Cardiac Rehabilitation - Amazon S3...Cardiac Rehabilitation Added by Riddhi Manjrekar on plexusmd.com | November, 2016 Uses of Cardiac Rehabilitation 1. Musculo-skeletal conditioning:

Cardiac Rehabilitation

Added by Riddhi Manjrekar on plexusmd.com | November, 2016


Riddhi Manjrekar

4th BPT, Seth GSMC & KEMH Mumbai November, 2016



Introduction

Cardiac rehabilitation (CR) is a process of restoring physical, psychological

and social functions to optimal levels in those individuals who have had

prior manifestations of Coronary Artery Diseases and their families. It

enables patients to attain the highest level of performance compatible with

the extent of disease.

American College of Sports Medicine (ACSM) defines CR as multifaceted

intervention program designed to halt or reverse the progression of

atherosclerosis (clogged arteries) and to reduce morbidity and mortality.

CVR programs are no longer just exercise programs, but should also

include comprehensive, evidence-based interventions to decrease risk of

recurrent events, control symptoms, and, above all, to influence health

behavior changes that lower risk factors.

British Association for Cardiovascular Prevention and Rehabilitation

(BACPR) defines CR as the coordinated sum of activities required to

influence favourably the underlying cause of cardiovascular disease, as well

as to provide the best possible physical, mental and social conditions, so

that the patients may, by their own efforts, preserve or resume optimal

functioning in their community and through improved health behaviour,

slow or reverse progression of disease

Comprehensive program involves the following:

1. Physical fitness conditioning

2. Secondary prevention

3. Psychological adaptations

4. Vocational counselling



Uses of Cardiac Rehabilitation

1. Musculo-skeletal conditioning: Adverse effects of reduced physical

activities and bed rest are avoided and restoration of strength, flexibility

and joint mobilization is gained by appropriate exercise and early

mobilization.

2. Improved functional capacity: It improves VO2 max from 9 to 56%

depending upon the extent of training programme and patient

characteristics.

3. Quality of life: Modest increment in physical capacity permits marked

improvement in quality of life permitting stair climbing and other

activities.

4. Improved work efficiency: For mild efforts such as walking. Training

may result from improved work efficiency or habituation rather than

increased aerobic capacity alone.

5. Psychological Benefits: There is an outlet from allaying anxiety and

preventing depression, gives a positive boost.



Cardiac Rehabilitation Programme

Phase I Phase II Phase III

0-21 days 3 weeks - 6 weeks – 9

weeks

9 weeks –Lifelong

Slow – Start Start - Progress Progress – Maintenance

Immediate inpatients Out patients Community Level

Very light – moderate

activities

(upto 5 MET)*

Moderate activities

with resistance training

(upto 9 MET)

Self- regulated exercise

training

( > 9MET)

MET = Metabolic Equivalent

*One MET is defined as 1 kcal/kg/hour and is roughly equivalent to the energy cost of

sitting quietly. A MET also is defined as oxygen uptake in ml/kg/min with one MET

equal to the oxygen cost of sitting quietly, equivalent to 3.5 ml/kg/min.



Components of a Training Session for Cardiac patients

Components Duration (min) Phase

Warm up 15-20

10-15

I

II, III

Muscular conditioning 10-20 II,III

Aerobics 5-20

20-60

30-60

I

II

III

Cool down 10 I, II, III

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

CABG- RHR+30

MI-RHR+20

CABG-RHR+30

60-85% HR max

reserve

Duration MI: 5-20 min

CABG: 10-20 min

MI:20-60 min

CABG: 20-60 min

30-60 min

Mode activity ROM, Walking,

Stationary cycle, 1

flight of stairs

ROM, walking,

walk jog, weight

training,

treadmill

Walk, jog, swim,

weight training,

endurance

sports

(MI: Myocardial Infarction, RHR : Resting Heart Rate, CABG : coronary Artery Bypass

Graft, ROM: Range Of Motion Exercises, Hrmax: Heart Rate maximum)



Objectives of Phase I

Patient and family education: It involves implementing risk

modification programme after the patient’s personal and family risks

have been identified. The programme needs to include the children

as they do not yet have any signs or symptoms and can have positive

impact on them. It should include discussion on dietary changes for

healthier eating, stress reduction, determining activities that are safe

to do at home, smoking cessation, sexual activities, long term

management of hyperlipidemia and blood pressure reduction.

Preventing deleterious effects of bed rest: This involves

mobilizing the patient as soon as they become medically stable. This

involves a low level programme that will prevent problems of muscle

atrophy, blood clot formation, pneumonia and general lethargy.

Patient is prepared to return to home with eventual goal of returning

to work and normal activities of daily living (ADL)

Outline cardiac rehabilitation programme

Behavioural modification

ICU

Chest physiotherapy to increase pulmonary ventilation and maintain

bronchial hygiene.

