Cardiac Rehabilitation

Mrs. M. P. JIANDANI
ASSOCIATE PROF
SETH GSMC &KEMH

1 M P Jiandani. PT , SGSMC & KEMH

 Cardiac Care Cycle

2 M P Jiandani. PT , SGSMC & KEMH

 Cardiac rehabilitation
simple monitoring program for the safe return to physical
activities

a multidisciplinary program including post-operative patient

care, the optimization of medical treatment, nutritional
counseling, smoking cessation, risk stratification, stress
management, hypertension management and the control of
diabetes or dyslipidemia.

3 M P Jiandani. PT , SGSMC & KEMH

 CR –Definition (WHO -1993)
 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.

4 M P Jiandani. PT , SGSMC & KEMH

 Definition
 The NIH consensus development panel, Physical activity &
cardiovascular health, JAMA 1996 describes –

“ Cardiac rehabilitation services are comprehensive, long term

programs involving medical evaluation, prescribed exercise,
cardiac risk factor modification, education & counseling. These
programs are designed to limit the physiological &
psycholoical effects of cardiac illness, reduce the risk for
sudden death or reinfarction, control cardiac symptoms,
stabilize or reverse the atherosclerotic process & enhance the
physcosocial & vocational status of selected patients.”
5 M P Jiandani. PT , SGSMC & KEMH
 CR: Definition: (AACVPR)

 “A process by which persons with cardiovascular

disease and their family system are restored to and
maintained at their optimal physiological,
psychological, social, vocational and emotional
status”.

6 M P Jiandani. PT , SGSMC & KEMH

  cardiac rehabilitation/secondary prevention programs currently
include –
 Baseline patient assessments,
 Nutritional counseling,
 Aggressive Risk factor management (i.e. lipids, hypertension,
weight, diabetes, and smoking),
 Psychosocial and Vocational counseling,
 Physical activity counseling and exercise training,
 Appropriate use of cardio-protective drugs that have
evidence-based efficacy for secondary prevention.

7 M P Jiandani. PT , SGSMC & KEMH

 Who should be enrolled-Spectrum of
diseases
Initially –
 Uncomplicated MI,
 CABG
 PTCA

Now – also include

 Complicated MI including residual myocardial ischemia,
 Heart failure & transplants
 Implanted devices
 Valvular disease with or without surgical correction
 Congenital heart diseases
 Elderly & Women populations
 Medically complex patients with significant co-morbidity often receiving multiple cardiac
medications.

8 M P Jiandani. PT , SGSMC & KEMH

 Who Should Not Participate ?
¤ 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

9 M P Jiandani. PT , SGSMC & KEMH

 CR
CR is a Co-ordinated multifaceted intervention. WHICH Stabilizes
,slows and reverses the process of atherosclerosis thereby reducing mortality and
morbidity.
 The ultimate goal of these activities is to allow the patients with CAD to regain
or even exceed former physical capabilities general level of well being and
return to work.
 It enables patients to attain the highest level of performance
compatible with the extent of disease.
 Patient plays a significant role to affect outcomes and secondary
prevention.

10 M P Jiandani. PT , SGSMC & KEMH

 UNDERUTILIZATION
 Barriers
 Patient oriented-motivation
 Provider oriented-referrals
 Social or health care oriented-lack of insurance coverage, non
availability of CR prog.

10-20%> 2 million eligible patients per year.

11 M P Jiandani. PT , SGSMC & KEMH

 Assesment
 Risk factor evaluation and stratification
 Assess whether ready to begin mobilization
 Postural changes
 ADL
 Work

Assesment for Lifestyle and behaviour modification

12 M P Jiandani. PT , SGSMC & KEMH

 Risk stratification (ACSM)
ACSM risk stratification categories for Atherosclerotic CVDs –
Low risk Asymptomatic men & women who have ≤1 CVD
risk factor
Moderate risk Asymptomatic men & women who have ≥2 risk
factors
High risk Individuals who have known cardiovascular,
pulmonary or metabolic disease or one or more
signs & symptoms

Major signs & symptoms – Angina, dyspnea, sncope, orthopnea /PND, ankle
edema, palpitations/tachycardia, intermittent claudication, known heart
murmur, unusual fatigue with usual activities.

