CARDIAC

REHABILITATIO
N
DR. Nouman Hussain; PT
 RECOMMENDED BOOKS
 https://www.pdfdrive.com/principles-practice-of-cardiopulmonary-
physical-therapy-e185452597.html

 https://sites.google.com/site/yuretr4873t487retye4ruy/p-d-f-essentia
ls-of-cardiopulmonary-physical-therapy-4e-full-books-by-ellen-hill
egass-edd-pt-ccs-faacvpr

Monday, August 12, 2024 2

LEARNING OBJECTIVES
By the end of lecture we will be able to know about;
 Cardiac surgery
 Introduction  Drugs to control the cardiovascular
 Goals of cardiac rehabilitation system
 Cardiac rehabilitation team  Physiotherapy
 Assessment
 Recording
 Role of the physiotherapist  Treatment
 Rationale for cardiac rehabilitation  Outcome evaluation
 Early ambulation  Complications of exercise
 Exercise training
 Secondary prevention
 Education  Other considerations
 The older patient
 Cardiac failure
 Valvular heart disease
 Manifestations of ischemic heart disease
 Cardiac arrest  Congenital heart disease
 Angina pectoris  Compliance
 Myocardial infarction  Cost-effectiveness
 Legal aspects.
Monday, August 12, 2024 3
INTRODUCTION
 “Integrated Treatment to regain physical function, promoting
emotional adjustment, secondary prevention of cardiac events and
lead active life.”

Monday, August 12, 2024 4

 WHAT IS CARDIAC REHABILITATION?
 Cardiac rehabilitation is a comprehensive exercise, education, and behavior
modification program designed to improve the physical and emotional condition of
patients with heart disease.

 Prescribed to control symptoms, improve exercise tolerance, and improve overall

quality of life.

 The primary goal of cardiac rehabilitation is to enable the participant to achieve

his/her optimal physical, psychological, social and vocational functioning through
exercise training and lifestyle change.
 Cardiac Rehab is a medically supervised program that commonly includes monitored
progressive exercise/activity, risk factor identification and behavior change assistance,
psychosocial referral and counseling (if needed), and communication with medical staff
to assist patients and physicians achieve desired outcomes.

 Outpatient/Phase II Cardiac Rehab typically meets 3 times a week for up to 12 weeks, but
will vary based on clinical status, risk stratification, risk factor status, and patient
progress/goals.
 World Health Organization classifies CR as ‘The sum of activities required to
influence favorably the underlying cause of the disease, as well as to ensure
the patient the best possible physical, mental and social conditions, so that they
may, by their own efforts, preserve or resume when lost, as normal a place as
possible in the life of the community’ (World Health Organization, 1993).
EVIDENCE SUPPORTING THE GUIDELINES

 Decreases Mortality at up to 5 years Post Participation

 Decreases Cardiovascular Events
 Improves Modifiable Risk Factors
 Improves Adherence with Preventive Medications
 Improves Function and Exercise Capacity
 Improves Quality of Life
 Encourage Lifelong Healthy Behaviors
CORE COMPONENTS OF CARDIAC REHABILITATION

 Prescribed exercise to improve cardiovascular fitness without exceeding safe limits

 Education about heart disease along with counseling on ways to stabilize or reverse heart disease by improving risk
factors
 Reduction/Cessation of Smoking
 Lipid Management
 Controlling High Blood Pressure
 Weight Loss/Control
 Improve/Manage Diabetes
 Increasing Physical Activity

 Encourage Healthy Eating Habits

 Improve Psychological Well Being

 Individualized personal and program goals are established with each patient upon entry into the
program.

 Cardiac Rehab assists patients in identifying and readdressing these goals based on medical status and
individual patient progress.

 Cardiac Rehab is dedicated to identifying high risk profiles and working with each patient and his/her
family toward developing strategies to maintain healthy lifestyle behaviors.

 This multifactorial process is designed to limit the adverse physiologic and psychological effects of
cardiac illness, reduce the risk of sudden death or reinfection, control cardiac symptoms, stabilize or
reverse the atherosclerotic process, and enhance the patient’s psychosocial and vocational status.

