Cardiac Rehabilitation and

Cardiovascular Disability: Role in

Assessment and Improving
Functional Capacity
A POSITION STATEMENT FROM THE AMERICAN
ASSOCIATION OF CARDIOVASCULAR AND
PULMONARY REHABILITATION

Larry F. Hamm, PhD, MAACVPR; Nanette K. Wenger, MD, MAACVPR; Ross Arena, PhD, PT, FAACVPR;
Daniel E. Forman, MD; Carl J. Lavie, MD; Todd D. Miller, MD; Randal J. Thomas, MD, MS, FAACVPR

The Social Security Administration (SSA) oversees the disability deter- K E Y W O R D S

mination process and the payment of disability benefits to Americans.
According to recent SSA data, approximately 900 000 persons are cardiac rehabilitation
receiving cardiovascular disability payments and about 145 000 adult
cardiovascular disability
claims for cardiovascular disability are processed by the SSA annually.
An objective and comprehensive examination of functional capacity is functional capacity assessment
an important part of the disability assessment process. This statement
reviews various protocols for disability assessment of aerobic capacity, social security disability
muscle function, and the physical requirements of job tasks. Cardiac
rehabilitation programs are ideal settings for conducting comprehen-
sive disability assessments of functional capacity in persons with car-
diovascular disease. In addition, exercise training provided by cardiac
rehabilitation programs can increase functional capacity in most
patients.

Author Affiliations: Exercise Science Department, School of Public Health and Health Services, The George Washington University,
Washington, District of Columbia (Dr Hamm); Division of Cardiology and Emory Heart and Vascular Center, Emory University School of
Medicine, Atlanta, Georgia (Dr Wenger); Division of Physical Therapy, Department of Orthopaedics and Rehabilitation and Division of
Cardiology, Department of Internal Medicine, University of New Mexico, Albuquerque (Dr Arena); Brigham and Womens Hospital,
Division of Cardiovascular Medicine and Harvard Medical School, Boston, Massachusetts (Dr Forman); Department of Cardiovascular
Diseases, Ochsner Medical Center, New Orleans, Louisiana, and the Department of Preventive Medicine, Pennington Biomedical Research
Center, Baton Rouge, Louisiana (Dr Lavie); and Division of Cardiovascular Diseases (Dr Miller) and Cardiovascular Health Clinic, Division
of Cardiovascular Diseases (Dr Thomas), Mayo Clinic, Rochester, Minnesota.

This position statement was approved by the Board of Directors of the American Association of Cardiovascular and Pulmonary
Rehabilitation on July 20, 2012.

The authors declare no conflicts of interest.

Correspondence: Larry F. Hamm, PhD, MAACVPR, Exercise Science Department, School of Public Health and Health Services, The George
Washington University, 2033 K Street, NW, Suite 210, Washington, DC 20006 (lfhamm@gwu.edu).