13 M P Jiandani. PT , SGSMC & KEMH

 Atherosclerotic CVD risk factor thresholds –
Positive Risk Factors Defining Criteria

Age Men ≥ 45 yrs; Women ≥ 55 yrs

Family history MI, coronary revascularization or sudden cardiac death before 55
yrs of age in mother or other female first-degree relative
Cigarette smoking Current cigarette smoker or those who quit within the previous 6
months or exposure to environmental tobacco smoke
Sedentary lifestyle Not participating in at least 30 mins of moderate intensity (40-60 %
VO2 physical activity on at least 3 days of a week for at least 3
months
Obesity BMI ≥ 30 kg/m2 or Waist girth >102cm (40 inches) for men & >88cm
(35 inches) for women
Hypertension SBP ≥140mm Hg & DBP ≥90mm Hg confirmed by measurements on
at least two separate occasions or on antihypertensive medications.
Dyslipidemia LDL≥130mg/dl or HDL<40mg/dl or on lipid lowering medication.
TC≥200mg/dl
Pre-diabetes Impaired fasting glucose≥100mg/dl but <126mg/dl or impaired
glucose tolerance ≥140mg/dl but <200mg/dl confirmed by
14 M P Jiandani. PT , SGSMC & KEMH
measurements on at least 2 separate occasions.
  Negative risk factor –
HDL ≥ 60mg/dl

Note : If HDL is high, subtract one risk factor from the

sum of positive risk factors.

15 M P Jiandani. PT , SGSMC & KEMH

 ACSM recommendations for current medical
examination and exercise testing prior to
participation
Low risk Moderate risk High risk

Moderate exercise Not necessary Not necessary Recommended

Vigorous exercise Not necessary Recommended Recommended

Sub-maximal test Not necessary Not necessary Recommended

Maximal test Not necessary Recommended Recommended

16 M P Jiandani. PT , SGSMC & KEMH

Assessment for Risks stratification.(AACVPR)
Low Risk
No significant left ventricular
dysfunction
No exercise induced or resting
arrhythmias
Uncomplicated MI; CABG;
angioplasty
Normal Heamodynamics with
exercise
Asymptotic on exertion or
recovery
Functional capacity of more
than or equal to 7 METs
Absence of clinical depression
17 M P Jiandani. PT , SGSMC & KEMH
Moderate Risk
LVF 40 – 49%
Signs & symptoms including
Angina at moderate levels of
exercise (5 – 6.9 METs) or in
recovery.
High Risk
LVF < 40%
Survivor of cardiac arrest.
Complex arrhythmias at rest
or with exercise
MI or surgery complicated by
cardiogenic shock CHF or
ischemia.
Abnormal Hemodynamics,
chronotropic incompetence
with increasing workload
Signs and symptoms including
angina at low levels of
exercise (<5 METs) or in
recovery.
Functional capacity of less
than 5 METs,
Clinical significant
depression .
 Assess

 system evaluation(CVS,Rs,MSK NSC,Integumentary,Psyc)

 Risk factor profile
 Investigations
 Orthostatic tolerance (supine-sit –unsupported sit-stand-walk)
 Cardiopulmonary response to activity
 ADL(self care) capabilities
 Functional capacity
 Medicines
 Support system
 Willingness and ability to return to work.

18 M P Jiandani. PT , SGSMC & KEMH

 CR- Program (phases)

19 M P Jiandani. PT , SGSMC & KEMH

20 M P Jiandani. PT , SGSMC & KEMH
 Phases of cardiac rehabilitation
Phase I ( In-patient phase)
 Purpose –
1. Avoid detrimental problems associated with bedrest &
immobilization
2. To maintain range of motion
 Intensity – low intensity with gradually increase in
duration begins with 1.5 METs progressing to 2-3 METs by
hosptital discharge
 Parameters – increase in HR (5-10 beats/min), increase in
SBP (5-10 mm Hg), RPE of 11-12
21 M P Jiandani. PT , SGSMC & KEMH
 Phase II (immediate out-patient supervised
program)
 Purpose –
1. Provide exercise guidelines to return to home activities, work &
secondary prevention.
2. Give progressive activity regimen to assist through convalescence
period of rehabilitation.
 Aerobic training –
 Prior to GXT, frequency is 1-2times/day, 5 days/week. During first
stage of convalescent period (4-6 weeks) the duration is shorter
& multiple aerobic sessions/day. Slowly increase duration upto
45 mins.
 If a low level GXT (upto 5 METs) is administered approx 3-6 weeks
post event , the intensity is set at 50%HHRmax (RPE = 13)
 A combination of clinic visits(2-3 days/week) & home program(2-
22
3days/week)
M P Jiandani. PT , SGSMC & KEMH
 Phase III- intermediate out-patient
 Purpose – Further physical development emphasizing
return to normal activities & secondary prevention.
 Cardiac conditioning

