By Dr.Vinod K. Ravaliya, MPT (Cardiothoracic Physiotherapy)

1. Dr. Vinod K. Ravaliya, MPT
Cardiothoracic Physiotherapy
Shree Krishna Hospital
KMPIP, Karamsad

2.  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

3. Question yourself ????

4. 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.

5. "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

6.  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.
 Cardiac rehabilitation has also been described as
The combined and coordinated use of
medical, psychosocial, educational, vocational
and physical measures to facilitate return to an
active and satisfying lifestyle.

7.  The Coordinated, multifaceted interventions
designed to optimize a cardiac patient’s
physicial, psychological, and social functioning,
in addition to stabilizing, slowing or even
reversing the progression of the underlying
atherosclerotic process, thereby reducing
morbidity and mortality
AHA Scientific Statement, Circ 2005;111:369-76

8.  Post-MI
 Post-CABG
 Angina
 PCI
 Valve replacement or repair
 Heart transplant
 Indications for CHF continue to be evaluated

9.  Offset deleterious pyschologic and physiologic
effects of bed rest during hospitalization
 Provide additional medical surveillance of patients
 Enable patients to return to activities of daily living
within the limits imposed by their disease
 Prepare the patient and the support system at
home to optimize recovery followed by hospital
discharge
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10.  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

11.  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

12. 1. Smoking cessation
2. Lipid management
3. Weight control
4. Blood pressure control
5. Improved exercise tolerance
6. Symptom control
7. Return to work
8. Psychological well-being/stress management

13.  A Cochrane review in 2004 concluded that exercise
only cardiac rehabilitation reduced all cause mortality
by 27% and cardiac mortality by 31%
 The Canadian Co-ordinating Office for Health
Technology Assessment reported reductions of all
cause mortality of 24% and cardiac mortality of 23%.
 A study by Witt et al in 2004 found that not only was
participation in cardiac rehab associated with
decreased mortality after MI but also with lower risk
of recurrent MI

14.  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.

15.  Vitals:PR, RR, BP, SpO2, ECG findings
 RS Examination
 Circulatory Examination
 MS Examination
 CNS Examination

16.  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

18.  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
 Acute myocarditis or pericarditis
 Active endocarditis
 Acute aortic dissection
 Acute noncardiac disorder that may affect exercise performance or be
aggravated by exercise
 Inability to obtain consent
Exercise standards for testing and training: a statement for healthcare professionals
from the American Heart Association. Circulation 2001; 104:1694

19.  Left main coronary stenosis or its equivalent
 Moderate stenotic valvular heart disease
 Electrolyte abnormalities
 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
Exercise standards for testing and training: a statement for healthcare professionals
from the American Heart Association. Circulation 2001; 104:1694;

21.  Conditioning from acute event/ post-CABG
 To make patient functionally independent
 To adjust with discharge from the hospital
 Psychological counselling
 Nutritional counselling
 Secondary prevention targetting

22.  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.

23.  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.

25.  Functional goals
– Exercise training under supervision/ at
home
 Psychosocial goals
– Anxiety/depression management
 Secondary preventive targets

26.  Phase II: This phase encompasses the
 Immediate post discharge period, which is typically a
period of four to six weeks.
 It focuses on
 health education and
 resumption of physical activity, however the structure of this
phase may vary dramatically from centre to centre.
 It may take the format of
 telephone follow up,
 home visits, or
 individual or group education sessions.
 Either way, some form of contact is maintained with the
patient, facilitating ongoing education and exchange of
information.

28.  Functional goals
– Exercise training under supervision
 Psychosocial goals
– Return to work
– Return to hobbies and lifestyle
– Anxiety/depression management
 Secondary preventive targets

29.  Phase III: This phase is sometimes erroneously
referred to as the ‘Exercise’ phase.
 It incorporates
 Exercise training in combination with ongoing
education and psychosocial and vocational
interventions.
 The duration of Phase 3 may vary from six to 12
weeks, with patients required to attend a CR unit two
to three times weekly for structured exercise and
other lifestyle interventions.

31.  Maintenance of achieved functional status
 Return to work
– Return to hobbies and lifestyle
modifications
 Secondary preventive targets

32.  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.

34.  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.
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35.  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
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36.  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).
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37.  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,
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38.  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.
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39.  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.
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40.  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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41.  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
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42.  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.
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43.  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
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44.  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.
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45.  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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46.  Patients requiring intermittent program (eg.
Peripheral vascular disease, low functional
capacity) should progress according to
symptoms and clinical status
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47.  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
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48.  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
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49.  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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50.  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.
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51.  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.
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52.  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
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53.  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 53