DOI: 10.1097/HCR.0b013e31827aad9e

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 Cardiovascular disease (CVD) in the United States
affects an estimated 82 600 000 persons with more
than half being older than 60 years. While CVD is
most prevalent in the elderly, nearly 40% of adults
aged 40 to 59 years have CVD.1 In 2008, 758 324
adults aged 18 to 64 years, whose primary impairment
was CVD, were receiving disability benefits from the
Social Security Administration (SSA).2(p54) With the
increasing prevalence of obesity, physical inactivity,
and type 2 diabetes mellitus in the adult US popula-
tion, CVD and CVD disability claims will likely
increase in the future. Thus, it is incumbent on the
SSA and medical community to identify the most
objective process for determining disability from CVD.
The SSA defines disability as the inability to
engage in any substantial gainful activity by reason of
any medically determinable physical or mental
impairment(s) which can be expected to result in
death or which has lasted or can be expected to last
for a continuous period of not less than 12 months.2(p43)
The SSA further describes disability as individuals
functioning at the lower end of the physical capacity
spectrum but could pertain to individuals functioning
at all levels along the physical capacity spectrum,
including persons whose work may involve high lev-
els of physical exertion. The Americans with Disabilities
Act Amendments Act of 2008 defines disability as
(1) a physical or mental impairment that sub-
stantially limits one or more major life activities;
or (2) a record of such an impairment; or (3)
regarded as having such an impairment. Major
life activities include, but are not limited to, car-
ing for oneself, performing manual tasks,
walking, standing, lifting, bending, and work-
ing. A major life activity also includes the opera-
tion of a major bodily function, including but
not limited to functions of the immune system,
normal cell growth, digestive, bowel, bladder,
neurological, brain, respiratory, circulatory,
endocrine, and reproductive functions.3
Given these broad definitions of disability, it is
important that individuals be assessed for disability
using the most appropriate methodologies and that
data from these assessments be interpreted in an
objective manner. The purpose of this focused state-
ment concerning cardiovascular (CV) disability is to:
Review the process for determining disability ac-
cording to the SSA rules and regulations and, in
addition, according to the more general definition
of disability, as used by the Americans with Dis-
abilities Act Amendments Act of 2008;
Discuss the recommended methods for functional
aerobic assessment;
2 / Journal of Cardiopulmonary Rehabilitation and Prevention 2013;33:1-11
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HCR200272.indd 2
Discuss the recommended methods for functional
assessment of muscular function;
Review the scientific basis for assessing the physi-
cal requirements of contemporary job tasks and
monitoring the CV responses to performing specific
occupational tasks; and
Discuss the potential role of cardiac rehabilitation
(CR) in assisting individuals in their return to oc-
cupational activities.
SOCIAL SECURITY DISABILITY
Background Information on the SSA
The major goal of the 1935 Social Security Act was to
provide older workers with a continuing source of
income after retirement (originally defined as age 65
years). Today, approximately 30% of SSA payments
are allocated to disabled, nonretired individuals
through 2 programs within SSA: (1) Social Security
Disability Insurance provides income support to
younger workers and (2) Supplemental Security
Income (SSI) funds adults with little or no income
who are elderly, blind, or disabled and children who
are blind or disabled. In 2008, 12.1 million4,5 adults
and children received benefits through these 2 pro-
grams. The process of applying for disability is the
same for Social Security Disability Insurance and
Supplemental Security Income.
SSA Disability Determination Process
The SSA uses a 5-step decision algorithm2(p8) to assess
disability (Figure 1). For step 1, the applicant cannot
be engaged in substantial gainful activity (defined by
an income standard of earning $1000 per month in
2010). For step 2, the applicant must have a physical
or mental impairment that significantly limits his or her
ability to work. The key point in the decision process
occurs at step 3, where it is determined whether an
applicants impairment meets or exceeds the severity
of a medical condition described in the SSA Listing of
Impairments (commonly referred to as the Listings),
describing more than 120 adult and 90 childhood dis-
eases that can cause disability grouped according to
14 body systems. There are currently 8 adult Listings
for CVD (Table 1).2(p47) Applicants who fail to meet the
criteria in 1 of the Listings proceed to steps 4 and 5.
These steps consider the applicants residual func-
tional capacity (generally defined as what the indi-
vidual can do in a work setting despite limitations
from medical impairments considering past work
experience, age, and education) to determine whether
the applicant is capable of returning to his or her prior
work (step 4) or performing any work (step 5).
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 shift in the step where the majority of allowances occur
from step 3 to step 5. In 1990, approximately 60% of
allowances occurred at step 3 compared with only 26%
in 2008.2 Step 3 allowances are determined by SSA state
agencies called Disability Determination Services,
where most teams are composed of 2 people, a lay
disability examiner and a physician. Allowances at
steps 4 and 5 are more laborious, expensive, and time-
consuming and commonly are resolved before an
administrative law judge.

