Dr.

C J JAYSON, MPT
Cardiothoracic Physiotherapy
Apollo hospitals
 Definition
 Members of CR
 Benefits of CR
 Assessment of risk factors and system-wise
examination
 Phases of CR
 Principles of exercise program for cardiac
patients
Question yourself ????
 Introduction
 Up until the 1950s, strict bed rest was
thought to be the best medicine after a heart
attack.
 Following discharge moderately stressful
activity such as climbing stairs was
discouraged for a year or more.
"The patient is to be guarded by day and night
nursing and helped in every way to avoid
voluntary movement or effort."

Thomas Lewis, 1933

 Cardiac rehabilitation has been defined as
The sum of activities required to ensure
cardiac patients the best possible physical,
mental and social conditions so that they
may, by their own efforts, resume and
maintain as normal a place as possible in the
community.
 Post-MI
 Post-CABG
 Valve replacement or repair
 Heart transplant
 Reduces cardiovascular and total mortality
 Does not increase non-fatal reinfarction rate
 Improves myocardial perfusion
 May reduce progression of atherosclerosis
when combined with aggressive diet
 No consistent effects on hemodynamics, LV
function or visible collaterals
 No consistent effects on cardiac arrhythmias
 Improves exercise tolerance without
significant CV complications
 Improves skeletal muscle strength and
endurance in clinically stable patients
 Promotes favorable exercise habits
 Decreases angina and CHF symptoms
 Clinical risk stratification is suitable for low to
moderate risk patients undergoing low to
moderate intensity exercise
  Exercise testing and echocardiography are
recommended for high risk patients and/or high
intensity exercise
  Functional exercise capacity should be
evaluated before and on completion of exercise
training.
 Vitals:PR, RR, BP, SpO2, ECG findings
 RS Examination
 Circulatory Examination
 MS Examination
 CNS Examination
 Exercise capacity
 Quality of life surveys (SF-12, SF-36)
 BP
 Weight
 Waist circumference
 Lipids
 Glucose/HbA1C
  Telemetry monitoring occurs during exercise
sessions
 Nutritional survey tool
 Stress level
 Absolute Acute myocardial infarction (within two days)
 Unstable angina
 Uncontrolled cardiac arrhythmias causing symptoms or homodynamic
compromise
 Symptomatic severe aortic stenosis
 Uncontrolled symptomatic heart failure
 Acute pulmonary embolus or pulmonary infarction
 Severe hypertension (systolic 200 mmHg and/or diastolic 110 mmHg)
 Tachyarrhythmias or bradyarrhythmias, including atrial fibrillation with
uncontrolled ventricular rate
 Hypertrophic cardiomyopathy and other forms of outflow tract
obstruction
 Mental or physical impairment leading to inability to cooperate
 High-degree atrioventricular block
 Conditioning from acute event/ post-CABG
 Assessment of haemodynamic response
 Determining the effectiveness of patient
medication
 Psychological counselling
 Family education
 Phase I relates to the period of
hospitalization following an acute cardiac
event. The duration of this phase may vary
depending on the initial diagnosis, the
severity of the event and individual
institutions, usually one week acute
event/post-operative.
 During this phase,
 Early mobilization and adequate discharge
planning.
 Individuals typically undergo a risk factor
assessment and risk stratification
 Receiving information regarding their diagnosis,
risk factors, medications and work/ social issues.
 Involvement and support of the partner and
family is facilitated and encouraged.
 Functional goals
– Exercise training under supervision/ at
home
 Psychosocial goals 
– Anxiety/depression management
 Secondary preventive targets 
 Phase II: This phase encompasses the
 Immediate post discharge period, which is
typically a period of 12weeks.
 It focuses on
 health education and
 resumption of physical activity, however the
structure of this phase may vary dramatically from
centre to centre.
 Increases the exercise capacity and
endurance
 Functional goals
– Exercise training under supervision
 Psychosocial goals 
– Return to work 
– Return to hobbies and lifestyle
– Anxiety/depression management
 Secondary preventive targets 
 Phase III: This phase is sometimes referred to
as the ‘Exercise’ phase.
 It incorporates
 Exercise training in combination with ongoing
education and psychosocial and vocational
interventions.
 patients required to attend a CR unit two to three
times weekly for structured exercise and other
lifestyle interventions.
 80% return to work by the end of this phase.
 Maintenance of achieved functional status
 Return to work 
– Return to hobbies and lifestyle
modifications
 Secondary preventive targets 
 Phase IV: This phase constitutes the components
of long-term maintenance of lifestyle changes
and professional monitoring of clinical status.
 It is when patients leave the structured Phase 3
programme and continue exercise and other
lifestyle modifications indefinitely.
 This may be facilitated in the CR unit itself or in a
local leisure centre.
 Alternatively, individuals may prefer to exercise
independently and
 Phase 4 may involve helping them set a safe and
realistic maintenance programme.
 Frequency
 Early mobilization:
▪ 3-4 times/day (days 1-3)
 Later mobilization:
▪ 2 times/day (beginning on day 4)
 Progression:
 Initially increase duration up to 10-15 min, then increase
intensity.
 The patient should not experience the fatigue as a result
of exercise, it there is a fatigue the freuency should be
reduced

HM734 Exercise Testing and Prescription: Cardiorespiratory 30

 By hospital discharge, the patient should:
 Demonstrate a knowledge of inappropriate
exercises
 Have a safe, progressive plan of exercise
formulated for them to take home

HM734 Exercise Testing and Prescription: Cardiorespiratory 31

 Selected moderate to high risk patients
should be encouraged to participate in
outpatient cardiac rehabilitation programs
&/or
 Manage their discharge rehabilitation plan
and report any cardiovascular symptoms
promptly (should they occur).

