Cardiac Rehabilitation

and Exercise
Prescription
Objectives
• Identify and describe the examination procedures used
to evaluate patients with heart disease.
• Describe activities that aggravate or relieve edema, pain,
or dyspnea in a patient with a compromised
cardiovascular system.
• Discuss and demonstrate PT interventions specific for
individuals with cardiopulmonary and circulatory
diseases.
• Discuss and demonstrate interventions appropriate for a
post-op patient, ie: CABG, angioplasty, transplants.
• Identify and describe strategies of intervention during
various phases of cardiac rehab.
Objectives
• Appropriately modify therapeutic intervention as well as
activities, positioning, and postures that aggravate or
relieve edema, pain, dyspnea, or other symptoms of a
patient during a patient-simulated scenario.
• Participate in a provide written patient-related
instruction to patients, family members, and/or
caregivers as a part of discharge planning in collaboration
with the supervising physical therapist.
• Analyze and interpret patient data and follow goals for
cardiac patient.
• Perform appropriately under emergency patient
conditions.
What is Cardiac Rehabilitation?
• It is defined as, “all measures used to help
cardiac patients return to an active and
satisfying life and to prevent re-occurrence
of cardiac events”.
• Cardiac Rehabilitation includes exercise,
education, and social and emotional
support.
• Rehabilitation can be hospital or home
based.
 Rehabilitation Outcomes and
Quality of Life
• Improves • Improves exercise
psychological and tolerance
physiological well • Decreases coronary
being risk factors
• Improves quality of • Reduces long term
life mortality
• Lowers hospital re- • Lowers the risk of
admission rates death in survivors
• Prevents by 20-25%
reoccurrence of • Decreases the need
future cardiac for medication
events
Barriers to Rehabilitation
• Lack of Knowledge
• Poor Motivation
• Insufficient understanding
• Lower perceived self-efficacy
• Forgetfulness
• Decreased support from family and care givers
• Cost
• Poor Patient referral by Nurses and Doctors
• Time conflict between work and rehabilitation
program
Cardiac Exercise Prescription:
Indications
• Medically stable
• Stable angina
• CABG
• Percutaneous transluminal coronary angioplasty
(PTCA)
• Compensated CHF
• Cardiomyopathy
• Heart transplant
• Valve/pacemaker insertion
• Peripheral arterial disease
• CAD
Normal Response to Exercise
• Must recognize the body's normal response to exercise
before we can expect to effectively treat those with
cardiovascular compromise

• Case Study: Normal Response to Exercise (Finnick)

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

VO2

CO

HR

Systolic BP

RR
Normal Response to Exercise

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

Total Peripheral
Resistance
Exercise Prescription:
Contraindications
• Unstable angina
• Systolic BP > 200 mm Hg diastolic > 110 mm Hg
• Acute illness
• Uncontrolled arrhythmias
• Uncontrolled sinus tachycardia >100 bpm
• Uncompensated CHF
• Recent embolism
• Thrombophlebitis
• Uncontrolled diabetes
STOP Exercise
• Persistent dyspnea
• Dizziness/confusion
• Onset of angina
• Leg claudication
• Excessive fatigue, pallor, cold sweat
• Ataxia, incoordination
• Bone/joint pain
• Nausea/vomiting
• Systolic BP that does not rise, or decreases
• Systolic BP>200 mmHg, Diastolic BP >110 mmHg
• Significant changes in ECG
Patient Assessment
• Who?
• What? (and How?)
• When?
• Where?
• Why?
Who to assess?
What to assess?
• Vitals (HR, BP, RR and rhythm, RPE, O2 sats, pulses)
• Dyspnea
• Auscultation of lungs
• Edema
• Skin color
• Surgical sites
• Heart rhythm via EKG if monitored
• Pain
• Posture
• ROM
• Strength
• Medications and effects
Case Study Discussion: Finnick
• Why is it important to note in what position Finnick's BP was
taken?
• Would you expect any difference in the values if his BP were
taken with his arm over his head?
• Why?
• What if his BP was taken while he was lying down? What
would you expect then?
Before Treatment
• HR 75 bpm

• BP 200/95

• What decisions do you make?

