardiovascular disease
• To decrease cardiac morbidity and to relieve symptoms
• To decrease anxiety and to increase knowledge & self
confidence
Additional effects of rehab program:

• Loss of excess weight or fat

• Lowering lipid levels LDL
• Elevation of level of HDL
• Reduction in elevated BP
• Improvement in glucose insulin dynamics
Indication of Cardiac Rehabilitation
• Cardiac rehabilitation programs are indicated for patients recovering
from recent MI,
• Following coronary bypass,
• Valve surgery or coronary angioplasty,
• Cardiac transplantation,
• Patients with stable angina or patient with compensated chronic
heart failure.
• Traditionally, cardiac rehabilitation has been provided to some what
lower risk patient who could exercise without getting into trouble.
However the rapid evolution in the management of IHD has now
changed the demographics of the patients who can be a candidate for
rehabilitation training.
 Contraindications to Cardiac Rehabilitation
•Acute pericarditis or myocarditis
• Unstable Angina
• Recent embolism
• SBP > 200 mm Hg or DBP > 110 mmHg
• Thrombophlebitis
• Orthostatic BP drop of > 20 mmHg with
symptoms • Resting ST – segment depression or
• Severe aortic stenosis elevation > 2 mm

• Uncontrolled atrial or ventricular • Uncontrolled diabetes (glucose > 400 mg /

arrhythmias dl)
• Uncontrolled sinus tachycardia • Acute systemic illness or metabolic
• Uncompensated heart failure problems

• 3rd degree AV block without pacemaker • Orthopedic problems that would preclude
exercise
AACVPR-LOW RISK
AACVPR-INTERMEDIATE(MODERATE) RISK
AACVPR-HIGH RISK
 Classification of Patients (AHA):
Functional Capacity Objective Assessment
Class I. Patients with cardiac disease but A. No objective evidence of
without resulting limitation of physical cardiovascular disease.
activity. Ordinary physical activity does not
cause undue fatigue, palpitation, dyspnea, or
anginal pain.
Class II. Patients with cardiac disease B. Objective evidence of minimal
resulting in slight limitation of physical cardiovascular disease.
activity. They are comfortable at rest.
Ordinary physical activity results in fatigue,
palpitation, dyspnea, or anginal pain.
 Classification of Patients (AHA): :
Functional Capacity Objective Assessment
Class III. Patients with cardiac disease resulting C. Objective evidence of
in marked limitation of physical activity. They are moderately severe cardiovascular
comfortable at rest. Less than ordinary activity disease.
causes fatigue, palpitation, dyspnea, or anginal
pain.
Class IV. Patients with cardiac disease resulting D. Objective evidence of severe
in inability to carry on any physical activity cardiovascular disease.
without discomfort. Symptoms of heart failure
or the anginal syndrome may be present even at
rest. If any physical activity is undertaken,
discomfort is increased.
EXERCISE PRESCRIPTION(ACSM):
F.I.T.T. PRINCIPLE
A formula in which each letter represents a
factor important for determining the
correct amount of physical activity.
F.I.T.T. PRINCIPLE
Frequency
Intensity
Time
Type
Frequency
• Most days of the week (4-7)
• For those with limited exercise capacities,
multiple short sessions (<10min) are
recommended
• Participants should be encouraged to do some
exercise session independently (without
supervision)
Intensity
Overload Principle: The principle of overload states
that a greater than normal stress or load on the body is
required for training adaptation to take place.
• The body will adapt to this stimulus. Once the body
has adapted then a different stimulus is required to
continue the change.
• In order for a muscle (including the heart) to increase strength, it
must be gradually stressed by working against a load greater
than it is used to. To increase endurance, muscles must work for
a longer period of time than they are used to.
• If this stress is removed or decreased there will be a decrease in
that particular component of fitness.
• A normal amount of exercise will maintain the current fitness
level.
Specificity principle: It refers to adaptation in metabolic &
physiological systems depending upon the demand imposed
on it
• Work load and work rest are selected so that training
resulting in:
1. Muscle strength without significant increase in total O2
consumption
2. Aerobic training without training anaerobic system
3. Anaerobic training without training aerobic system
Intensity
Various methods can be used to prescribe intensity:
1. RPE
2. HR
• Age predicted
• Exs testing
• HRR
3. MET
4. VO2 max
Intensity
• Rating of perceived exertion (RPE), 6-20 scale
– Early rehab upper limit: 11-13 (fairly light to somewhat
hard)
– Progress to 14-16 if asymptomatic
– High inter-individual variability
– Used with the Talk Test
• Age adjusted predicted maximal rates can be used
MHR= 220bpm-Age
THR= 60-70% of MHR
• HRR: 40-80% of exercise capacity using HR reserve or
Karvonen method if maximal exercise data is available.
– This method necessitates a HR monitor
• THR always 10bpm below:
– 1mm horizontal or downsloping ST segment 
– Anginal symptoms or other CV insufficiency
– SBP 250mmHg, plateau SBP or SBP
– DBP 115mmHg
–  frequency ventricular arrhythmias
– Other significant EKG disturbances
– Radionuclide evidence LV dysfunction
– Mod/sev wall motion abnormality with ex
– Other s/s of intolerance
– Consider timing of medication
• MET:
Resting 1-1.5
Sitting 1.5-2
Standing 2-2.5
Ambulation(assisted) 2.5-3
Ambulation(independent) 3-4
Stair climbing 4-5
Skipping 8-10
Free style swimming 9-10
• VO2 max:
50-85%
• Talk test-Talk without becoming breathless while exertion
It is imp. To observe the individual for the signs of,
• Exercise breathlessness-Excessive
• Loss of quality of movement
• Excessive sweating
• Unusual pallor
 VO2 – Heart Rate Relationship for Exercise Rx