Exercise should be low level in intensity i.e 1-2 MET such as sitting

supportive, self-care activities, selected arm and leg movements, bed

side toilet activities.

In a surgical patient (CABG) measures for pain relief and sterna

discomfort.

Wound care

Care for ankle oedema in view of SVG graft.



Upper extremity exercises to prevent adhesions, poor posture and

enhance tissue repair.

Intermediate Care

Light moderate activities of 2-3 METs with an RPE(Rate of Perceived

Exertion)* of 10- 12

Warm up exercises which includes flexibility and stretching

Dynamic exercises with precautions

Walking

Stair climbing

Note: BP pre and post exercises should be recorded in phase I patient is

generally weak and cannot tolerate long bouts of exercises hence low

intensity less duration exercises are given with greater frequency.

*RPE is measured using the Borg’s Scale. The Borg Scale takes into account

your fitness level: It matches how hard you feel you are working with

numbers from 6 to 20; thus, it is a “relative” scale. The scale starts with “no

feeling of exertion,” which rates a 6, and ends with “very, very hard,” which

rates a 20. Moderate activities register 11 to 14 on the Borg scale (“fairly

light” to “somewhat hard”), while vigorous activities usually rate a 15 or

higher (“hard” to “very, very hard”). Dr. Gunnar Borg, who created the

scale, set it to run from 6 to 20 as a simple way to estimate heart rate—

multiplying the Borg score by 10 gives an approximate heart rate for a

particular level of activity.



The Borg’s scale is given below:

How you might

describe your

exertion

Borg rating

of your

exertion

Examples

(for most adults <65 years old)

None 6 Reading a book, watching television

Very, very light 7 to 8 Tying shoes

Very light 9 to 10 Chores like folding clothes that seem to take

little effort

Fairly light 11 to 12

Walking through the grocery store or other

activities that require some effort but not

enough to speed up your breathing

Somewhat hard 13 to 14

Brisk walking or other activities that

require moderate effort and speed your

heart rate and breathing but don’t make you

out of breath

Hard 15 to 16

Bicycling, swimming, or other activities that

take vigorous effort and get the heart

pounding and make breathing very fast

Very hard 17 to 18 The highest level of activity you can sustain

Very, very hard 19 to 20 A finishing kick in a race or other burst of

activity that you can’t maintain for long



Ward (Pre discharge)

Activity level 3-5 MET with RPE of 12-13

Patient is ambulatory on their own

Warm up exercises

Walking (3-4 mph), stationary cycle(6-8mph) can be given as

aerobic activity

Cool down – flexibility and stretching exercises.

Home programme which includes general instructions, symptoms

guide, monitoring of pulse and progress charts.

Use of activity log books

Basic guidelines

After Discharge

Patient may have to come to the medical centre for training.

Purpose of this stage is to introduce exercises at low level and allow

time to adapt properly to initial rigors of training.

Starter phase: These are low intensity exercises which includes joint

readiness, light calisthenics, low level aerobic exercises, circuit

training and resistance training.

Duration frequency and intensity are increased gradually

Monitoring with accurate record keeping is essential

Resumption of sexual activities



PHASE II

Objectives of Phase II

Give the patient safe, monitored environment for exercise.

Monitoring consists of measuring the patient’s BP, HR ECG, heart

sounds and lung sounds, RPE and symptoms.

Increase exercises work capacity in progressive fashion with self

monitoring.

Relieve fear and anxiety

Occupational and recreational activities

Exercise programme for Phase II

Mode is determined by the accessibility to equipments, medical

centre etc. Walking, walking upslope, walk –jog programme can be

given.

Frequency is generally 3-4 days per week, for high risk patients

frequency may b 5 days per week as intensity is low.

Duration can usually start at 15 mins of steady state exercises

preceded by 5-10 mins of warm up and followed by 5-10 mins of cool

down.

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

RHR and 5-10 bpm below symptoms.

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.

Rate of progression: is determined by the cardiovascular response to

graded increase in duration, frequency and intensity. Slow to

moderate rate of progression 50Kcal to 200Kcal



PHASE III

Objectives of Phase III

Weight training and circuit training

Aerobic exercises and endurance training

Risk factor – secondary prevention strategies

Frequency – 3 times a week

Duration 30 -60 minutes

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

Periodic graded exercises testing

Exercise program for Phase III

These sessions are provided by the cardiac rehabilitation team in the

physiotherapy department. They are specifically designed to help one find

out how much activity they can safely do, and provide them with the

confidence and information to become more active.

The exercises include:

It consists of one hour’s exercise twice a week, with one education

session before or after the exercise class on one day a week.

There is a warm-up of ten/fifteen minutes prior to the circuit.