2010 Recommended Revision of the CV Listings

The SSA CV listings are periodically revised with the
latest recommended revision occurring in 2010. The
SSA asked the Institute of Medicine (IOM) to convene
an expert panel to incorporate advances in the diag-
nosis and treatment of CVD into the Listings,2 with the
goal of shifting more of the allowances from steps 4
and 5 to step 3 for individuals who are ultimately
awarded disability, making the process more efficient
and economical.
During its deliberations, the IOM Committee noted
that there was significant underutilization of the exer-
cise test (ET) in the disability evaluation process.
Social Security Administration examiners have the
authority to order selective noninvasive tests, includ-
ing an ET, when this information is absent from the
Figure 1. Five-step disability determination process.2(p8) Reprinted applicant medical records. However, SSA examiners
with permission by the National Academies of Science. Courtesy generally have been reluctant to order an ET for sev-
of the National Academies Press, Washington, District of Columbia.
eral reasons, including concern about the safety of
testing, lack of clinical familiarity with the applicant,
CV Disability Statistics uncertainty concerning ownership of the test results,
Approximately 900 000 individuals receive CV disability and subsequent medical management of the appli-
payments.2(pp54-55) The number of adult CV claims sub- cant. Broader use of an ET, especially a cardiopulmo-
mitted varies modestly from year to year and has aver- nary exercise test (CPX), would enhance the objectiv-
aged 145 000 claims annually for the past 20 years.2(p55) ity of the disability determination process and facili-
Although the allowance rate using the 5-step process tate the application of the Listings.
has remained constant at about 40%, there has been a
CV Listings
Each of the individual CV Listings (as proposed by
T a b l e 1 Adult Cardiovascular Listingsa the 2010 IOM Committee) shares the requirement for
4.02 Chronic heart failure a CV anatomical abnormality plus a functional
4.04 Ischemic heart disease limitation (with a few exceptions). The anatomical
abnormality is specific to each Listing, whereas the
4.05 Recurrent arrhythmias
functional impairment is a common pathway for the
4.06 Congenital heart disease majority of the Listings and reflects an inability to
4.09 Heart transplant perform activity requiring 5 metabolic equivalents
4.10 Aneurysm of aorta or major branches
(METs) of energy expenditure. The requirement for a
functional limitation relates to the highly variable
4.11 Chronic venous insufficiency
impact on physical capacity of patients with the same
4.12 Peripheral arterial disease anatomical disease. If the results of an ET are not
a
Adapted from Institute of Medicine.2(p10) Reprinted with permission by the available in the applicant medical record, functional
National Academies of Science. Courtesy of the National Academies Press, capacity can be determined from the applicants
Washington, District of Columbia.
limitations of activities of daily living described in the