Phase IV – Maintenance
 Purpose – long term development & maintenance of
achieved health benefits.

23 M P Jiandani. PT , SGSMC & KEMH

24 M P Jiandani. PT , SGSMC & KEMH
 Phase I is meant to be preventative

¤ To have the patient operate within safe limits -

not too little exercise and not too much
¤ The patient must know what activities are safe
and okay
 Phase I is also Diagnostic

¤How large was the infarct ?

¤When do symptoms come on ?
¤Patients should have had a LLGXT before discharge ?

In order for a patient to enter Phase I Cardiac Rehab, they must be

medically stable

25 M P Jiandani. PT , SGSMC & KEMH

 PHASE I-objectives

1. Patient & Family Education

2. Prevent Deleterious Effects Of Bedrest
3. Provide A Safe Discharge To Home

26 M P Jiandani. PT , SGSMC & KEMH

 Phase I
¤ Can the patient do bed exercise and tolerate
positional changes.
¤ Can the patient sit on bedside chair or
commode ?
¤ Can the patient walk in place or in the room ?
¤ Can the patient sit UIC x 15 - 30 minutes at a
time ? While the patient is being monitored
continuously by EKG telemetry, for BP & HR :
¤ walk 25 feet & rest - do it again
¤ progress overtime as able with EKG, BP & HR
unremarkable
27 M P Jiandani. PT , SGSMC & KEMH
 Phase I –post operative
 Chest physiotherapy to increase pulmonary ventilation and maintain Bronchial
hygiene.

 Exercise should be low level in intensity i.e. 1 –2 METs such as sitting

supportive, self care activities, selected arm and leg exercises, Bed side toilet
activities

 In a surgical patient (CABG) measures for pain relief and sternal discomfort

 Wound care

 Care for ankle oedema in view of SVG graft

 Upper extremity exercises to prevent adhesions, Poor posture, and to

enhance tissue repair

28 M P Jiandani. PT , SGSMC & KEMH

 Intermediate Care
 Light moderate activities of 2-3 METs with an RPE of 10-12 .

 Warm up exercises which includes flexibility and stretching

 Dynamic exercises with cane

 Walking

 Stair climbing: BP before and after stair climbing at slow comfortable

pace when taking reading have the patent alternately shift weight from
one leg to the other to help prevent venous pulling and hypertension

In Phase I patient is generally weak and cannot tolerate long

bouts hence low intensity less duration exercises are give with
greater frequency. Improvements in CVS function have been
found after 6 – 10 training sessions lasting only 5-10 minutes a
day. Health benefits can come from lower intensities of effort
29 M P Jiandani.
than thosePT , SGSMC & KEMH
recommended by ACSM
 Ward (Pre discharge)
 Activity level 3 –5 METs with an RPE of 12 –13
 Patient is ambulatory on their own
 Warm up exercises
 Walking (3 –4 mph) Stationary cycle (6- 8 mph) can be given as aerobic
activity
 Cool down - flexibility & stretching exercises
 Stair climbing before discharge
 GXT (may or may not be done
 Home programme, which includes general instructions, symptom guide,
monitoring of pulse and progress charts.
 Use of activities logs
 Basic guidelines
 Intensity of Exercise is determined using 10-20 bpm above standing
resting heart rate.(Symptom limited graded exercise data at hospital
discharge have shown that 30 –40 bpm above standing resting heart
rate is nearly maximum for many patients and 13 on RPE scale is
approximately 20 bpm above standing resting heart.
30 M P Jiandani. PT , SGSMC & KEMH
 Activity classification Guide for inpatient
activities
 Class I- 1-1.5 Mets
 Does own self care activity
 Sits up in bed with assistance
 Stands at bedside with assistance
 Sits up in chair 15-30 minutes 2 – 3 times per day.

 evaluation and patient education

 Class II- 1.5 – 2 Mets

 Sits up in bed independently.
 Stands independently
 Does self care activities in bathroom seated.
 Walks in to room and to bathroom (may need
assistance)
 Education- identification of CAD risk
factors
 Room limited Hall ambulation

31 M P Jiandani. PT , SGSMC & KEMH

  Class III-2-2.5 METs  Class V -3-4 METS
 Sits and stands independently  Walks moderate distances 250 –300 feet
 Does own self care activities in bathroom with minimum assistance 3-4 times per
seated or standing day. Independent hall ambulation as
 Walks in hall with assistance short
advised. Arm exercises.
distances 50-100 feet as tolerated upto 3
times per day.progressive hall Class VI-4-5 METS
ambulation -progressive ambulation as
tolerated .
 Class IV -2.5-3 METS flight of stairs.
 Does own self care activity and baths
 Walks in hall short distances 150 –200
feet with minimum assistance 3-4 times
per day. Can do trunk exercises

32 M P Jiandani. PT , SGSMC & KEMH

 Assessment for abnormal responses

Objective Subjective
Heart Rate Chest pain (Anginal score)

Blood Pressure Giddiness

Rate Pressure Product Breathlessness

Rate of perceived exertion Palpitations

ECG Muscle cramps

Partial pressure of Oxygen

33 M P Jiandani. PT , SGSMC & KEMH

 Hemodynamic variables to be
monitored
 No systolic drop in BP > 10 mm hg or increase >30 mm
Hg
 No HR increase > 12 if beta blocked, or no HR increase
> 20 if not beta blocked
 No complaints of dizziness, lightheadedness, or angina

 Perceived exertion < 13/20

34 M P Jiandani. PT , SGSMC & KEMH

 Should I do it ?
Activity is desired

Is it within lifting
limits
No Stop
Yes
Is it within MET
limits
No Stop
Yes
Can I do the
activity for a
limited mount of
time
Yes
Do activities for
five minutes and
take pulse
Slow down or stop
Yes Yes
DO symptoms
develop ?
No Yes
Is pulse rate Work for shorter
exceeded ? Yes time periods with
less difficulty
No
Perform activity
Tired or exhausted Gradually increase difficulty
for 20 minutes
at end of day or next No and length while monitoring
35 M P Jiandani. PT , SGSMCpulse
taking at 10
& KEMH morning ? for symptoms and pulse
and 20 minutes
 SYMPTOM ADVISORY FOR PATIENTS
Symptom
Very irregular or unusually
irregular pulse; 2) a fluttering or
palpitation in the chest or throat;
3) a sudden burst of rapid heart
beats or a very slow pulse;
compare these with normal
pulse.
Pain, discomfort, or heaviness
occurs in chest arm, jaw or neck
during or following an exercise
session.
Dizziness, light-headedness,
cold sweating, confusion, in
coordination, or fainting occurs
during exercise.
36 M P Jiandani. PT , SGSMC & KEMH
Cause
It could indicate extra beats,
dropped beats, or problems
with the heart rhythm
Angina
Not enough blood is reaching
the brain
What to do
Check with the doctor if they are
benign.
Sit down and rest. If prescribed NTG
take as instructed. If pain continues
for 20 minutes contact your doctor.
Stop exercising immediately. Lie
down with your feet elevated or sit
down and put your head between your
knees. Stay there until you are feeling
better. Check with your doctor before
resuming exercise.
 Symptom
Heart rate reaches or exceeds
the upper limit set for you:
pulse rate stays high after you
have stopped exercising.
Nausea or vomiting occurs
during or right after exercise
Uncomfortably short of breath,
Extreme tiredness or fatigue,
during exercise or up to 24 hrs
after exercise
Sleep difficulties develop after
starting an exercise
programme.
Shin splints or pain on the front
and sides of foreleg
Pain or cramping in calves only
with exercise.
Side stitch or side ache while
exercise
37 M P Jiandani. PT , SGSMC & KEMH
Cause
The exercise may be too
vigorous
Not enough blood is
reaching the intestine, you
could be exercising too hard
or stooping the exercise
suddenly.
Exercises are too strenuous
The tissues of the lower leg
are inflamed and irritated
Muscle cramps may be due
to poor circulation or
unconditioned muscles.
Spasm of the diaphragm or
respiratory muscles.
What to do
Check your pulse more often during
the exercise session.
Exercise correctly and at the right
speed. Stress on the cool down
period.
Use shoes with thicker softer soles.
Avoid exercise on concrete.
Lean forward while sitting and rub
your sides.
 After discharge