max HR

85% HR max

70% HR max

Heart Rate

60 % VO2 max 80% VO2 max VO2 max

60 % HRR 80 % HRR

VO2 or Workload
Time
• Optimal duration for conditioning depends on
1. Total work done
2. Exs intensity
3. Frequency
4. Fitness level
• Warm-up/Cool-down activities should last 5-10 minutes each
• Aerobic conditioning= 20-60 minutes is goal
– May have to start with multiple short bouts
– Increase time by 10-20% per week, as per patient tolerance
Type
• Large-muscle-group aerobic activities, emphasizing caloric
expenditure
• Include upper and lower extremities
• Variety of activities
• Use of various exercise equipment
– Arm ergometer, cycle ergometer, elliptical, rower, stair climber, treadmill
Endurance training:
Flexibility training:
Resistance training:

4 methods of training
1. Continuous training
2. Interval training
3. Circuit training
4. Circuit-Interval training
Resistance Training in Cardiac Patients
• Type:
– Elastic bands, light free weights, wall pulleys, machines

• Technique:
– Slow, controlled movements
– Regular breathing pattern (no holding)
– RPE 11-13
– Monitor symptoms
Prescription Guidelines: AACVPR
• 40% of 1 RM and high repetition-Low MVO2
• 2-4 sets/muscle group, 12-15 reps
• 2-3 days/week
• Exercise large muscle groups before small
• Avoid sustained, tight grip
• Exhale on exertion
• Stopping exercise with any warning signs
• Increase weight 2-5lbs/wk (arms), 5-10lbs/wk (legs)
Indication:
• 5 wks after MI, 8 wks post CABG, 3 wks after PTCA
• Diastolic pressure < 105 mmhg
• Not complicated by CCF, unstable symptoms or disrythmias

Contraindication:
• Abnormal hemodynamic response to exercise
• Ischemic changes
• Poor left ventricular function
• Uncontrolled Hypertension
Progression From Medical Supervision to Independent
Exercise
• Ideally, most should participate in supervised program
to facilitate exercise & lifestyle changes
• Criteria for independent exercise:
– Cardiac symptoms stable/absent
– Stable ECG, BP, HR responses
– Knowledge of exercise principles, symptom management
– Motivation
Programme schedule
• Four components of the cardiac rehab
1) Education
2) Behavioral modification
3) Nutrition
4) Exercise
Cardiac Rehab Phases
• PHASE I acute period beginning in the cardiac care unit (0 -8 days)
• PHASE II The convalescent stage, continuing program at home (8th
day -6 weeks)
• PHASE III Training phase ,supervised out patient program with
aerobic conditioning to improve patients physical work capacity (6
weeks -12 weeks)
• PHASE IV Long term maintenance program in the community to
maintain the effects achieved with exercise
Goals:
Inpatient
• Early assessment and mobilization
• Identification and education of risk factors
• Assessment of pt. readiness for activity
• To reduce psychological and emotional disorders
• To facilitate adjustments - hospital environment
• Create positive attitude- motivate
• Discharge planning