How to assess?
Outcome measures and tools
• Pulse ox • ETT – Exercise
• Borg Scale Tolerance Test
• Dyspnea Scale • Swan-Ganz catheter
• BMI • EKG
• Patient journals • Heart
• Questionnaires catheterization
• METs • Echocardiogram
• Re-hospitalization
data
Dyspnea Scale
Exercise Tolerance Test (ETT)
• Or “Graded Exercise Test” (GXT)
• Determines safe aerobic exercise levels without symptoms
• Sets the level of exercise just below the onset of symptoms
• Pt. exercises thru increasing levels of workload
• Example: Bruce protocol p. 608
• Use of 12 lead EKG and face mask
• Gathers info on perfusion, rhythm, and conduction changes
• Read as either positive or negative
• Goals:
• 1. Detects presence of ischemia
• 2. Determines functional aerobic capacity
• http://www.youtube.com/watch?v=JddtTcTptjE&sns=em
ETT Results

Point was O2 supply was

reached where adequate for the
O2 demands of needs of the
myocardium myocardium
exceeded supply
Exercise Tolerance Testing
• Testing Modes
• Treadmill or cycle ergometry (UE)
• Step tests
• Max or Submax
• Age adjusted HR max (220 – age)
• THR or THRR
• Karvonen’s formula
• Continuous
• Progresses steadily in 2-3 minute stages
• Discontinuous
• Allows rest between stages
Metabolic Equivalents (METs)

• Measurement of estimated energy expenditure

• Oxygen cost of the body to do activity
• Measured in L/min; kcal; ml O2/kg/min
• One MET = basic O2 requirement at rest
• Five METs = 5x the O2 requirement needed at
rest
• VO2: Oxygen consumption of the body
• VO2 max: Maximal O2 consumption
• O’Sullivan: p. 558; ScoreBuilders p. 246
METs
• 3-4 METs, when continuous, can promote
endurance
• 5 METs required to safely resume most daily
activities

How many METs?

How many METs?
MET chart
• 2-3 METs: 2 mph walking, bartending, auto
repair, bowling
• 4-5 METs: 3.5 mph walking, scrubbing floors,
raking leaves, table tennis, doubles tennis
• 6-7 METs: 5 mph walking, splitting wood, water
skiing, swimming, square dancing
• 8-9 METs: 5.5 mph running, vigorous basketball
• 10+ METs: 6 mph running, competitive handball,
competitive swimming (>40 yds/min)
• See book for more examples, p. 558
Results of ETT
• How do you use the results to
determine treatment parameters?
When to assess?

• exercise • exercise • exercise

BEFORE DURING AFTER
Where to assess?
• Wherever the rehab is being performed
Why to assess?
• Safety
• Documentation
• Outcomes
• Progression
• Reimbursement
Exercise prescription
Four Variables
Exercise - Demonstrate
• Aerobic
• Anaerobic
• Resistive
• Maximal
• Submaximal
Exercise Prescription Variables
• I. Type (Mode)
• II. Intensity
• III. Duration
• IV. Frequency
I. Mode (Type)
• Aerobic LE activity (treadmill)
• Aerobic UE activity (UE ergometer)
• Aerobic activities (high inter-individual
variability)
• Swimming, dancing, cross country skiing
• Resistive exercise (typically 40% of max
contraction)
II. Intensity

• Selected as a percentage of the functional

capacity determined on the ETT, within
40% - 85%
• Use a combination of HR, RPE, and METs
(VO2) to determine training intensities and
to assess pt’s response to treatment
Heart Rate