 Late part of phase I programme

 Starter phase: These are low intensity exercises which includes joint
readiness, stretching, light calisthenics, low level aerobic exercises,
circuit training and resistance training
 Purpose of this stage is to introduce exercises at low level and allow
time to adapt properly to initial rigors of training
 Duration, Frequency and intensity are increased gradually
 Patients may have to come to the medical center for training
 Supervised Vs Unsupervised programmes based on patients risk.
 .Monitoring with accurate record keeping is essential. In cardiac
programmes 44 of 61 major complications occur during warm up or
cool down with the type of facility use not affecting the result. Therefore
there is a need for adequate supervision during rest breaks and
minimum 15 – 20 minutes post exercise surveillance is necessary.
38 Resumption
M P Jiandani.ofPTsexual activities
, SGSMC & KEMH
 Exercise Programming

39 M P Jiandani. PT , SGSMC & KEMH

 Principles of exercise prescription
 Mode

 Frequency

 Intensity
Specificity Frequency
 Duration
Overload Intensity

 Progression : Reversibility Time

 Session progression Cross transfer Type
 Programme progression
 Initial phase
 Improvement phase
 Maintenance phase.

40 M P Jiandani. PT , SGSMC & KEMH

 Programme components
 Warm up

 Stimulus / Conditiong

 Cool down

 Types of training programme :

 Continuous training
 Intermittent training
 Circuit training.

 Equipment
 Resistance training equipment
 Cardio vascular training equipment
 Circuit training

41 M P Jiandani. PT , SGSMC & KEMH

 Target Heart Rate
Age predicted maximum
(220 – Age) x % = Target

208 – 0.7 X Age

 Actual maximum
Peak Heart rate x % = Target
 Karvonen method : Using Heart Rate Reserve (HRR) to calculate
intensity

 Heart Rate Reserve (HRR) = (HRmax- HRrest)

 Target HR = HRrest + 40%-85% (HRmax- HRrest)

 Beats above rest:
Acute MI usually : 20 beats
CABG/Surgery : 30 beats
 Heart rate range :
Atrail arrhythmias : Range above rest
42 M Pacemaker
P Jiandani. PT , SGSMC & KEMHparameters
: Within
 VO2 & METs
 Target Workload Using Percentage of Oxygen Consumption
Reserve:
VO2 reserve = (VO2max- VO2rest)

Target VO2 = VO2rest + 40%-85% (VO2max- VO2rest)

 Target Workload Using Percentage of Maximum Oxygen
Consumption:
Target VO2 = intensity fraction (VO2max)
 Target Workload using METs:

Target METs = 1 + (intensity fraction) [(VO2max in METs)

– 1]
43 M P Jiandani. PT , SGSMC & KEMH
 Intensity
% HR max % VO2R RPE Classification
HRR original revised
_____________________________________________
_
<35 <20 <10 <1 Very Light
35-54 20-39 10-11 2 Light
55-69 40-59 12-13 3-4 Moderate

70-89 60-84 14-16 5-6 Hard

90-99 85-99 17-19 7-8 Very Hard
100 100 20 9-10 Maximal
44 M P Jiandani. PT , SGSMC & KEMH
 Correlation of training level with perceived
exertion and heart rate
Percieved %MHR from
Exercise Rate of percieved
breathing symptom limited
Training Level exertion (Borg)
rate exs test

6 No exertion at all
7 Very,Very light
8
9 Very light
10
LOW 11 Fairly light SING 50-60
12
MODERATE 13 Somewhat hard TALK 60- 75
14
HIGH 15 Hard (heavy) GASP 75- 85
16
17 Very Hard
18
19 Very,Very hard
45 M P Jiandani. PT , SGSMC 20 Maximal exertion
& KEMH
 Goals of phase II
 Give the patient safe, monitored environment for exercise. Monitoring
consists of measuring the patients BP, HR, EKG, Heart sounds and
lung sounds, RPE, and symptoms

 Increase exercise work capacity in progressive fashion with self-

monitoring

 Relieve fear and anxiety

 Occupational and recreational activities.