Outpatient
• Develop safe exercise program
• Provide appropriate supervision
• Return patient to normal activities and assist in modifying daily activities where
necessary
• Secondary prevention and risk factor modification
Phase 1
• CPK- MB
• Last upto discharge
• In uncomplicated MI usually patient discharge in 5 days.
• Type of activity in this phase: bed mobility, sitting,
ambulation, hall walking under observation, walking
outside the hall, self care under observation, lower limb
exercise, stair climbing
• Monitoring system
• Intensity: resting HR+ 20bpm ( MI)
resting HR+ 30 bpm ( CABG)
RPE < 11
• Frequency: 2-3 times/ day
• Duration: as per patient’s tolerance: 5-20 min
Haemodynamic stability
HR and BP before and after exercise
orthostatic hypotension

Criteria to terminate the exercise:

increase of HR more than 50bpm
fall in systolic blood pressure
fall in diastolic blood pressure
elevated blood pressure more than
sbp>210
dbp> 110
ECG abnormality- ST segment depression
Angina
severe leg claudication
Dyspnea
TYPES AND RESPONSE OF ACTIVITIES USED IN EARLY
CARDIAC REHABILITATION
ACTIVITY METHOD METS AVERAGE HR
RESPONSE
Toileting Bed pan 1-2 5-15 beats increases
Commode 1-2 from RHR
Urinal (in bed) 1-2
Urinal (standing)
1-2

Bathing Bed pan 2-3 10-20 beats increase

Tub bath 2-3 from RHR
shower 2-3
Walking Flat surface 5-15 beats increase
2mph 2-2.5 from RHR
2.5mph 2.5-2.9
3mph 3-3.3
ACTIVITY METHOD METS AVERAGE HR
RESPONSE

Upper body While standing 2.6-3.1 10-20 beats

exercise Arms 2-2.2 increase from RHR
Trunk 2.5-4.5
Leg 15-25 beats
increase from RHR

calisthenics Stair climbing 10-25 beats

1 flight -12 steps increase from RHR
Down 1 flight 2.5
Up 1 -2 flights 4
 ICU management
Day Activity

Day1 Bed to chair

Day 2 Sitting, warm up, walking in room, self

care activity,
Day 3,4,5 Walking 5-10 minutes in hall
Up and down one flight of stairs
LEVEL-1-CCU-ESSENTAIALLY BED REST (1-
1.5METs)
• Evaluation and patient education
• Arms supported for meals and ADLs
• Bed exercises and dangle with feet supported

Education:
• Introduction to CR and role of physical therapy
• Monitored progression of activity
• Home exercise/activity guidelines/outpatient cardiac rehab
LEVEL-2-SITTING LIMITED ROOM
AMBULATION (1.5-2METs)
• Sitting 15-30min, 2-4 times/day
• Leg exercises
• Commode privileges
• Reclining upright chair
• Limited ADL
• Electric razor
• Limited supervised room ambulation for small uncomplicated MI
Education:
• Identification of CAD risk factors
• Concept of “healing interval” and need to pace activities
LEVEL-3-ROOM LIMITED HALL AMBULATION
(2-2.5METs)
• Room or hall ambulation up to 5min as tolerated 3-4 times/ day
• Standing leg exercise (optional)
• Sit on side of bed or in bathroom to wash (per discreation nurse/ PT)
• Manual shave
• Bathroom privileges
• Independent or assisted ambulation in room or hall as advised by PT
Education:
• Size of infarct and how it related to the end of gradual resumption of
activities
• Impact of exercise on reducing risk factors
• Teach RPE
LEVEL-4-PROGRESSIVE HALL AMBULATION
(2.5-3METs)
• Hall ambulation 5-7 min as tolerated 3-4times/day
• Standing trunk exercise (optional)
• Independent or assisted ambulation in hall as advised by PT

Education:
• Teach pulse taking and appropriate parameters with activity
• Reinforce benefits of outpatient CR
LEVEL-5-PROGRESSIVE HALL AMBULATION
(3-4METs)
• Hall ambulation 8-10min as tolerated
• Arm exercise (optional)
• Standing shower
• Independent ambulation in hall as advised by PT

Education:
• Written home exercise/activity guidelines reviewed
• Patient given written information on outpatient CR
LEVEL-6-STAIR CLIMBING (4-5METs)
• Progressive hall ambulation as tolerated
• Full flight of stairs (or as required at home) up and down one step at a
time