The aerobic phase lasts about thirty minutes and consists of

o a treadmill

o biceps curls

o lunges

o press ups

o static bicycle

o upright row

o stepping

o wall squats

o hamstring curls

o lateral raises



To conclude the exercise session, there is a ten/fifteen minute cool-

down in order to taper off the exercise gradually.

Graded exercise should be accompanied at this stage by other

interventions tailored to meet your individual requirements.

The second hour of each session is focused on this lifestyle education.

Lifestyle changes should be encouraged and supported where

appropriate, e.g. weight reduction, smoking cessation, retraining with

a view to returning to work.

This will be accompanied by education concerning the cardiac

condition and the reasons why changes in lifestyle might be

desirable.

Exercise program for special population

High risk patients can take prophylactic NTG before beginning an

exercises session

Use of ECG for signs of ischemia

Avoid exercising in presence of angina, dyspnoea or extreme fatigue

Allow for very gradual warm up and cool down.

Regulate exercises intensity according to functional capacity and

ischemic threshold from graded exercises test data.

Frequency: multiple daily sessions, 3-6 times a week

Duration: intermittent to continuous

Progression: dependent on intensity and duration

Resistance with weight low enough to perform 15-20 repetitions

without strain.

Numerous studies done at various institutes all over the world, has made

enough evidence available to prove that compared with no exercise control,

exercise-based Cardiac Rehabilitation (CR) reduces the risk of

cardiovascular mortality but not total mortality. A significant reduction is

seen in the risk of hospitalisation with CR. Evidence also supports

improved HRQL with exercise-based CR. Thus exercises based CR plays a

significant role in reducing further risk of any cardiac event however it

doesn’t ensure complete absence of such an event.



References

1) American College of Sports Medicine (2010). Exercise prescription

for patients with cardiac disease. In WR Thompson et al., eds., ACSM's

Guidelines for Exercise Testing and Prescription, 8th ed., pp. 207-

224. Philadelphia: Lippincott Williams and Wilkins.

2) Arrigo 2008 . Arrigo I, Brunner-LaRocca H, Lefkovits M, Pfisterer

M, Hoffmann A. Comparative outcome one year after formal cardiac

rehabilitation: the effects of a randomized intervention to improve

exercise adherence. European Journal of Cardiovascular Prevention

and Rehabilitation2008;15(3):306-11

3) Bocalini DS, dos Santos L, Serra AJ. Physical exercise improves the

functional capacity and quality of life in patients with heart

failure. Clinics (Sao Paulo, Brazil) 2008;63:437-42.

4) Brunner 2007. Brunner EJ, Rees K, Ward K, Burke M, Thorogood

M. Dietary advice for reducing cardiovascular risk. Cochrane

Database of Systematic Reviews 2007, Issue 4.

5) Fagard RH, Cornelissen VA. Effect of exercise on blood pressure

control in hypertensive patients. European Journal of Cardiovascular

Prevention and Rehabilitation 2007;14:12-7.

6) Gordon NF, Gulanick M, Costa F, Fletcher GF, Franklin BA, Roth EJ, et

al. Physical activity and exercise recommendations for stroke

survivors. An American Heart Association Scientific Statement from

the Council on Clinical Cardiology, Subcommittee on Exercise,

Cardiac Rehabilitation, and Prevention; the Council on

Cardiovascular Nursing; the Council on Nutrition, Physical Activity,

and Metabolism; and the Stroke Council. Circulation2004;109:2031-

41.

http://www.webmd.com/fitness-exercise/default.htm

http://www.webmd.com/fitness-exercise/ss/slideshow-7-most-effective-exercises



About the Author

Riddhi Manjrekar

4th Year Physiotherapy Student,

Seth G S Medical College, Mumbai

PlexusMD Management intern

She wishes to specialize in Musculoskeletal Physiotherapy.

Connect at: http://www.plexusmd.com/msRiddhiManjrekar

Email: [email protected]

http://www.plexusmd.com/msRiddhiManjrekar



About the Reviewer

Dr Joshua Samuel

Manager - Research and Development and Consultant Physiotherapist at RECOUP Hospital, Bangalore

Editor at PlexusMD

Dr. Joshua Samuel holds a Graduation and Post Graduation Degree in

Physiotherapy, specialized in Neurology from Dr. M.G.R. Medical University, Chennai. He has more than 50 scientific publications and conference presentations at State, National and International level to his credit. He has around 5 years of Clinical experience in Paediatric

and Adult Rehabilitation.

Connect at: https://www.plexusmd.com/drjoshua

Email: [email protected]

https://www.plexusmd.com/drjoshua

mailto:[email protected]



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Cardiac Rehabilitation - Amazon S3...Cardiac Rehabilitation Added by Riddhi Manjrekar on plexusmd.com | November, 2016 Uses of Cardiac Rehabilitation 1. Musculo-skeletal conditioning: