5. Cardiac rehabilitation-(CR)
I. The WHO (1993)- defines as the rehabilitation of
cardiac patients is the sum of activities required to
influence favorably the underlying causes of the
disease as well as the best possible physical, mental
and social conditions , so that they may best their
own efforts preserve or resume when lost as normal
a place as possible in the community.
• Rehabilitation cannot be regarded as an isolated
form of therapy ,but must be integrated with whole
treatment of which it form only one facet
6. II. BACPR 2002 -CR is the process by which patients
with cardiac disease in partnership with
multidisciplinary team of health professionals are
encouraged and supported to achieve and
maintain optimal physical and psychosocial
health
III. AACPR –CR as the application of rehabilitative
service to improve and maintain patients
physiological, psychosocial &vocational
functioning at an optimal level
7. IV. US dept of Health & Human services - CR is
comprehensive long term program involving
medical evaluation, ex’s prescription, cardiac
risk modification, education, counseling to
limit the physiological &psychological adverse
effects of cardiac illness
8. Indications for C R
1. Congestive Heart Failure
2. Angina pectoris
3. Myocardial Infarction
4. Post-open heart surgery
5. Post-heart transplantation
6. Balloon angioplasty
7. Pacemaker
8. Congenital heart disease
9. Arrhythmia
10.Rheumatic Heart disease
9. Contraindications for CR:
- Unstable angina
- Severe hypertension ( resting systolic pressure
> 200 mmHg or resting diastolic BP > 120 mmHg)
- Moderate or severe aortic stenosis
- Any acute systemic illness of fever
- Uncontrolled atrial or ventricular arrhythmia
- Uncontrolled tachycardia
- Heart Block
- Active pericarditis/myocarditis
10. -Recent pulmonary embolism
- Thrombophlebitis
- ECG evidence of ischemia
- Uncontrolled DM
- Dissecting aneurysm
- Symptomatic ventricular aneurysm
- Major orthopedic problems prohibiting exercise
- NYFC Class III and IV (NewYorkHeartAssociationFunctionalClassification)
- Resting ST displacement > 3 mm.
13. GOAL:
Help patients reverse their symptoms and maximize
cardiac function
• Cardiac rehabilitation includes , but is not limited to,
the following activities:
• Establishing a progressive exercise program to build
fitness and functional capacity
• Providing educational classes to help adjust to or
change the patient’s lifestyle and habits such as
smoking cessation and nutrition classes
14. 1. Stress management techniques and techniques to
reduce anxiety
2. Counseling and educating the patient with regards to
his/her specific heart condition/disease and the best
management approach for that specific condition
3. Preparing the patient to return to work
15. Four Phases of Cardiac Rehabilitation
PHASE TYPES OF PROGRAM DURATION
I In patient days
II Outpatient, immediate
post-hospitalization
2-12 weeks
III Late recovery period Minimum of 6
months beyond
phase II
IV Maintenance Program Indefinite
16. New York Heart Association Functional Classification
Class Description METS
O2
Consumpti
on
I Have cardiac disease but without
resulting limitations of physical
activity. Ordinary
activity does not cause undue
fatigue, palpitation, dyspnea or
anginal pain
> or = 7.0 >or=24.5
II With slight limitation of physical
activity. Comfortable at rest.
Ordinary physical
activity results in fatigue,
palpitation dyspnea or anginal pain
5-6 17.5-21
17. III Have cardiac disease resulting in
marked limitation of physical
activity. Less than
ordinary physical activity causes
undue fatigue,palpitation, dyspnea
or anginal pain
3-4 10.4 -14
IV With inability to carry on any
physical activity without
discomfort. Symptoms of cardiac
insufficiency or of anginal
syndrome pay be present even at
rest
1-2 3.5 -7
18. Phase I -IP/ CRP
1. Educate the patient and attain competence in areas of :
a. strategies to modify risk factors
b. signs and symptoms of MI
c. diet modification
d. stress management
e. smoking cessation
f. relaxation techniques
g. energy conservation techniques
h. administering/monitoring medications
I. taking/monitoring own pulse
j. community resources
2. Maximize self care
3. Maximize functional mobility & positive attitude
19.
20. 1. Program Focus
a. Patient education regarding disease process and recovery
increase knowledge of energy conservation and work simplification
techniques
increase knowledge of the approximate metabolic cost of activities
b. improve ability to carry out self care and low level functional activities
c. decrease anxiety
d. support smoking cessation and dietary modification efforts if warranted
e. discharge to home
2. Evaluation and intervention
a. Initiated at beside with a monitored functional assessment of self-care
and mobility
b. activity is started when a person is pain free, no arrhythmia and has
normal pulse rate
c. intense monitoring during activity especially at coronary care unit (CCU)
21. d. beginning activities at MET level = 1-2
• bed mobility, static standing
• transfer from bed to chair/bedside commode
• Bed bath, feeding, grooming at sink in sitting
• AROM/warm-up exercises
• wheelchair mobility/ ambulation in room
e. Parameters
• Mode- supervised monitoring progressive, stepwise, aerobic
ex’s
• Intensity – RHR +20 bpm, MET <2 -4
• Duration- 5- 10 minutes progressed 20-30 minutes
• Frequency -2 times daily
f. All activities use energy conservation techniques
g. Breathing exercises are done: abdominal , diaphragmatic,
pursed lip breathing
22. h. VS are monitored prior to each activity, or at peak of
each activity and 4-5 minutes post activity
i. As patient’s activity improves, more strenuous, higher
MET level activities are added in profession from basic
ADL to instrumental ADL
j. Observe any contraindication /precautions per
physician’s orders.
k. Patients are generally discharged to Phase 2 when
they are able to carry out activities at MET level 3.5-4
23. l. Educate individual about heart disease and the recovery
process, provide emotional support
m. Main thrust: institute a program of progressive activity to
increase ADL independence and prevent the deconditioning
effects of bed rest
n. pre-discharge exercise stress test recommended but should
not exceed 5 METS
24. PHASE-I
Exercise/activity goals
• Initiate early return to
independence in ADL ,
typically after 24 hours or
until the patient is medically
stable for 24 hours
• Counteract deleterious
effects of bed rest
Specific goals
• Maintain muscle tone
Reduce orthostatic
hypotension
• Help allay anxiety and
depression
• Provide medical
surveillance
• Provide patient and family
educ.
• Promote risk factor
modification
25. Wenger protocols
Medical
Step 1 – MET 1- 1.5
• Relaxed breathing ex’s-
AROM-all extremities
• Ankle pump movements
Step 2
• Plus above & increase
repetition rate movts
Step 3
• Repeat ex’s with mild
resistance movts
Surgical
Step 1 – MET 1- 1.5
• All ex’s of medical pt’s
• Makes sit-up on chair 2 times
• Walk with assistance in room
& corridors
Step 2
• Bed level 45 * angle
• Continue walking
Step 3
• Increase walking levels,
26. Medical
• Step 4
• Mild resistance active &
short leverage
Step 5 MET 1.5- 2
• Active ROM , Moderate
resistance
• Walking tolerance < 50 feet
Step 6
• Active ROM extremities 1-2
lbs
• Scapular movts
• Walking > 100 feets
Sx
• Walking without assistance
• Long distance with
assistance
Step 5 MET 1.5- 2
• Ex’s standing with 1-2 l bs
wt cuff , lateral trunk
bending
Step 6
• Walking without assistance
27. Medical
Step 7 MET 1.5 -2
• Walking tolerance > 200
feet
Step 8 MET 1.5- 2.5
• Walking tolerance > 300
feet
Step 9 MET 2- 2.5
• Knee bending
• 4 way body bends
• Increase walking tolerance
& walk down 1 flight stairs
own upon elevators
surgical
• Continue walking , trunk
bending
• Walk down 1 flight of stairs
down up on elevators
Step 8 MET 1.5 – 2.5
• Walk down 2 flight of stairs
down up on elevators
Step 9 MET 2- 2.5
Up and down 1 fight stairs with
assistance
28. Medical
Step 10 MET 2- 2.5
• Down 2 flight of stairs with
assistance
Step 11 MET 2.5- 3
• Walk 1 flight of stairs up &
down
Sx
Step 10 MET 2- 2.5