Education:
• Answer patient’s questions
• Check for understanding of activity guidelines
CRITERIA TO TERMINATE EXERCISE
• Fatigue

• Tachycardia

• Light-headedness, confusion, ataxia, cyanosis, dyspnea, nausea, or

peripheral circulatory insufficiency

• Onset of angina with exercise

• tachycardia
• Onset of 2nd or 3rd degree heart A-V block.
• Exercise hypotension (>20 mm Hg drop in systolic BP)
• Excessive blood pressure risk: systolic >220 or diastolic >110 mm Hg
• Inappropriate bradycardia ( <10 beats/min) with no increase in
workload
• ST displacement >3 mm from rest
• Ventricular tachycardia
• Exercise-induced left bundle branch block
AT DISCHARGE
• Patient is taken for a low level stress test
• It is conducted with possible end points like
• 20 to 30 heart beats above the RHR
• METs 4to 6
Phase 2
• OUT PATIENT PHASE
• Start the phase 2 within 2 weeks of discharge
• Monitoring of ECG, HR, BP
• Prior to training perform 6 minute walk test so you can judge patient’s
functional capacity
• Start aerobic exercise
OBJECTIVES
• Enhance Cardiovascular function, Physical work capacity, Strength,
Endurance & Flexibility.

• Detect Arrhythmias & ECG changes during Ex

• Patient Education on proper Ex Technique

• Work with patient, family, and significant
others to establish healthy lifestyle

• Enhance Pt’s Psychologic Function

• Prepare patients for a return to work and

resumption of normal family and social roles

• Provide patients with guidelines for a long-term exercise

LOW RISK
• No significant LV dysfunction (EF > 50%)
• No Resting or Exercise induced Myocardial ischemia or Complex
Arrhythmia.
• Uncomplicated MI, CABG, Angioplasty, Atherectomy, Stent
• Asymptomatic including absence of Angina with Exertion or Recovery.
• Functional capacity > or = 7.0 METS
• Angina / ST segment displacement.
INTERMEDIATE

• Moderately impaired LV function ( EF = 40– 49% )

• S & S at Moderate levels of exercise ( 5 -6.9 METS) / in Recovery

including Angina
• Exercise induced MI(1 -2 mm ST seg
depression) / Reversible Ischemic defects
HIGH

• Decreased LV function (EF< 40%)

• Survivor of Cardiac Arrest or Sudden Death

• Complex Ventricular Dysrhythmia at Rest / with exercise.

• MI / cardiac surgery complicated by Cardiogenic Shock or CHF

• Decrease in Systolic BP > 15mm Hg during

Exercise / Failure to rise with increasing

Exercise workloads

• Severe CAD & Marked Exercise induced

MI(>2mm ST segment depression)

AMERICAN HEART
ASSOCIATION 2005
CLASS A
Apparently healthy individual
1. Men<45, Women<55yrs who have no symptoms or known heart
disease

2. Men>=45, Women>=55 who have symptoms or known heart

disease and with > 2 major cardiovascular risk factors.
CLASS B
Known, stable cardiovascular disease with low risk for complication
with vigorous exercise, but slightly greater than for apparently
healthy individuals
• CAD whose condition is stable and have clinical characteristics
• Valvular heart disease excluding stenosis or regurgitation with
clinical characteristics.
• Congenital heart disease
• Cardiomyopathy; ejection fraction >=30 %includes stable
patient with heart failure and clinical characteristics
• Exercise test abnormalities that don't meet any of the high risk
criteria
Clinical characteristics
1. Exercise capacity >=6 METs
2. No evidence of CHF
3. No evidence of myocardial ischemia or angina at rest or exercise
test < 6 METs
4. Absence of sustain or non sustain ventricular tachycardia at rest
or with exercise
5. Ability to self monitor intensity of activity
CLASS C
Those at moderate to high risk of cardiac complications during
exercise and/or unable to self-regulate activity or to understand
recommended activity level
• CAD with clinical characteristics
• Valvular heart disease excluding stenosis or regurgitation with
clinical characteristic
• CHD
• Cardiomyopathy; ejection fraction <=30 %includes stable
patient with heart failure and clinical characteristics
• Complex ventricular arrhythmia not well controlled
Clinical characteristics
• Exercise test results:
- <6 METs
- Angina or ST depression at workload <6METS
- Fall in systolic BP below resting level during exercise
• Previous episode of cardiac arrest
• A life threatening medical problem
CLASS D
• Unstable disease with activity restriction
• Unstable ischemia
• Severe and symptomatic valvular stenosis or regurgitation
• Congenital heart disease
• Heart failure that is not compensated
• Uncontrolled arrhythmia
• Other medical condition aggravated by exercise
Recommended ECG monitoring
lowest risk
• Monitored-6 to 18 sessions
• Up to 30 days post-event