HM734 Exercise Testing and Prescription: Cardiorespiratory 32

 Goals are to:
 Provide appropriate patient monitoring and
supervision to detect a deterioration in clinical
status and to provide timely feedback to the
referring physician to enhance effective medical
feedback,
 Contingent upon patient clinical status, return
patient to pre-morbid vocational &/or recreational
activities, modify or find alternative activities,

HM734 Exercise Testing and Prescription: Cardiorespiratory 33

 Goals are to:
 Develop and help the patient to establish and
implement a safe and effective home exercise
program and recreational lifestyle,
 Provide patient and family education and
therapies to maximize secondary prevention.

HM734 Exercise Testing and Prescription: Cardiorespiratory 34

 In general, patients should engage in multiple
activities to promote total conditioning
including aerobic and resistance exercises.
 Principles of prescription are those for
healthy adults but adjusted to take into
account the patients clinical status.

HM734 Exercise Testing and Prescription: Cardiorespiratory 35

 Use of RPE. Particularly useful when GXT has
not been performed or medications change.
 Normally 11-13 (fairly light to somewhat
hard) for Phase II.
 Later (Phase III or IV) may use 12-15
(Approximately 60-80% VO2R

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 RPE can be used with beta-blockers BUT
 Should remember that significant and serious
ST segment and/or arrhythmias can still
occur at low intensities and RPE’s

HM734 Exercise Testing and Prescription: Cardiorespiratory 37

 Some patients: need to know when
abnormalities occur to enable exercise below
anginal or ischemic threshold
 Use of HR monitor with alarms
 Peak exercise HR 10 bpm below appropriate
threshold.
 Need to allow for medication effects on
exercise tolerance and HR.

HM734 Exercise Testing and Prescription: Cardiorespiratory 38

 Signs and symptoms below which an upper limit for
exercise should be set:
 Onset of angina or other symptoms of CV insufficiency
 Plateau or decrease in SBP, SBP > 240 or DBP > 110
mmHg.
  1mm ST-segment depression
 Increasing frequency of ventricular arrhythmias
 Other significant ECG changes
 Other signs or symptoms of intolerance to exercise

HM734 Exercise Testing and Prescription: Cardiorespiratory 39

 Desire to have 20-60 min of continuous or
intermittent activity
 Inversely proportional to intensity
 May be able to accumulate in short (10-15
min) bouts.

HM734 Exercise Testing and Prescription: Cardiorespiratory 40

 Depends upon patient functional capacity and
prognosis
 Generally, progress over 3-6 months to 1000
kcal/week
 Follow principles of initial, conditioning and
maintenance phase
 Generally progress every 1-3 weeks with goal of
achieving 20-30 min of continuous exercise.

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 Patients requiring intermittent program (eg.
Peripheral vascular disease, low functional
capacity) should progress according to
symptoms and clinical status

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 Functional capacity  8 METS or twice
occupational level
 Appropriate hemodynamic response to exercise
 Appropriate ECG response
 Adequate management of risk factor
intervention strategy and safe exercise
participation
 Demonstrated knowledge of disease process,
abnormal signs and symptoms, medication use
and side effects
HM734 Exercise Testing and Prescription: Cardiorespiratory 43
 Initial intensities determined according to
length of time from acute cardiac event and
associated complications, duration since
discharge and patient information (ADL’s
current home program, associated signs and
symptoms)
 Use of Duke Activity Status Index

HM734 Exercise Testing and Prescription: Cardiorespiratory 44

 Previously required abstinence from
resistance training for several months post
MI.
 Now many patients can start by carrying up
to 13 kg by 3 weeks post MI.
 Generally use approx. 50% 1RM or use of
other modes such as bands, hand weights
etc. in Phase II.

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 Should not begin until 2-3 weeks post MI.
 After 4-6 weeks post MI, may start bar bells
and/or weight machines
 Note: surgical patients need to adjust
program to accommodate sternotomy
 Normally begin resistance program 2-3
weeks after initiating aerobic program.

HM734 Exercise Testing and Prescription: Cardiorespiratory 46

 Advocate 1 set of 8-10 different exercises that
focus on large muscle groups, 2-3 days/week.
Will result in significant improvements
 Additional sets/reps do not seem to result in
substantial improvements.

HM734 Exercise Testing and Prescription: Cardiorespiratory 47

 Initially start with 1 set of 10-15 reps to moderate
fatigue using 8-10 different exercises
 Increase 1-2 kg/week for arms and 3-5 kg/week for
legs.
 Check rate, pressure product. Shouldn’t exceed
that for endurance exercise
 RPE: 11-14.
 Avoid Valsalva

HM734 Exercise Testing and Prescription: Cardiorespiratory 48

 Initially start with 1 set of 10-15 reps to moderate
fatigue using 8-10 different exercises
 Increase 1-2 kg/week for arms and 3-5 kg/week for
legs.
 Check rate, pressure product. Shouldn’t exceed
that for endurance exercise
 RPE: 11-14.
 Avoid Valsalva

HM734 Exercise Testing and Prescription: Cardiorespiratory 49