46 M P Jiandani. PT , SGSMC & KEMH

 Exercise Programme (Phase II )
Mode: is determined by the accessibility to equipments, medical centre,
etc.
Frequency: is generally 3-4 days per week . for high risk patient
frequency may be 5 days per week as intensity is low.

Duration: can usually start at 15 minutes of steady state exercise preceded

by 5-10 minutes of warm-up and followed by 5-10 minutes of cool down

Intensity: in the early stage of phase II it is generally 20-30 bpm above

RHR and 5-10 bpm below symptoms. In the late phase 5-10 bpm below
achieved HR at GXT. Above the minimum threshold intensity the
magnitude of improvement depends on total work or energy cost of
exercise regimen
.

47 M P Jiandani. PT , SGSMC & KEMH

 Exercise Programme (Phase II )
Resistance: Strength training: it is integrated as a part of total fitness
program and as a result of the need a patient may have in preparation of
return to work or leisure activity.

Light to moderate intensity resistance training can be recommended for

most cardiac patients who have an 8+ MET capacity and who are
considered at low risk.

Rate of progression: the speed at which a patient is advanced through

their exercise program is determined by their cardiovascular response to
graded increases in duration ,frequency and intensity. Slow to moderate
rate of progression. 50kcal to 150 Kcal to 200 Kcal .

48 M P Jiandani. PT , SGSMC & KEMH

 Guidelines for progression to independent
exercise with minimum or no supervision
 Functional capacity of more than 8 METs

 Appropriate haemodynamic response to exercise and recovery

 Appropriate ECG response at peak exercise.

 Cardiac symptoms stable or absent.

 Adequate management of risk factor intervention strategy.

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 Phase III
 Weight training Vs circuit training

 Aerobic Vs endurance

 Risk factor – secondary prevention strategies

 Frequency-3 times a week .

 Duration –30 x 60 minutes

 Intensity 60-75 % of HR max reserve progressing to 85%.Current

SLGXT is important and should not be more than three months old.

50 M P Jiandani. PT , SGSMC & KEMH

 Guidelines for exercise, prescription in
cardiac patients.
Prescription Phase I Phase II Phase III

Frequency 2 – 3 times per day 1 – 2 times per day 3 – 5 times per

week

Intensity MI: RHR + 20 MI: RHR + 20 60 – 85 % HR max

CABG: RHR + 30 CABG: RHR + 30 reserve

Duration MI: 5 - 20 min MI: 20 - 60 min 30 – 60 min

CABG: 10 – 20 min CABG: 20 – 60 min

Mode Activity ROM, Walking, ROM, Walking, Walk Walk, Jog, Swim,
Stationary cycle, 1 jog, cal, weight Weight training,
flight of stairs training. cal, endurance
sports.

51 M P Jiandani. PT , SGSMC & KEMH

 Exercise programmes for special population

 High Risk
 High risk patients can take prophylactic NTG before beginning an
exercise session.
 Use of ECG for signs of ischemia
 Avoid exercising in presence of angina, Dyspnea, or extreme
fatigue.
 Allow for a very gradual warm up and cool down.
 Regulate exercise intensity according to functional capacity and
ischemic threshold from GXT data
 Frequency :multiple daily sessions , 3-6 times a week
 Duration : intermittent to continuous
 Progression : Dependant on intensity and duration
 Resistance with weight low enough to perform 15-20 repeat ions
without strain.