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 T a b l e 2 Methodologies for Assessing Functional Aerobic Capacity
Assessment Type Advantages
Questionnaires Inexpensive
No clinical expertise required to administer
6MWT Inexpensive but not commonly used in general CVD
Ability to monitor ECG, HR, BP, SpO2
ET Less expensive than CPX
Ability to monitor ECG, HR, BP, SpO2
Widely available in clinical facilities
CPX Aerobic capacity is accurately measured
Ability to monitor ECG, HR, BP, SpO2
Level of effort can be documented
Abbreviations: BP, blood pressure; CPX, cardiopulmonary exercise test; CVD, cardiovascular disease; ECG, electrocardiogram; ET, exercise test; HR, heart rate;
6MWT, 6-minute walk test; SpO2, peripheral oxygen saturation.
medical record or by the requirement for 3 hospi-
talizations during the preceding year to treat the
condition.2 This latter criterion reflects both the dif-
ficulty of stabilizing the medical condition and the
challenge for the applicant to maintain a job in the
face of frequent absences to receive hospital medical
treatment.
ASSESSMENT OF FUNCTIONAL
CAPACITY
A comprehensive examination of functional capacity
is a primary component of disability assessment.
Cardiac rehabilitation programs represent an ideal set-
ting for the systematic assessment of cardiac disability.
Both aerobic capacity and muscle force production
should be included in the quantification of functional
capacity. The different approaches to functional
capacity assessment are detailed in the following
sections, and the methods for assessing functional
aerobic capacity are summarized in Table 2.
Aerobic Capacity Assessment
A CPX incorporates ventilatory expired gas analysis with
traditional ET procedures, as reviewed elsewhere.6,7 The
use of CPX allows the most accurate quantification of
aerobic capacity, expressed as peak oxygen uptake
.
(Vo2) in mLkg1min1. A peak aerobic capacity of 15
mLkg1min1 has been proposed as a key threshold for
2(pp14-15,18)
disability assessment. While an individual at or
.
below this peak Vo2 level is clearly limited, it is impor-
tant to consider aerobic capacity in relation to unique
energy demands of both the home and occupational
setting.8 Since age and gender each have a significant
influence on aerobic capacity .in normal circumstances,
it is recommended that peak Vo2 also be reported as a
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HCR200272.indd 4
Disadvantages
No documented response to exercise
Estimated aerobic capacity is subject to error
Variability in the administration of the test
Estimated aerobic capacity is subject to error
Aerobic capacity estimated from exercise workload is
subject to error
Unable to objectively quantify level of effort
Potential for an untoward event
Most expensive option
Less availability in clinical facilities
Requires specialized equipment and specially trained staff
Potential for an untoward event
percent-predicted value, which can be derived from
established regression equations.9 Ventilatory expired
gas analysis also allows for the determination of exercise
intensities that can be sustained for prolonged periods of
time through the detection of ventilatory threshold,
which is of particular value in individuals whose occu-
pational requirements involve sustained periods of aero-
bic activity. Finally, peak respiratory exchange ratio
(RER) defined as the ratio of carbon dioxide production
and oxygen uptake provides an accurate determination
of subject effort. Attainment of a peak RER 1.10 is
widely recognized as a valid and reliable indicator of
excellent patient exercise effort.1 When exercise is termi-
nated at a peak RER 1.00, in the absence of an abnor-
mal exercise response (hemodynamic, electrocardio-
.
gram [ECG], pulse oximetry, etc), the peak Vo2 obtained
may not be a valid representation of the individuals true
aerobic capacity.6
During a CPX, abnormalities detected in blood pres-
sure (hypertension or hypotension), ECG (ST-segment
changes, arrhythmias), and/or pulse oximetry (desatu-
ration) should be documented. Rating of perceived
exertion as well as angina and dyspnea should be
quantified using established scales.7,10,11 Coupling
abnormal response(s) with the exercise intensity at
onset of the abnormality is valuable in providing rec-
ommendations for activity/occupational modifications.
Specifically, activities corresponding to workloads that
surpass a threshold at which ischemic ECG changes,
oxygen desaturation, onset of arrhythmias, or angina/
dyspnea occur should be avoided.
Aerobic ET Without Ventilatory Expired
Gas Analysis
Because of requirements for additional equipment
and increased staff expertise, most ETs are performed
without analysis of ventilatory gas. Aerobic capacity is
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 estimated from the workload achieved on the given Six-Minute Walk Test
modality employed (ie, ergometer or treadmill) and is
The 6-Minute Walk Test (6MWT) is frequently used in
