Cardiac Rehab | Physiosimplified

CARDIAC REHABILITATION

Definition- Cardiac Rehabilitation refers to coordinated, multifaceted interventions designed to optimize a patients physical, psychological and social functioning, in addition to stabilizing, slowing and even reversing the progression of underlying atherosclerotic processes, thereby reducing morbidity and mortality.
(according to American heart association 2018)

Cardiac rehab is multidisciplinary and may include the physician, nurses, physical and occupational therapists, exercise physiologist, nutritionist, and social service caseworker

Indications:

Post CABG
Post PTCA
Post Myocardial infarction
Congestive heart failure
Pacemaker
Coronary artery disease
Heart transplant
Any other cardiac surgery

Contraindications:

Unstable angina
Symptomatic and uncompensated heart failure
Uncontrolled arrhythmias
Moderate to severe aortic stenosis
Uncontrolled diabetes
Resting blood pressure > 200/100
Uncontrolled resting tachycardia

GOALS

Decrease cardiac morbidity and relieve symptoms
Promote risk modification and secondary prevention
Decrease anxiety and increase knowledge and self confidence
Increase fitness and ability to resume normal activities.
Increase aerobic capacity
Strength, power and endurance should be improved

Exercise Prescription for Cardiac Patients:

The AACVPR established guidelines to check for contraindicated conditions. Once these conditions are corrected and appropriate begin the exercise program. Exercise prescription depends upon frequency, intensity, and duration of training, mode(type) of activity, patient risk status, and initial level of fitness. Of these factors intensity of activity is difficult to determine. Too high intensity is related to increased rate of cardiac events. Intensity may be prescribed by:

Borg RPE scale,

Karvonen’s formula: - Target Heart Rate = [(max HR − resting HR) × %Intensity] + resting HR.

Risk stratification criteria by AACVPR

High Risk
- Left ventricular ejection fraction < 40%
- Survivor of cardiac arrest
- Complex ventricular arrythmias at rest or with exercise
- MI or cardiac surgery complicated by cardiogenic shock, CHF, and/or complex ventricular arrythmias
- Decreasing systolic blood pressure during exercise or failure to rise consistent with exercise workloads
Low Risk
- Left ventricular ejection fraction > 50%
- No resting or exercise-induced myocardial ischemia.
- Uncomplicated MI, CABG, angioplasty, or atherectomy.
- Functional capacity >6METS 3 or more weeks
Moderate Risk
- Functional capacity <5-6 METS
- Mild to moderately depressed LV function
- Failure to comply with exercise prescription

PHASES

Inpatient Phase (average 3-5 weeks)
Immediate Post Discharge Phase (2-6 weeks)
Supervised Outpatient Phase(6-12weeks)
Maintenance Phase

INPATIENT PHASE: 3-5 weeks

It is usually 3 to 5 days. Role of physical therapist is to monitor activity tolerance, prepare for discharge, educate the patient to recognize adverse symptoms with activity etc.

The immediate inpatient phase has 6 levels:

Level 1
1-1.5 METs
Arms supported for meals and ADLs.
Interventions - Bed exercises like ankle pumps, Deep breathing exercises, limited personal care.

Level 2
1.5- 2 METs
Interventions - Leg exercises- ATMs, knee extension, marching in place

Level 3
2-2.5 METs
Interventions - Standing leg exercises, Independent or assisted ambulation

Level 4
2-2.5 METs
Interventions - Hall ambulation, standing trunk exercises, Independent or assisted ambulation in hall

Level 5

3-4 METs
Interventions - Hall ambulation, Arm exercises, Standing shower.

Level 6
4-5 METs
Interventions - Full flight of stairs, Progressive hall ambulation

Warm-up: 15-20 mins

Frequency: 3-4 times/day

Intensity of activity is low level and PRE should be “fairly light” of Borg scale or 1-2 METs.

Duration - Myocardial Infarction: 5-15 min

Coronary Artery Bypass Graft: 5-15min

Type of activities- ROM, walk cycle, stairs/steps

Cool down: 5-10 mins

Home Exercise Program

Patients needs to understand recognition of symptoms and appropriate activity guidelines.
Goal of 20-30 minutes of ambulation one to two times/day at 4-6 weeks.
Patients are encouraged to walk comfortably, dress appropriately and try to exercise in ambient temperature
HEP includes combination of rest and low-level activity including ambulation of UE & LE.
Patient is encouraged to change positions every 1-2 hrs.

IMMEDIATE POST DISCHARGE PHASE: 2-6 weeks

Warm up: 15-20 mins
Frequency: - 1-2 /day, 5days/week
Duration: - MI:15-45 min
CABG: 15 -45 min
Intensity: - RHR: +20/BPM
RPE: 12-13
Type: Walk, cycle, stairs, weight training
Cool down: 15 mins

Strength Training

Resistance training may begin with the use of elastic bands and light hand weights(1-3lb) and progress to load that allows 12-15 repetitions.

Guidelines for resistance training include
Exercising large muscle groups
Exhalation with exertion
Avoiding sustained tight grip
Focusing on RPE 11-13
Slow controlled movements
Stop exercise with any warning signs.

SUPERVISED OUT PATIENT PHASE: 2-6 weeks

Warm up: 10-15 min
Frequency: 3-5days/week
Duration: 30-60 Mins
Intensity: 40/50-85% OF HRRmax (VO2 max)
Type: walk, cycling, jogging, swimming, wt. training.
Cool down: 15 mins

MAINTENANCE PHASE: 2-6 weeks

Warm up: 10-15 mins
Frequency: 3-5 days/week
Intensity: 50-85% HRRmax
65-90% HRRmax
RPE- 12-16
Duration: 30-60 mins
Type: Walk, cycling, jogging, wt. Training, swimming, lifestyle activity.

Cool down:15mins.

Additional intervention for patients with congestive heart failure:

Ventilatory muscle training:
- Diaphragmatic breathing
- Pursed lip breathing
- Improve strength with help of inspiratory muscle trainer, acapella etc
Activity pacing and energy conservation techniques:
- Frequent rest intervals
- Easy and difficult tasks with rest intervals
- Adjust environment to make tasks easier and sit when feasible while doing strenuous activity.

Refrences
Physical Rehabilitation 6th editionSusan B. O'Sullivan
Cardiac rehabilitation by Nanette K. Wenger et al.