(AHCPR Clinical Practice Guidelines for Cardiac Rehabilitation)

GOALS OF CARDIAC REHAB
 Identify, modify, and manage risk factors to reduce disability/morbidity &
mortality
 Improve functional capacity
 Alleviate/lessen activity related symptoms
 Educate patients about the management of heart disease
 Improve quality of life
 Daily Activities Active lifestyle
 Emotional/Psychological adjustment
 Risk Factor Reduction
 Smoking cessation
GOALS OF CARDIAC REHABILITATION
 Limit the adverse physiologic effects of cardiac illness
 Limit the adverse psychological effects of cardiac illness
 Reduce the risk of sudden death or reinfection
 Control cardiac symptoms
 Stabilize or reduce atherosclerosis
 Improve functional capacity
 Enhance psycho-social and vocational status
 TARGET PATIENT GROUPS
 Following Myocardial Infarct
 Post CABG
• Percutaneous Coronary Intervention

 Chronic Stable Angina

 Congestive Heart Failure
 Pacemaker/Valve surgery
 Valvular heart disease
 Peripheral arterial disease
 Cardiovascular prevention in women
PT CONSIDERATIONS
 Prevention of pulmonary complications
– Upright positioning & early mobilization
– Deep breathing
– Airway clearance techniques
 Incisional precautions for 2 wks
– No submersion in water; running water is alright
– No cream or lotion directly in incision
 PT CONSIDERATIONS-- STERNAL PRECAUTIONS
 Do not lift more than 8 pounds. (A gallon of milk weighs 8 pounds.)

 Do not push or pull with your arms when moving in bed and getting out of bed.

 Do not flex or extend your shoulders over 90°.

 Avoid reaching too far across your body.

 Avoid twisting or deep bending.

 Do not hold your breath during activity.

 Brace your chest when coughing or sneezing. This is vital during the first 2 weeks at home.

 No driving.

 Avoid long periods of over the shoulder activity.

 If you feel any pulling or stretching in your chest, stop what you are doing. Do not repeat the motion that caused
this feeling.
 Report any clicking or popping noise around your chest bone to your surgeon right away.
OUTCOME MEASURES
 Medical  Rehabilitation
– Morbidity – Quality of life
– Mortality – ADL performance
– Complication rates – Symptom impact
– Hospital LOS – Habitual physical
– Ejection fraction activity level
– Quality of life – Balance
CARDIAC REHAB PROFESSIONALS
Partners in Patient Care:
 Medical Director
 Referring Physician
 Registered Nurses
 Exercise Physiologists
 Physiotherapist
 Dieticians/Nutritionists
 Social Services/Psychosocial
 Pharmacists
 Cardiac Rehab uses a multidisciplinary approach to patient care. All cardiac
rehab staff directly involved report to and consult with the referring
physicians and other medical specialists. Cardiac rehab programs vary in the
staff professionals they use to form the best team to meet the specific needs of
each program.
 (please identify the healthcare professionals involved in your specific
program).
 IMPAIRMENTS & FUNCTIONAL LIMITATIONS
FOLLOWING CABG
 Incisional (sternotomy and donor graft leg) pain and drainage
 Continuous pain from the shoulders and neck
 Thoracic pain
 Respiratory problems
 Feelings of weakness
 Sleeping difficulties including chest wall pain with side lying.
 Waking frequently and early, more nightmares than usual
 Problems with wound healing
 Dissatisfaction with postoperative supportive care
 Problems with eating
 Ineffective coping
 Depression
 COMPONENTS OF CR.
 Lifestyle:
 Diet and weight management
 Smoking cessation
 Physical activity and exercise
 Secondary prevention
 Education
 Psychosocial care
 Long-term management strategy
 PHYSICAL ACTIVITY
 Assess and risk stratify
 Develop individual exercise plan
 Teach FITT principle
F – frequency
I – intensity
T – duration / time
T – mode / type
 Regain/develop physical fitness
 Regain confidence in physical activity
 Develop long-term activity plan
 Self monitoring
 SECONDARY PREVENTION
 Cholesterol management