Moderate risk
• Monitored-12 to 24 sessions
• up to 60 - 90 days post-event

Highest risk
• monitored -18 to 24 sessions
• for 90 days or more post-event
PRINCIPLES OF EXERCISE PRESCRIPTION
• FREQUENCY
• INTENSITY
• DURATION
• MODE
• FREQUENCY

• ACSM recommends 3 to 5 days a week

INTENSITY OF TRAINING
VO2 MAX TESTS
• Exercise tolerance testing or stress testing is an essential first step in
exercise training phase of any cardiac rehab program.
• It is used to create an individualized exercise prescription
• To assess the ability of the cardiovascular system to accommodate to
increasing systemic oxygen demands
• The patient exercises through stages of increasing
workloads,expressed in units of oxygen which may be expressed in
L/ min ,ml/kg/min ,k cal or metabolic equivalents
• Major goals of exercise testing are to detect the presence of ischemia
and to determine the functional aerobic capacity of the individual.
• The patient is monitored with a 12 lead ECG throughout the test and
recovery
• Exercise tolerance testing can be done in Treadmill ,Bicycle
Ergometer,Upper extremity Ergometer.
• Some of the commonly used tests are treadmill tests,astrand rhyming
bicycle ergometer test ,six min walk test
CONTRAINDICATIONS TO STRESS TESTING
• ABSOLUTE CARDIAC CONTRAINDICATIONS
• Unstable angina with recent chest pain
• Untreated life threatening cardiac arrhythmias
• Uncompensated congestive cardiac failure
• Advanced atrioventricular block
• Acute myocarditis or pericarditis
• Critical aortic stenosis
• Uncontrolled hypertension
• Acute myocardial infarction
• Acute endocarditis
• ABSOLUTE NON-CARDIAC COMPLICATIONS

• Acute pulmonary embolus or pulmonary infarction

• Acute systemic illness
• RELATIVE CONTRAINDICATIONS

• Significant pulmonary hypertension

• Significant arterial hypertension
• Tachycardia or bradycardia
• Moderate valvular heart disease
• Left main coronary obstruction
• Hypertrophic cardio myopathy
• Psychiatric illness
HEART RATE

• Training HR is ideally based on information derived from a maximal or

a symptom limited exercise test.
• Age adjusted predicted Hrmax is given by the formula 220-age
• Training HR is set at 60 to 70% of this age predicted maximum
• Alternative method is to prescribe training at 60 to 75% of heart rate
reserve (HRR)
• HRR=MHR-RHR
• KARVONENS FORMULA =60-75% of HRR + RHR
RELATIONSHIP BETWEEN MAX HR AND VO2
MAX %
• Max heart rate VO2max
• 60 40-45
• 70 55-60
• 85 80
BORGS SCALE
TALK TEST
• Too easy- sing several phrases of a song without breathing hard
• Good intensity- light conversation
• Working too hard- speech starts to break, slow, or cause discomfort
MET s
• One MET= 3.5 ml/kg/min

• Very light- <3.2

• Light- 3-5
• Moderate- 5-7
• Hard- 7-10
• Very hard- >10.3
• Max- 12
MODES OF EXERCISES
• The exercise mode should reflect
• Purpose of the program(endurance or flexbility or strength program)
• The interest and ability of the participant
• The physical limitation
COMPONENTS OF TRAINING SESSION
• Warm up -5 to 10 min
• Conditioning phase
• Recreational game(optional)
• Cool down (5 to 10 min)
Intensity
• by HR or RPE
• Borg scale 6 – 20 is better than that of modified Borg
scale
• MHR by ETT
• 75-85% of maximum HR very deconditioned patient
can be benefited by 50-60% of MHR
• ETT can be perform in MI patient after 4-6 weeks
Duration