52 M P Jiandani. PT , SGSMC & KEMH

  Angina / Silent ischemia

 Watch for angina and ischmic ECG changes

 Be Alert for heart rhythm changes during warm up and cool down
 Reinforce proper use of NTG
 Maintain activity below angina threshold.
 Using GXT data note the level at which symptoms and ischemia
occurs.
 Set HR at greater than or equal to 10 bpm below the ischmic
threshold
 Decrease intensity if angina rating is +2 or more on 1- 4 angina
scale.
 Frequency 3-7 times per week
 Duration : longer more gradual warm up and cool down.

53 M P Jiandani. PT , SGSMC & KEMH

  Progression : The patient progresses to independent home exercise
or to a less supervised setting based on the results of GXT.
If ST depression < 1.5 and patient is asymtomatic intensity can
be set at 70 – 85% of HR max.
If patient is symptomatic ST depression > 2 mm at HR > 135
intensity can be set at 70 – 85 % of HR at onset of 1.5 mm of ST
depression or angina.
 Resistance : Use light resistance, avoid isometric strain and
valsalva’s maneuver

54 M P Jiandani. PT , SGSMC & KEMH

  Congestive Heart Failure

 Observe for tolerance to exercise training

 Stop exercise if the patient shows BP change or sudden changes in
the symptoms
 Monitor ECG for arrhythmias often caused by abnormal electrolytes
 Observe for excessive dyspnea addressed.
 Ensure prolonged warm up and cool down
 Avoid isometric activities
 Use moderate intensity or RPE 11 – 14. RPE scales are preferred
over target HR.
 Intermittent exercise may be necessary

55 M P Jiandani. PT , SGSMC & KEMH

Smart N, Marwick TH . Exercise training for patients with heart
failure: a systematic review of factors that improve mortality and
morbidity.
Am J Med. 2004 May 15;116(10):693-706.

 There were no reports of deaths that were directly

related to exercise during more than 60,000
patient-hours of exercise training.

 CONCLUSION:
Exercise training is safe and effective in patients with
heart failure.

56 M P Jiandani. PT , SGSMC & KEMH

  Diabetic Patient

 Reinforce importance of proper foot wear and foot care.

 Ensure adequate hydration.
 Monitor a signs of hypo or hyperglycemia.
 Insulin should not be injected into an exercising muscle. If it is
injected exercise should be delayed for one hour post injection
 To prevent exercise induced hyperglycemia the insulin dose may
be decreased or carbohydrate may be increased before exercise.
 Mode : Use non weight bearing activities
 Intensity : RPE use is strongly recommended
 Frequency : Daily to maintain consistent blood glucose control late
evening excersie should be avoided because of the risk of
nocturnal hyperglycemia.
 Resistance : use less weight , increase repetitions to 10-15
 Avoid high intensity isometrics

57 M P Jiandani. PT , SGSMC & KEMH

  Contraindications

 Blood glucose > 300 mg/dl.

 Blood glucose > 250 mg/dl with ketones.
 Untreated proliferative retinopathy or recent therapy for retinopathy
 Uncontrolled kidney failure
 Severe autonomic neuropathy.
 Resting HR more than 100 bpm
 Drop in SBP more than 20 mmhg on postural change
 Acute illness
 Peripheral neuropathy

58 M P Jiandani. PT , SGSMC & KEMH

  CABG

 Avoid extreme tension on upper body to avoid injuring the surgical wound n
which requires 4 – 8 weeks to heal.
 Focus on gentle progressive ROM programme for the upper body
 Observe for infection or discomfort along incisions
 The alert for anxiety or denial of angina in a patient who has undergone
intervention.
 Monitor for anemia and CABG
 Suggested upper limit for exercise is Heart rest + 30 bpm
 RPE 11 – 13 inpatient and 12 –15 for outpatient
 Frequency : multiple times , daily for inpatient , progressing to once daily to
3 5 days per week for out patients.
 Duration: varies from 5 – 10 minutes of intermittent activity , 60 minutes of
continues activity.
 Progression inpatient activity should progress to levels equivalent to patients
home ADL before discharge.

59 M P Jiandani. PT , SGSMC & KEMH

 GXT after discharge assists in prescribing the appropriate level of
exercise
Resistance : 40 –50 % of one RM avoiding Valsalva , 2 – 3 times per
week , 1-3 sets , 10 –15 repetitions.

60 M P Jiandani. PT , SGSMC & KEMH