commonly expressed in METs, where 1 MET equates
populations with chronic diseases such as those with
to 3.5 mLkg1min1. A peak MET level of 5 has been
heart failure and chronic obstructive pulmonary dis-
proposed as a key threshold for disability
ease to assess functional status and prognosis.17 Pulse
assessment.2(pp14-15,18) This equa-tes to an estimated
oximetry, heart rate, ECG via telemetry, and subjective
oxygen cost of 17.5 mLkg1min1, which is higher
symptoms can be monitored during the 6MWT.
than the 15.0 mLkg1min1 threshold proposed
Research has consistently demonstrated a large and
when oxygen uptake is directly measured. This dis-
clinically unacceptable standard error of estimate
crepancy is due to the fact that estimated. aerobic
(~3.8 mLkg. 1min1) using 6MWT distance to esti-
capacity can significantly overestimate true Vo2.
mate peak Vo2 in an individual patient.18 For this
Logistical Considerations for Clinical Aerobic ET reason, the 6MWT may not be an ideal approach for
disability assessment. A 6MWT distance of 300 m or
Treadmill and lower extremity ergometry are the 2
less identifies patients with a poorer prognosis.12
most common modes utilized during ET. It is recom-
Others have proposed a graded classification accord-
mended that both modes be available to match the
ing to 6MWT distance to assess prognosis and clinical
needs of the individual patient being assessed. For
status.19 It has also been proposed that a 6MWT dis-
example, a patient with balance deficits or orthopedic
tance 500 m is considered a normal response during
limitations may have difficulty with treadmill ambula-
a disability assessment.3 Research is needed to iden-
tion and should ideally be tested on a cycle ergometer,
tify 6MWT distance thresholds that accurately quantify
although aerobic capacity is 10% to 20% lower on a
the level of disability.
cycle ergometer than on a treadmill.12 These mode-
dependent differences in aerobic capacity should be Questionnaires for Estimating Aerobic Capacity
considered during the disability assessment. When
Questionnaires that estimate aerobic capacity, such as
aerobic capacity is estimated from treadmill speed and
the Duke Activity Status Index, are available.20-23
grade, handrail. use likely results in overestimation of Although aerobic capacity estimated from these. ques-
actual peak Vo2 and can potentially invalidate the
tionnaires statistically correlates with peak Vo2 or
results of the disability assessment. For example, the
METs achieved during ET, a considerable degree of
difference in recommended thresholds to define dis-
error between questionnaire-estimated aerobic capac-
ability is 2.5 mLkg1min1 greater when estimating
ity and the ET response does exist. Thus, using
aerobic capacity from workload achieved. This dis-
questionnaires to quantify aerobic capacity for disabil-
crepancy reflects the expected error associated with
ity assessment is not currently recommended.
estimating aerobic capacity. The mean difference
between estimated and measured aerobic capacity in
Computer Adaptive Testing
patients undergoing ET for the evaluation of suspected
myocardial ischemia was greater than 7 mLkg1min1.13 An assessment tool currently under study with the
In this study, all subjects underwent an ET using the potential for determining physical function related to
aggressive Bruce protocol and were allowed to use disability is Computer Adaptive Testing (CAT),24 which
handrail support, both of which likely contributed to uses an extensive item pool specific to a diagnosis or
this large discrepancy in a synergistic fashion. condition and the patient rates his or her ability to
There are numerous ET protocols that vary greatly perform each functional task addressed in the test
in the adjustment of workload between stages and, items. CAT software assesses previous patient respons-
ideally, the ET should last about 8 to 12 minutes.12 es to select subsequent items from the pool that are
The Bruce protocol is the most aggressive in terms of appropriate to the individual level of functioning. This
speed and grade adjustment and is an inappropriate results in fewer and unnecessary items being adminis-
choice for most, if not all, patients undergoing a dis- tered. The computer software also includes rules for
ability assessment given that some level of aerobic starting, stopping, and scoring the test.
impairment is expected in this population. The degree.
of error between estimated (METs) and measured Vo2
is significantly higher when an aggressive protocol, ASSESSMENT OF MUSCLE FUNCTION
such as the Bruce, is utilized.14,15 Use of conservative
ramping protocols has been shown to minimize this Strength assessment and strength-related training
discrepancy in patients with significant functional goals are important components of exercise and
limitations16 and is recommended for patients under- potentially even more important in assessment of
going a disability assessment. potential limitations pertaining to disabilities. Strength,