• % of HR max determined by ETT or other

methods
• HR might not be the best indicator of exercise
intensity
• Beta blockers or Calcium channel blockers affect
HR’s ability to rise during exercise
• Pacemakers with limited HR elevation with
exercise
• UE work, Valsalva, or isometrics may affect HR
and BP
Rating of Perceived Exertion
• Original Borg Scale (6-20)
• RPE of 10-11 (fairly light) equates to 45-50% of
HR range
• RPE of 12-13 (somewhat hard) equates to 60% of
HR range
• RPE of 16 (hard) equates to 85% of HR range
• Must allow pt to become familiar with the scale
to learn how to use it
• Not all pts will be able to accurately use it
• Very important with pts where HR would not be
accurate
Original Borg Scale
Modified Borg Scale
METs
• A measurement of the oxygen requirements for
the level of activity performed
How is intensity determined?
III. Duration

• 5-10 min Warm Up and Cool Downs

• Conditioning phase: 15 – 60 min
• Average time is 20 – 30 min for moderate
intensity
• May require short bouts spaced throughout the
day
• Increase duration before increasing intensity
IV. Frequency
• Dependent on duration and intensity
• Lower intensity and lower duration would pair
with greater frequency
• Average: 3-5 sessions per week for moderate
work (>5 METs)
• Daily or multiple daily sessions for low intensity
work (<5 METs)
4 Variables of Exercise?
Progression