• 30-40 mins of aerobic exercise but increment should

be in a gradual manner
• 5-10 mins of warm up
• 5-10min of cool down
• Adequate warm up so gradual increase in myocardial
o2 demand and allow coronary artery to vasodilate .
Vasodilatation lead to balance in demand and supply.
Frequency
• 3-5 times per week
Mode of training
• Bicycle
• Treadmill
• Walking
• Stair climbing
• Rowing
• Arm ergometry
Difference between phase 2 & 3 is monitoring of
patient
• In phase2 patient require intensive monitoring
• In phase 3, patient do not require intensive monitoring. Only some
patient who is thermodynamically unstable they require monitoring
• In phase 3 you can start resisted exercise
PHASE III
• It is compose of safe incremental progression of activity and health
education involving risk factor modification and providing
psychological support through counseling and stress management
program
• To improve and maintain physical fitness.
• To monitor heart rate, blood pressures ECG, signs and symptoms that
are
potential contraindications for exercise.
• To provide professional supervision for exercise
• Provide smooth transition- less monitored, supervised exercise
program
• Continue with educational and behavioral prog
• Provide the foundation for safe and effective home-based program.
• To promote the importance of a lifetime commitment to physical
exercise and healthy lifestyle
• To introduce new exercise activities
• To teach skill for self monitoring and self awareness
• To prevent the recurrence and complication of CHD
• Intensity

• Above training threshold but below that which induces

abnormal clinical signs and symptoms
• For deconditioned cardiac patients: 40-50% of VO2
Reserve (VO2R).
RPE:-
12-15 (somewhat hard to hard )
(Approximately 60 - 80% VO2 Reserve and 60 – 85%
HRmax)
PHASE IV

• Important phase of all,because if neglected ,the benefits of the

training phase are lost within a few weeks time.

• Patient commitment
• Maintenance of endurance and strength

• Minimal or unsupervised exercise program

• Self exercise and sports programs

• Long tem behavioral modifications

GUIDELINES FOR MINIMAL SUPERVISION
PROGRAM
• Functional capacity  8 METS or twice occupational level
• Appropriate hemodynamic response to exercise
• Appropriate ECG response
• Adequate management of risk factor intervention strategy and
safe exercise participation
• Demonstrated knowledge of disease process, abnormal signs
and symptoms, medication use and side effects
• Intensity
• 60 - 80% of VO2 reserve
• 70 - 85% of HRR
• RPE 12 - 15 (somewhat hard to hard)
• MET (according to MET log)
• Duration
• Desired 30 - 60 min continuous workout
• Intermittent workout
Exs bouts of 15 - 20 min
• Frequency
• One session/day
• 3 - 4 days/week
TECHNIQUE TO REDUCE RISK OF INJURY
Determine the following

• Range of motion
• Resistance load
• Breathing techniques taught
• Avoid excessive hand gripping and breath holding (inhale- eccentric
phase, exhale- concentric phase) –
RISK FACTOR MANAGEMENT
• Nutritional counseling
• Weight management
• Blood pressure management
• Lipid management
• Diabetes management
• Tobacco cessation
• Psychological counseling
• Exercise training
• Physical activity counselling
Effects of drugs on exercise response

EFFECTS MEDICATION
May increase heart rate Quinidine ,procainamide bronchodilators
May decrease heart rate Propranolol and other beta blockers,
reserpine,some anti hypertensives eg. Aldomet.
May decrease BP Aldomet,apresoline,propranol,diuretics,nitrates
May increase BP Bronchodilators,epinephrine,aminophyline,nasal
sprays,decongestants
May increase cardiac Digitalis,aminophiline type drugs
contractility
May decrease cardiac Propranolol and other beta blockers
contractility .procainamide and other anti dysrhythmics
Benefits Of regular exercise training

• Loss of body weight

• Decreases blood pressure
• Decrease in serum triglycerides
• Decreases the risk of type 2 DM
• Increase in High density Lipo protein
• Improvement in insulin sensitivity
• Glucose homeostasis
• Increased physical fitness
• Reduced angina
• Decreased arrhythmias and heart rate variability
• Improved thrombolysis
• Psychological well being
• Improves quality of life
• Return to work is much faster
Effects of training on exercise capacity- CENTRAL
CHANGES
• VO2
• CARDIAC OUTPUT
• STROKE VOLUME
• HEART RATE
• RATE PRESSURE PRODUCT
VO2
CARDIAC OUTPUT
STROKE VOLUME
HEART RATE
PERIPHERAL CHANGES