• Repeat without assistance
29. Termination criteria
• Fatigue, headaches, confusion, ataxia, pallor,
cyanosis , dyspnoea, nausea
• Onset of angina, ventricular tachycardia
• ST displacement >3 mm from rest
• Ex’s induced LBBB
• Onset 2*/ 3* AV block
• R on T phenomena (pvcs)
• SBP drops >20 mmhg
• SBP> 220 mmhg& DBP > 110 mmhg
30. Phase I: Inpatient CR
Exercise/activity guidelines
• Home exercise program
General rehabilitation mangt guidelines
• Low-risk patients may be safe
candidates for unsupervised
exercise at home -gradual
increase in ambulation time:
goal of 20- 30 minutes, 1-
2x/daily at 4- 6 weeks post-MI-
UE and LE mobility exercises
• Patient should be skilled in self
monitoring procedures
• Family training in CPR
31. Goals of Phase II- OPD CRP
1. Continued patient education in
a. self monitoring of heart rate
b. contraindications to exercise
c. risk factor modification
d. warning signs of cardiac dysfunction
e. components of an exercise program
2. Maximize functional mobility
3. Maximize endurance to activities
32. B. Phase II
Outpatient rehabilitation/Early Post Hospitalization Stage
criteria- 2 weeks after discharge or 6-8 weeks Post-MI
3-4 weeks post CABG
a. Most intensive and most rigorous phase
b. Highly supervised
c. Duration: 8-12 weeks
d. primary physiological component: exercise conditioning (
cornerstone of Phase II)
33. Parameters
e. Type of exercise: aerobic
f. Intensity based on age-related target heart rate
g. start with low level exercise
h. exercise frequency -3x/weekly
warm-up :5-10 min
aerobic exercise :30-40 min
cool-down :5-10 min
34.
35. Educate patient
Build up activity tolerance
Improve ability to carry out ADLs
and community tasks Support .
person’s efforts in smoking cessation
and lifestyle changes
Home evaluation
Consumer and family education
Graded exercise program
Functional activities
Energy conservation techniques
and compensatory techniques in
daily tasks
Community activities
Work site evaluation, if possible
Program Focus
Evaluation and intervention
36. • Entry level criteria--capacity of
5METs , clinically stable angina,
medically controlled
arrhythmias during exercise
• Progression is from supervised
to self-regulation
• Progression to 50-85% of
functional capacity
• Regular medical check-ups and
periodic ETT generally required
utilize motivational techniques
to maintain compliance and
exercise programs, life-style
modification
• Discharge typically in 6-12
months
37. Guidelines for graduating from the program
Total physical work capacity
Age Male Female
< or =-49 10 METS 8 METS
50-59 9 METS 7 METS
60-69 8 METS 6.5 METS
> or = 70 7METS 6.5 METS
38.
39. Exercise/activity guidelines
• Exercise/activity goals
General rehabilitation
management guidelines
• Improve functional capacity
Progress toward full
resumption of ADL, habitual
and occupational activities
• Promote risk-factor
modification, counseling as to
lifestyle changes
• Encourage activity pacing,
energy conservation: stress
importance of taking proper
rest periods
40.
41.
42. Phase-III
• Exercise guidelines
• Outpatient program:
• average of 36 visits allowed
• Risk-factor modification
• Frequency: 3-4 sessions weekly
• Duration: 30-60 minutes with 5-
• 10 minutes of warm-up and cool
• down
• Programs may offer single mode
of training or multiple modes (
circuit training), strength training
• Patients are gradually weaned
from frequent monitoring to self
monitoring
• Suggested exit point: 9 MET,
functional capacity (5 MET
capacity is needed for safe
resumption of most daily
activities)
46. General rehabilitation management guidelines-
Phase IV: Maintenance program
Designed to promote optimal health
Requirements for participation in a Phase IV program:
. Independence with self-monitoring of exercise
. Stable cardiac status
. No contraindications to exercise
. At least a 5 MET capacity for activities