 BP management

 Blood sugar management

 Cardio-protective drug therapy

 EDUCATION
 CHD as a disease

 Treatment including medication

 Recovery process

 CHD risk factors

 Symptom management

 Living with CHD

 PSYCHOSOCIAL CARE
 Reduce fear and anxiety

 Assist with adjustment

 Promote positive attitude

 Facilitate behaviour change

 Identify need for further support

I. PATIENT & FAMILY EDUCATION
 Modification of risk factor profile
 Treatment of hyperlipidemia
 Smoking cessation
 Treatment of hypertension
 Control of diabetes
 Regular exercise
 Dietary changes
 Behavior modification
 stress management at home
 stress management at work
 creation of hobbies - time out
 conflict resolution skills
 Involve the children
 They don’t have pathology yet but they have all of the
same stresses
 They also should know how to help at home
II. PREVENT DELETERIOUS
EFFECTS OF BED REST
 Mobilize the patient soon
• Prevent muscle atrophy
• Prevent blood clot formation
• Prevent pneumonia
• Prevent lethargy
III. PROVIDE A SAFE
DISCHARGE TO HOME

Provide enough physical stamina to go home

and perform ADL’s
Reduce fear
 ASSESSMENT
 SYMPTOMS : Chest Pain, Palpitations
 EXAMINATION : CHF, Wound, Concurrent Illness, Musculo-Skeletal disease,
Emotional Status(Anxiety/Depression)
 DIAGNOSTIC STUDIES : Lipid Profile, Hb A1C, PFT
 ECG before exercise/Telemetry
 STRESS TEST : Sub maximal modified NAUGHTON’S
> 5-7 METS
> 80-85% THR
 ECHO : LV functions,
 STRESS THALLIUM : Viable Myocardium
Useful in patients with abnormal ECG’s
 VO2 Max with Stress Test to differentiate between Cardiac and Pulmonary
dyspnoea.
 EXERCISE TRAINING (REHABILITATION)
 Walking for 15-30 mins /3-5 times a week
 Patient can still talk while walking (Brisk Walk for initial 2 weeks)
 Contra indication to exercise training
>Unstable Angina
>Resting BP more than 200 mm/ 100 mm Hg
>Postural BP drop to more than 20 mm Hg
>Aortic Stenosis
>Acute illness or fever
>Uncontrolled Atrial or Ventricular Arrhythmias
>Uncontrolled CHF
>Musculo-Skeletal Disorders
EXERCISE PRESCRIPTION
 Aerobic Exercise preferred than resistive or weight training
 Walking/Cycling
 Intensity/Frequency/Duration will depend on tolerance
 THR (220- Age in years) try to achieve 80-85% THR
 EXERCISE PRESCRIPTION CONTD.
 Exercise session
 Warm Up (2-5 mins)
 Stimulus (conditioning 20-30 mins)
 Cool Down (5-10 mins, slow speed, prevents low BP
and joint pains)
 Graded Exercise with telemetry in high risk population recommended.
 1-3 months Target 7-8 METS followed by self directed maintenance
BENEFITS OF EXERCISE TRAINING
  work capacity  fatigue
  Heart rate during Exercise
  symptoms of CHF
  Atherogenicity by maintaining body weight  HDL  TG  platelet
aggregation
 Improve blood glucose level
 Improves coronary blood flow and myocardial perfusion
BENEFITS OF EXERCISE TRAINING
 Endurance Training
  VO2 max 10-40%,  BP,  HR

 Positive changes in body composition

  body weight (1-3 kg),  % fat (1-3%)
 Positive metabolic changes
  insulin sensitivity,  cholesterol
 Resistance Training
  strength
 PHASES OF
CARDIAC REHABILITATION

 Phase I: In-patient

 Phase II: Immediate post discharge (Outpatient ecg monitored)

 Phase III: 2-4 weeks post discharge (Outpatient with decreasing monitoring)

 Phase IV: Community based, independent exercise

PHASE I
 Post-MI, Post-surgery, Post-stent (no MI), CHF, heart transplant
 Patient may begin if:
 GP approval/order
 No chest discomfort (8 hours)
 No new signs of decompensated heart failure
 No abnormal EKG changes (8 hours)
PHASE I
 Goals
 normal cardiovascular response to changes in position and ADLs
 reach 3-4 MET activity level by discharge

 Activity--Slow progression of activity intensity (increase by 1 MET/day)

PHASE I
 Frequency: 2 – 3 times daily
Symptom limited by breathlessness / angina / fatigue
 Timing: 5-20 minutes <5 minutes rest period
 Type: sitting/standing functional activities, ROM exercises, walking
SURGICAL VS. MEDICAL PATIENTS
LIMITATIONS TO ACTIVITY
 Post-MI: HR < 120 beats/min or 20 beats above resting allowed with activity
 Post-surgery: 30 beats above resting is allowed
 Surgical patients may have sternal precautions
THE EVALUATION
Medical Chart Review
Patient Interview
Patient Examination
Patient’s Tolerance For Exercise
MONITORING
 HR
 BP
 SaO2
 EKG
 Symptoms
 At each change in position
 WHO SHOULD NOT DO PHASE I ?