• When HR is lower than target range

• When RPE is lower than previous
• When symptoms of ischemia do not appear
• Increase duration first, then intensity
• Rate of progression depends on age, health,
functional capacity, goals, and preferences
Reduce Activity/Exercise
• Acute illness
• Acute injury
• Increase in edema, unstable angina
• Change in medications
• Environmental stressors (heat, cold, humidity,
smoke, pollution)
Cardiac Rehab Candidates
• Post Myocardial Infarction
• Post Cardiac Surgery
Phase I: Cardiac Rehab
In-Patient Cardiac Rehab
Inpatient Cardiac rehab
• Length of stay commonly 3-5 days for
uncomplicated MI
• 4 goals of therapy
1. Activity guidelines (3-5 METs at D/C)
2. Exercise guidelines
3. Patient and family education
4. HEP
1. Activity Guidelines
1. Initiate early return to independent ADLs (after
24 hours or until pt is stable for 24 hours)
2. Counteract effects of bedrest
3. Reduce anxiety and depression
4. Provide medical surveillance
5. Provide enough stamina to go home
2. Exercise guidelines - MI
• First 24 hours: bedrest, bed mobility, ankle pumps,
breathing exercise (1-1.5 METs)
• Once stable for 24 hours: sit EOB, sit OOB x 30 min
several times a day, LE exercise (1.5-2 METs)
• Gradual increase in ambulation up to 5 min., several
times a day (2-2.5 METs)
• ADLs, selected arm and leg exercises, progressive
ambulation up to 10 min, several times a day (2.5 – 4
METs)
• Activity needs for home – stairs (Up to 5 METs)
• RPE in light range (HR increase 10 – 20 bpm), constant
monitoring of vital signs and pt response
Exercise Guidelines –
Post PTCA
• May ambulate at comfortable pace following
surgery
• Avoid aerobic training for 2 weeks post-op
• Exercise prescription to be based on post-op
ETT results
• Often progress faster than MI patients
Exercise Guidelines –
Post CABG
• Sternal or intercostal incision
• Sternal precautions for 4-6 weeks
• LE incision
• Address soft tissue impairments
• Address posture and scapular retraction
• UE ROM if cleared by MD
• Energy conservation
3. Pt and family education
• Modification of risk factor profile
• treatment of hyperlipidemia
• smoking cessation
• treatment of hypertension
• control of diabetes
• regular exercise
• dietary changes
Pt and family education
• Behavior modification
• stress management at home
• stress management at work
• creation of hobbies - time out
• conflict resolution skills
Pt and family education
• Education
• Improve understanding of cardiac disease
• Empower pt to gain control of disease via
modifications
• Teach self-monitoring procedures
• Teach general activity guidelines, pacing,
energy conservation
• CPR
4. HEP
• Low-risk patient may be safe candidates for
unsupervised exercise at home
• Gradually increase ambulation time (goal 20-
30 min 1-2x/day at 4-6 weeks post MI)
• UE and LE mobility exercises
• Assist pt in planning out the day alternating
between activity and rest
• Elderly homebound pts may benefit from home
cardiac rehab program
• Patients should be skilled in self-monitoring
procedures
Carl
• 56 yo, married with three teenage girls
• Business owner, travels 2-3x/month
• Weighs 200 lb, BMI of 30, often resorts to a fast food diet
• Admitted to hospital 2 days ago with acute chest pain
• Diagnosed with MI, stable, evaluated by PT this morning, BP at
rest was 130/80
• Transferred to sit EOB with min assist
• Goals by discharge:
• Patient and family education
• Indpt in ADLs
• Ambulate 100’ with SBG A
• I with HEP
Phase II
• Outpatient cardiac rehabilitation
Exercise goals and outcomes
• Improve functional • Encourage activity
capacity pacing, energy
• Progress toward full conservation; stress
return to ADLs, importance of taking
hobbies and work proper rest periods
activities
• Risk-factor
modification,
counseling for
lifestyle changes
Exercise guidelines
• Frequency: 36 visits allowed by payers (3x/wk x
12 wks)
• Duration: 30-60 minutes (5-10 min of warm-up
and cool down)
• Mode: walking and/or cycle/arm ergometer and
strength training
• Intensity: Submaximal, or determined by ETT
data
Exercise guidelines: con’t
• Strength training
• begin at 3 weeks
cardiac rehab, 5
weeks post MI, 8wks
post CABG
• Begin with bands
and light weights (1-
3 lbs)
• Progress to
moderate loads, 12-
15 reps
Benefits of Phase II
• Beneficial for pt at risk for arrhythmias, angina
and other complications with exercise
• Availability of ECG monitoring, trained personnel
and emergency support
• Group camaraderie and support
• Pts gradually taken off continuous monitoring to
self monitor
• D/C: 5 METs needed for daily activities; 9 METs
recommended
Adelle
• 62 yo s/p CABG 6 weeks ago, Hx of HTN
• (+) ETT with symptoms of ischemia at 5 METs
• Resting BP 125/83, controlled with Lopressor (a beta blocker)
• Head Baker at Publix
• Lives alone, has 2 sons that live out of state, smokes
• PT eval showed low endurance, decreased strength, and
forward posture
• Goals in 12 weeks (asymptomatic):
• Patient education
• Increase endurance to ambulate 60 min at RPE of 12-13
• Increase strength to 4/5 overall to lift and carry groceries and
household objects
• I in HEP
Phase III
• Community exercise programs
Exercise goals
• Improve functional capacity
• Promote self-regulation of exercise programs
• Promote life-long commitment to risk-factor