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 endurance, and power are 3 aspects of function used
to denote specific properties of muscle-related func-
tion.25 The shift from sitting in a chair to standing, for
example, relies on strength, the maximum force pro-
duced by a muscle or group of muscles, generated by
muscles in the lower limbs to facilitate the lift.
Endurance is the separate but related capability to
sustain repeated muscular contractions over time.
One may rely on strength to lift groceries, but it
requires endurance to carry them into a car. Endurance
tends to be greater if the functional task entails a rela-
tively smaller percentage of ones maximal strength.
Power relates to the speed with which force can be
implemented. Power characterizes critical timing of
force generation, such that falling may be averted if
force in a potentially stabilizing leg is sufficiently
swift. Power has been correlated with mobility, inde-
pendent of maximum strength.
The combination of muscle strength, endurance,
and power are often critical for disabled individuals.
It is also important to recognize the interconnection
between muscle function and aerobic capacity. Adults
lacking sufficient strength components predictably
have diminished mobility. Impaired strength can
result directly from an underlying disease (eg, degen-
erative disease) and be compounded by the effects of
decreased physical activity (PA) and subsequent
deconditioning that result from the disease limitations.
Despite the strong rationale to focus on strength,
endurance, and power as elemental parts of disability
evaluations, these assessments are not straightfor-
ward and are often omitted. No single test definitively
evaluates composite muscle health. Assessments
often vary with the muscle group being tested, the
type and speed of contraction, the type of equip-
ment, and the joint range of motion (ROM). Even
patient size is relevant. Angles and acceleration of
movement vary with the proportions between patient
and equipment and potentially influence results.
Muscle testing requires steps to achieve proper pos-
ture, consistent speed of movements, full ROM, and
suitable warm-up.
Muscle Strength
Strength can be measured statically, with no overt
muscle movement, or dynamically, wherein the mus-
cle changes in length.26,27 Static or isometric exercise
assessment is achieved by devices that measure force
generated in the upper and lower extremities. Cable
tensiometers and handgrip dynamometers are popular
devices, because of their relative convenience and
safety. However, because each assessment character-
izes only a specific muscle group and angle, there are
some limitations in their capacity to assess overall
muscular strength. Most dynamometers are now size-
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HCR200272.indd 6
adjustable, and recent guidelines on handgrip assess-
ments reflect efforts to standardize techniques and
increase reliability of assessments.27
Dynamic strength assessments are more complex,
as they require measurement of force over the ROM,
entailing concentric and eccentric contractions over
time.26,27 Specialized isokinetic devices provide a tech-
nological mechanism to regulate speed and resistance
to ensure stable resistance across the ROM. Although
isokinetic assessment has a solid theoretical basis, it is
seldom used in the clinical setting.
Traditionally, the 1-repetition maximum (1-RM) is
the standard of dynamic assessment, that is, the
maximum resistance that can be moved 1 time
through the full ROM. Given that strength fluctuates
across a ROM, the 1-RM reflects the weakest strength
across the ROM. It is usually determined by adding
weights (using free weights or an exercise machine)
until an individual can no longer achieve a full ROM.
1-RM evaluations reflect inherent variability in regard
to increments of resistance added until the 1-RM is
determined: amount of time between tries; differ-
ences in warm-up, posture, spotting, speed of move-
ment; the steps to ensure that full ROM is completed;
and the fundamental motivation of the person being
assessed. However, the 1-RM is often not used in
clinical practice. Instead, clusters of RM, such as a
4-RM or even 6-RM, can be used and are particularly
good for evaluating persons with disability or muscle
weakness.
Muscle Endurance
Endurance is assessed by measuring the number of
contractions performed using a specific percentage of
a 1-RM. Assessments can be made using timing of
static contractions until fatigue, or measuring the
number of active contractions until fatigue. Endurance
assessments are not routinely incorporated into clini-
cal evaluations but provide important perspective on
general health and functional capacity.26-28 Among
disabled adults, endurance assessments provide func-
tional perspectives, which are useful in quantifying
the clinical impact of limitations from disease or
injury, and providing important benchmarks with
which strength training and adjunctive care can be
guided and monitored.
Muscle Power
Power evaluations are even less commonly per-
formed despite a growing body of literature highlight-
ing their clinical relevance. Assessment of power
requires expensive specialized equipment that mea-
sures 1-RM as well as percentages of 1-RM that are
able to capture the associated timing dynamics. In
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 general, peak power is lowest in relation to both very
low and very high 1-RMs and greatest in relation to
the movements at 60% to 85% of the 1-RMs. While this
may seem too theoretical to recommend as part of
standard assessment, the impact of power on mobility
is unequivocal.29
Integrated Assessment Tests
While direct assessments of strength, endurance, and
power are each inherently problematic, the concep-
tual utility of muscle performance assessment remains
clear. An alternative approach is to consider integra-
tive movement assessments that incorporate aspects
of muscle strength in tests that reflect normal activities
and that are relatively easy to administer. The 30-sec-
ond chair stand test and the Timed Up and Go Test
are 2 assessments commonly utilized as part of geriat-
ric assessments that can be applied to others who may
be weakened and/or susceptible to falls due to lack
of strength.30-32 In the 30-second chair stand test, mea-
surement of the number of times an individual can get