 Patients with unstable angina

 Patients with acute CHF
 Patient’s with uncontrolled rhythms
 Patients with a systolic BP >200 mm Hg
 Patients with acute pericarditis
 Patients with recent emboli or clots
 Patients with severe cardiomyopathies
 Patients with uncontrolled DM
 PHASE II

 Home visits.

 Telephone support.

 Clinics
PHASE II
 2-6 weeks
 Time of high anxiety for the patients
 Heart manual
 Answer questions, reinforce daily walking, home exercise as
appropriate, discuss symptoms and activities
 Facilitate review of risk factors modification goals and achievements,
and Preparation for phase III
 30 minutes of walking once or twice daily
 CARDIAC REHAB PHASE II
 Supervised outpatient program 6-8 wks
 Exercise test performed prior to rehab
 EKG monitoring every session
 Goals - increase exercise capacity to 5 METS
 Patient education on HR, exercise, symptoms
PRE-REQUISITES
 Exercise Testing Prior to
starting program
COMPONENTS OF PHASE II

50% HRR, 3x/week, 60 minute sessions

including warm-up and cool-down

HRR = heart rate reserve

HRR = HRmax - HRrest
SAFETY
 Selection of appropriate patients
 Proper monitoring
 All professional exercise personnel must be able to do basic life support, including
defibrillators
 Emergency procedures must be specified
 Warm up and cool down are required
 PHASE III
Reassess health & risk factors first.

 Health Education

 Exercise

 Relaxation
 PHASE III
 Frequency: 1-2 times/week at a rehabilitation class and 1-2 times/week home
exercise circuit , other days at home leisure activities
 Intensity: 60-75% maximal HR
 Time: 20-30 minutes conditioning period exclusive of warm-up and cool
down
 Type: aerobic/endurance training involving large muscle groups in dynamic
movement
PHASE III OUTCOMES
 Functional capacity goals > 8 METS or 2x energy requirements of work
 Training effects expected
 No cardiac symptoms
 EKG monitoring happens occasionally, or when increasing activity parameters
 Patients learn self-monitoring of HR and symptoms
CARDIAC REHAB PHASE IV
 Unsupervised program
 Community Based
 Maintenance of exercise/activity
 On-going lifestyle support
PHASE IV
 Significant improvement in functional capacity
 Psychological adaptations to chronic diseases
 The foundation of behavioral and life style changes required for
continued risk factor modification
 Challenges for the Pt and Family
•Frightening, life threatening event (MI, major surgery)
•A chronic illness, reduced life expectancy, symptoms
•Fears for family and partner being left alone
•Threat to employment and financial status
•Medication side effects (lethargy, impotence)
•Being treated differently by other people
•Neurological impairment (esp. cardiac arrest pts.)
•Making lifestyle changes, smoking, diet, activity
 DELIVERING CR
Can be done individually or in a group

Venue: Home
Community
Clinics
Menu: Mixing up of all 4 phases too provide an individualised package of care.
 Sample Cardiac Rehabilitation Menu
Activity / Fitness Education
• hosp exercise group • Hospital educational programme
• home exercise programme • Home educational programme
• advice on resumption of active life • Mentor / volunteer / lay-worker
• Age Concern Health Mentor • Internet
• Walk for Health
• Phase 4 exercise programme Psychological adjustment
• Self help advice materials
• Stress management class
Smoking • Stress management on tape
• Willpower alone • Counselling psychologist
• smoking cessation clinic
• Clinical Psychology / Psychiatry
• Nicotine replacement Social support
• Referral for medication • Patient support group
• Internet programme • Mentoring scheme

Diet / Weight loss

• Self-management of diet / medication Other services / Professions
• dietetics referral 1. Sexual medicine clinic
• Weight Watchers 2. Welfare rights bureau
• Internet programme 3. Social worker
• Coach Programme 4. Specialist heart failure nurse