modification
Exercise guidelines
• Located in community centers, YMCA or clinical
facilities
• Entry level: 5 METS, clinically stable angina,
medically controlled arrhythmias during exercise
• Progress from supervised to self-regulation of
exercise
• Progression to 50-80% of functional capacity 3-4
times/week, 45 minutes or more per session
• Regular medical check-ups and periodic ETT
generally required
• D/C 6-12 months
Edwin
• 78 yo s/p angioplasty 16 weeks ago
• D/C’ed from PT 4 weeks ago
• Lives with wife of 49 years
• Hx of hyperlipidemia, HTN, non-smoker
• Avid golfer, 5 days a week prior to procedure
• BP 128/75
• D/C report states I with ADLs and community ambulation
• Strength 4/5 overall
• Tolerated treadmill for 20 min at 5 mph
• Personal goal: to return to golfing at the club
 CHF
(Marty)
CHF
• Criteria for exercise
• Medically stable
• Exercise capacity >3 METS
• Exercise training
• Prolonged Warm up and cool down
• Low intensities (40-60%)
• Increase duration as tolerated
• Maintain HR below 115 bpm
• Monitor RPE: fairly light
• Avoid isometrics
• May include light resistance
Classes of Congestive Heart
Failure
• Class I:
• Mild; no symptoms up to 6.5 METs
• Class II:
• Mild; dyspnea, fatigue, angina with activity at 4.5 METs
• Class III:
• Moderate; limited up to 3 METs by dyspnea, fatigue,
angina
• Class IV:
• Severe; symptoms present even at rest; 1.5 METs
cause discomfort
Cardiac Transplant
Cardiac transplant
• Present with:
• Exercise intolerance due to extended inactivity
• Side effects from immunosuppressive drug
therapy: hyperlipidemia, hypertension,
obesity, diabetes, leg cramps
• Decreased LE strength
• Increased fracture risk from long-term
corticosteriod use
Cardiac Transplant
• HR alone is not an appropriate measure of
exercise intensity (heart is denervated).
• Use RPE, METS, dyspnea scale, BP
• Use longer periods of warm-up and cool-down
because the physiological responses to exercise
and recovery take longer
Pacemakers
Pacemakers
• Should know setting for HR limit
• Use RPE
• ST segment changes may be common
• Avoid UE aerobic or strengthening exercises
initially after implant
• Electromagnetic signals may cause devices to fire
or slow down or speed up
Diabetes
Diabetes
• Poorly controlled blood glucose, CV disease, renal
disease, neuropathy, peripheral vascular disease and
ulceration and/or autonomic dysfunction
• Exercise testing
• May need to use submaximal ETT
• With PVD and peripheral neuropathy, may need to use
arm UBE
• Exercise training
• Exercise prescription (40-60% functional capacity)
• Monitor for signs of hypoglycemia (shaking, dizzy, HA,
sweating)
• Proper footwear important
Pulmonary Disease
• Intensity:
• Training effect is achieved with 60-95% of VO2 max when
spaced with rest periods
• Use of warm up and cool down (5-15 min)
• Emphasize controlled breathing
• Use of a THR range
• Pts will reach ventilator limit before their
cardiovascular limit
• May be able to work at top end of THR range
• Dyspnea scale
• Exercise at moderate to severe level on the scale (3 –
6)
Pulmonary Disease
• Mode:
• Varies
• Duration:
• Within THR at least 20 -30 min, continuous or with rest
breaks
• Increase duration first when progressing
• Shorten rest breaks
• Frequency:
• 3-5x/wk if 20-30 min of exercise can be achieved
• Increase frequency if duration is shorter or for patient
with low functional abilities
Pulmonary Disease
• Stretching
• Posture
• Strength Training
• Increase resistance with aerobic exercise
• Weight training
• Progression:
• Increase intensity once 20 minutes of
continued activity is tolerated
Pulmonary Disease
• Patient education
• Symptom recognition, self management,
airway clearance techniques, pacing
• HEP
• Use of an exercise log and journal
Effects of cardiac rehab
1. Decreased HR at rest and during exercise
2. Increase stroke volume
3. Increase myocardial oxygen supply
4. Improved respiratory capacity during exercise
5. Improved functional capacity of exercising muscles
6. Reduced body fat, weight reduction
7. Decrease serum lipoproteins
8. Improved glucose tolerance
9. Improved coagulability
10. Improved measures of psychological status
Objectives
• Identify and describe the examination procedures used
to evaluate patients with heart disease.
• Describe activities that aggravate or relieve edema, pain,
or dyspnea in a patient with a compromised
cardiovascular system.
• Discuss and demonstrate PT interventions specific for
individuals with cardiopulmonary and circulatory
diseases.
• Discuss and demonstrate interventions appropriate for a
post-op patient, ie: CABG, angioplasty, transplants.
• Identify and describe strategies of intervention during
various phases of cardiac rehab.
Objectives
• Appropriately modify therapeutic intervention as well as
activities, positioning, and postures that aggravate or
relieve edema, pain, dyspnea, or other symptoms of a
patient during a patient-simulated scenario.
• Participate in a provide written patient-related
instruction to patients, family members, and/or
caregivers as a part of discharge planning in collaboration
with the supervising physical therapist.
• Analyze and interpret patient data and follow goals for
cardiac patient.
• Perform appropriately under emergency patient
conditions.