in and out of a chair has been correlated to the 1-RM
in older individuals and isometric assessments of
quadriceps strength. High test-retest reliability has
been demonstrated. Similarly, in the Timed Up and
Go Test, measurement of how long it takes for a
patient to rise from an arm chair, walk 3 m, turn, walk
back, and sit down again has been validated as a pre-
dictor of falls. It has been used as a test of strength-
related functional mobility, particularly in relation to
frailty and/or disability.
ASSESSING PHYSICAL REQUIREMENTS
OF JOB TASKS
Recommended Monitoring
It is often not feasible to perform CPX at the work site
but CPX can be performed in the clinical laboratory
while patients are duplicating their job tasks (eg, lift-
ing, carrying heavy objects, climbing). From a practi-
cal standpoint, ambulatory monitoring is more easily
carried out at the work site where heart rate can be
determined for specific job tasks and compared to ET
results. Ambulatory ECG monitoring provides useful
heart rate and heart rhythm information. In some
clinical situations where work-induced hypertension
or hypotension is suspected, ambulatory blood pres-
sure monitoring, either alone or combined with ECG
monitoring, can also be performed during working
conditions. While more precise testing can be per-
formed in the laboratory (see the Simulated Job
Tasks section), ambulatory monitoring has the advan-
tage of assessing patients during true environmental
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HCR200272.indd 7
conditions, as well as during psychological stress dur-
ing working conditions.
The use of additional clinical expertise (eg, occu-
pational therapist, physical therapist) may be helpful
when conducting job task analysis. In addition, car-
diac rehabilitation clinical staff may require additional
training to assess job tasks.
Physical Requirements From the Literature
Several important sources have compiled data for a
wide spectrum of human PA.8,33-35 Estimates of PA are
limited by the use of many different sources with var-
ied detail and methodology. In addition, data gener-
ally do not fully account for variations in climate,
body size and composition, age, and gender. Various
PAs are listed as multiples of the resting MET level
ranging from sleeping (0.9 METs) to running at high
speeds (eg, close to 11 mph or 18 METs). The compi-
lation from various reports includes a wide range of
PAs that include general PA, transport, domestic
chores, various occupational activities (which are
important to this manuscript), and sports and recre-
ational activities for both genders.
ON-SITE JOB TASK ASSESSMENTS
Several investigations have monitored cardiac param-
eters during occupational tasks.36-40 Twenty-two male
city bus drivers with ischemic heart disease per-
formed an ET followed by telemetry, ambulatory
blood pressure, and subjective symptom monitoring
during work. Heart rate, blood pressure, and subjec-
tive symptoms were approximately half the values
reached during the ET.36 On-the-job monitoring can
be used to determine whether abnormalities mani-
fested during the ET are reproduced during actual job
tasks. This information can be used to structure rec-
ommendations for modified work assignments, if
needed.
Initial research assessed CV responses during less
strenuous occupations. More recently, research accu-
rately quantifying the CV and metabolic demands of
highly strenuous occupations, such as firefighters and
police officers, has been conducted.39-41 Maximal heart
rate responses during a fire-suppression simulation far
exceeded the values obtained during a maximal ET in
49 young, apparently healthy . male firefighters.39 In
another study, heart rate and Vo2 responses during a
fire and rescue obstacle course exceeded the typically
prescribed aerobic exercise training intensities in
23 apparently healthy male firefighters.40 Similar find-
ings occurred in 30 apparently healthy police officers
and cadets completing an obstacle course.41 Assessment
in the workplace may not be necessary when the
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 physiological response to exercise is normal and the
peak aerobic capacity achieved exceeds physical
demands for a given occupation. However, in occupa-
tions with extreme physical demands, a clinical ET may
be insufficient to determine clearance to return to work.
In such cases, a comprehensive functional assessment
in the clinical setting in addition to a real or simulated
work site assessment is recommended.
While ET constitutes the standard by which cardiac
abnormality is customarily assessed, it does not
account for potential instability that can be induced
by mental strain.42 Adults who show no signs of car-
diac instability during routine exercise assessments
may develop ischemia, arrhythmia, and other manifes-
tations of cardiac instability in a stressful employment
environment. This is an additional reason to conduct
a disability assessment in the workplace. Telemetry or
ambulatory ECG monitoring during workplace assess-
ment may reveal significant consequences that are
otherwise not apparent. Additional research is needed
to resolve issues related to work site assessment and
establish its value.
SIMULATED JOB TASKS
Simulating selected physical requirements of job tasks
in a clinical setting can provide valuable information
concerning ability to return to work,43-46 especially
when the physical requirements of the job are sub-
stantially different from the work performed during an
ET. Monitoring should include continuous ECG telem-
etry, intermittent blood pressure determinations, and
assessment of symptoms.
The first step in assessing simulated job tasks is to
identify job-related tasks that are agreed to by the
patient, management, and, if appropriate, the union.
The simulation of job tasks should include specific
information related to the performance of each PA.
For example, if the task is lifting and carrying, the
information should include the minimum and maxi-
mum weight to be lifted, the height of lifting, and the
distance walked while carrying. A standardized
weight-carrying and weight-lifting test protocol46,47 or
1 customized to reflect specific job tasks can be used.
Compared to handgrip testing, weight-carrying
resulted in significantly higher heart rate, systolic
blood. pressure, rate-pressure product, ventilation,
and Vo2 in patients with coronary heart disease.48