• Increase in the number of mitochondria

• Increase in oxidative enzyme activity
• Increase in capillarisation
• Increase in myoglobin
INFLAMMATION AND IMMUNITY

• lowers the systemic inflammation- reduction in plasma levels of

cytokines such as TNFalpha, interleukin-6 and CRP

• Promotes natural cell mediated cytotoxicity, especially during the

post exercise period
CARDIAC REHAB IN CERTAIN CARDIAC
CONDITIONS

• Coronary artery bypass grafting

• Cardiac transplantation
• Pace maker
• Valvular heart disease
• PTCA
CARDIAC REHAB IN SPECIAL POPULATION
• Geriatric
• Pediatric
• Arthritis
• Diabetes mellitus
• Hypertension
• Obesity
• PAD
Endurance Exercise Rx for Healthy People: ACSM Guidelines
Frequency
• 3 to 7 sessions per week

Intensity
• 70% - 85% of peak HR (60% - 80% of peak VO2 )
• 40% - 50% of peak VO2 initially for sedentary people

• Heart Rate Reserve Method for Calculating THR (Karvonen Formula)

THR = [Intensity % x (MHR – RHR)] + RHR

• RPE: 12 – 16 on Borg Scale (5 to 8 on a 10 point scale)

• While exercising, a conversation should be possible

Duration
• 20 – 60 minutes, an average being 20 – 30 minutes
* Overuse injuries increase dramatically with a duration > 45 min.
Note: some experts are now recommending 60 minutes to combat obesity epidemic

Goal: expend 300 - 400 kcal at least 3 days / week

Progression Rate for Exercise Rx: ACSM Guidelines

Focus of Exercise Rx: ADHERENCE

• Initial Conditioning Stage

• may lasts up to 4 weeks for previously sedentary individuals
• 3 days / week
• 40% - 50 % HRR (slightly higher if subject is active)
• 15 minutes (even less if client has been very sedentary)
• Improvement / Progression Stage
• lasts 4 to 5 months
• duration and frequency before intensity
• 3 - 5 days / week
• intensity to 70% - 85% HRR
• duration to at least 30 minutes
• Maintenance Stage
• Review goals (consider re-testing for more accurate Rx)
• 3 -5 days / week
• 70% - 85 % HRR
• minimum of 30 minutes
 Exercise Rx for Impaired and Sedentary People:
ACSM Guidelines

Frequency and Duration

• Functional Capacity < 3 METS: 3 sessions of 5 minutes (daily)
• Functional Capacity 3 – 5 METS: 1 – 2 sessions (daily)
• Functional Capacity > 5 METS: normal parameters

Intensity
• 40% - 50% of peak VO2 initially for sedentary people
• Progress by increasing duration and frequency before intensity
• Always below pain and symptom threshold
Exercise RX for Cardiac Patients: ACSM Guidelines

Inpatient (Phase 1)
• Self care activities and ambulation as precursors
• Resting HR + 10 to 30 beats/min
• 2-4 session/day for 3 – 10 minutes per session
• Progress by u bout duration and then d number of bouts
• Borg Scale < 13
• ECG and hemodynamics should be constantly monitored
Outpatient (Phase II)
• Functional capacity < 5 METS: inpatient parameters
• Functional capacity > 5 METS: low end of normal parameters
• Progress to a goal of 20 – 30 minutes 3 times / week
• Progress to a goal of burning a minimum of 1000 Kcal / week
• ECG monitor required for those with:
• LV malfunction
• Signs of ischemia
• Arrhythmias
• Low functional capacities
 Exercise Intensity Threshold
Guidelines for Cardiac Rehabilitation

Set intensity level below

• Onset of angina (at least 10 beats per minute below)

• Plateau or decrease in SBP
• SBP of 240 or DBP of 110
• ST- segment depression of 1 mm
• Signs of left ventricular dysfunction (heart failure)
• Signs of increasing ventricular ectopy or ventricular arrhythmias
• Significant AV – block
• Significant supraventricular arrhythmias (tachycardia, A-fibrillation, etc.)
Home base cardiac rehab
• Uncomplicated low risk patient is the candidate of cardiac rehab
• Patient should be educated about self monitoring, nutrition, medication.
• Pt has to keep daily log book
• Weekly call is made by a member of cardiac rehab team and discuss about
progress and problem
• Initially at every two weeks follow up than at every month upto 6 -12
months.