Most assessments can be conducted using existing
equipment or purchasing inexpensive additional
equipment (eg, adjustable shelving unit, crates to hold
free weights). A significantly more sophisticated and
expensive approach involves the use of specialized
work simulators, such as the Simulator II (BTE
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HCR200272.indd 8
Technologies, Inc, Hanover, Maryland), that can
expand the range of the simulated testing. Simulated
job task testing does not account for psychological or
environmental stress that may be encountered by the
patient on the job. Occupational therapists can provide
valuable additional expertise for this type of testing.
Continuous ECG monitoring and intermittent blood
pressure determinations can provide documentation
of myocardial ischemia, cardiac dysrhythmias, and
hypotensive or hypertensive episodes that may be
elicited by the job task simulation. The equipment
necessary for this monitoring is readily available in
outpatient CR facilities. Occupational therapists can
provide additional expertise for simulated job task
assessments.
ROLE OF CARDIAC REHABILITATION IN
IMPROVING FUNCTIONAL CAPACITY
Since its origins in the 1950s, the aim of CR services has
been to assess, manage, and reverse disability in
patients with cardiac conditions49,50 and these remain
pertinent and important today. Research has shown
that CR is safe and effective, resulting in multiple sig-
nificant patient benefits, including improvements in
all-cause mortality, cardiac morbidity, physical work
capacity, return to work, control of CVD risk factors,
and quality of life.51-55
Cardiac rehabilitation is indicated for 6 specific
groups of patients: myocardial infarction, percutane-
ous coronary intervention, coronary artery bypass
graft surgery, chronic stable angina, heart valve sur-
gery, and/or heart transplantation. While evidence
suggests benefits of CR for patients with heart failure
and with peripheral arterial disease, these conditions
are not currently included in the Centers for Medicare
& Medicaid Services indications for CR but are
included in selected clinical guidelines.51 Less is
known about the impact of CR in patients with other
CV conditions associated with CV disability, such as
high-grade arrhythmias, hypertrophic cardiomyopa-
thy, or congenital heart disease.
Disability in patients with a recent cardiac event is
significant and relatively common. The average exer-
cise capacity for patients entering a CR program was
only 4 METs and 5.5 METs in women and men,
respectively, which approaches levels seen in patients
with heart failure and is consistent with CV disabil-
ity.56 Cardiac rehabilitation can increase aerobic exer-
cise capacity by 20% to 30%, with the greatest increase
in patients who are the most disabled at entry.53,57 If a
disability assessment was performed prior to a patient
completing CR, a subsequent second assessment
should be completed.
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 Several key steps can help maximize the role of CR
programs in the assessment, treatment, and reversal of
CV disability:
Train CR staff about key components of CV disabil-
ity assessment and treatment strategies that reduce
CV disability.
Include activities in CR that simulate work condi-
tions, specific to job-related responsibilities, in pa-
tient assessment and treatment plans.58
Measure impact and outcomes of cardiac disability
assessment and treatment program services, rela-
tive to patient physical work capacity, psychologi-
cal health, and return to work.
Provide education and communications to local
providers regarding the need for and availability of
cardiac disability assessment and treatment services
provided through the local CR program.
SUMMARY AND FUTURE DIRECTIONS
The deliberations of the IOM Committee to Revise the
Criteria for Cardiovascular Disability in its Listing of
Impairments sought to identify tests or procedures that
would quantify functional capacity, which would be
generally available either in the claimant medical record
or for purchase for the assessment of potential claim-
ants. Highlighted in the Committee report2 was the lack
of consistent relationship between the CV anatomic
alterations and resultant functional capacity; hence,
delineating the anatomy should be used solely to define
the presence and severity of disease, but the disability
process requires additional information on the func-
tional limitations imposed by the disease. Cardiac reha-
bilitation facilities offer a unique resource for functional
assessment for disability determination, given the avail-
ability of test procedures and the trained skilled person-
nel accustomed to interaction with individuals with
CVD. Not related specifically to the SSA disability pro-
cess, but relevant to the national public CV health and
occupational requirements, are issues of work assess-
ment, recommendations for work modification, and
specific CV exercise trainingall of which should con-
tribute to an enhanced opportunity for individuals with
CVD to appropriately return to the workforce. The
resulting monograph addresses in succinct summary the
validated and available test procedures and thus consti-
tutes a valuable resource for clinicians and for the SSA.
The IOM Committee further addressed future direc-
tions for improving the Listings. Policy issues involve
the potential of health insurance reform to increase
access to CV health services, including tests and pro-
cedures that could be used to meet or revise the
Listings. In addition, increased access to health ser-
vices may reduce the decline in an individuals CV
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Copyright 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
HCR200272.indd 9
health and the resultant inability to work. Social
Security Administration should support research on
the disability-related effects of health insurance
reform to improve program planning and future
updates of the Listings.
It would appear to be cost-effective to conduct
research to validate the Listings, both at SSA and
externally, with a full and balanced program of
research addressing policy implications, program-
matic issues, correlation of CV impairments and
impairment severity with functional limitations related
to work capacity, and the underlying prevalence of
trends in CV impairments in the population.
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