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LESSON 9: Cardiac Rehabilitation

FACULTY OF HEALTH AND SPORT SCIENCES

Bachelor of Physiotherapy
Physiotherapy Practice in Cardiorespiratory Conditions - 6214
By: Suvinlal Stalin(suvinlal@mahsa.edu.my)
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LESSON 9: Cardiac Rehabilitation

CARDIAC REHABILITATION
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LESSON 9: Cardiac Rehabilitation

Cardiac Rehabilitation?
Group activities or individual based
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LESSON 9: Cardiac Rehabilitation

What is Cardiac Rehab?

• Cardiac rehabilitation is a comprehensive exercise,
education, and behavior modification program designed to
improve the physical and emotional condition of patients
with heart disease.
• Prescribed to control symptoms, improve exercise tolerance,
and improve overall quality of life.
• The primary goal of cardiac rehabilitation is to enable the
participant to achieve his/her optimal physical,
psychological, social and vocational functioning through
exercise training and lifestyle change.
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LESSON 9: Cardiac Rehabilitation

Definition of Cardiac Rehabilitation

“The sum of activities required to ensure patients

the best possible physical, mental and social
conditions so that they may resume and maintain
as normal a place as possible in the community”.
World Health Organisation
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LESSON 9: Cardiac Rehabilitation

Core Components
• Prescribed exercise to improve cardiovascular fitness without
exceeding safe limits
• Education about heart disease
• Counseling on ways to stabilize or reverse heart disease by
improving risk factors
• Reduction/Cessation of Smoking
• Lipid Management
• Controlling High Blood Pressure
• Weight Loss/Control
• Improve/Manage Diabetes
• Increasing Physical Activity
• Encourage Healthy Eating Habits
• Improve Psychological Well Being
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Cardiac Rehabilitation Team members

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Indication
• Lower-risk patients following an acute cardiac event
• Patients who have undergone coronary bypass surgery
• Patients with chronic stable angina pectoris
• Patients who have undergone heart transplantation
• Patients following percutaneous coronary angioplasty.

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Conti….
• Patients without prior events but at risk because of remarkably
unfavorable risk factor profile.
• Patients with stable heart failure.
• Patients following non-coronary cardiac surgery.
• Patients with previously stable heart disease now seriously
deconditioned by co morbid illnesses .

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Contra indication
• Unstable angina
• Systolic BP>200mmHg, Diastolic BP > 100mmHg
• Moderate to severe aortic stenosis
• Acute systemic illness
• Uncontrolled arrhythmias
• Uncontrolled tachycardia
• Uncontrolled congestive heart failure
• Active pericarditis, myocarditis
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Benefits
• Decreases Mortality at up to 5 years
post participation
• Decreases Cardiovascular Events
• Improves Modifiable Risk Factors
• Improves Adherence with Preventive Medications.
• Improves Function and Exercise Capacity
• Improves Quality of Life
• Fosters Lifelong Healthy Behaviors.
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Short-term goals:
– "Reconditioning" sufficient enough for resumption of
customary activities
–Limiting the physiologic and psychological effects of heart disease
–Decreasing the risk of sudden cardiac arrest or
reinfarction
–Controlling the symptoms of cardiac disease

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Long-term goals
• Identification and treatment of risk factors
• Stabilizing or even reversing the atherosclerotic process
• Enhancing the psychological status of the patients

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Structure of Cardiac Rehabilitation

BACR – British association for Cardiac rehabilitation
AACVPR – American Association of CV & Pulmonary rehab.

BACR AACVPR Phase Duration

Phase 1 In-patient 3-5 days
Phase 2 Immediate post discharge Up to 4-6 weeks
Phase 1

Phase 3 Phase 2 Out patient - Exercise 4-6 weeks post

training period discharge to 4-6
Months

Phase 4 Phase 3 Long-term, on-going, 4-6 months onwards

Maintenance
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Phase 1: A patient walking in the hallway with a PT

following CABG

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Cardiac rehabilitation: In Patient phase 1 (AACVPR)

• This program begins while patients are still in the hospital.

• Phase 1 includes a visit by a member of the cardiac rehabilitation
team, education regarding the disease and its recovery process,
personal encouragement, and inclusion of family members in
classroom group meetings.
• Some of the older patients may serve as volunteers and share
their experiences about learning to live with heart disease

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• Team members include cardiac nurses, exercise

specialists, physical therapists, occupational therapists,
dietitians, and social workers.
• In the coronary care unit, assisted range of motion
exercises can be initiated within the first 24-48 hours.
• Low-risk patients should be encouraged to sit in a
bedside chair and begin to perform self-care activities.
(eg, shaving, oral hygiene, sponge bathing).

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• On transfer to the step-down unit, patients should try to sit up,

stand, and walk in their rooms in the beginning.
• Subsequently, they should start to walk at least twice daily
either for certain specific distances or as tolerated without
pushing.
• Standing heart rate and blood pressure should be obtained
followed by 5 minutes of warm-up or stretching.
• Walking, often with assistance, is resumed with target heart
rate of <20 beats above the resting heart rate, and RPE under
14.
• Starting with 5-10 minutes of walking each day, exercise time
gradually can be increased to up to 30 minutes daily.

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Cardiac rehab - immediate post discharge phase 1(AACVPR)

• This phase begins after the patient returns home from the hospital.
• Better understanding of how to keep the heart healthy and strong is
emphasized.
• Team members work with patients and family members.
• This phase of recovery includes low-level exercise and physical
activity and instruction about changes for resumption of an active
and satisfying lifestyle.
• Risk reduction strategies are emphasized again.
• After 2-6 weeks of recovery at home, the patient is ready to start
cardiac rehabilitation phase 2.

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Phase 2 (AACVPR)
Exercise testing and training on a treadmill.

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Cardiac rehabilitation: supervised exercise Phase 2

(AACVPR)
• The patients who have completed hospitalization and 2-6 weeks of
recovery at home can begin phase 2 of their cardiac rehabilitation
program.
• Physician and cardiac rehabilitation staff members formulate the
level of exercise to meet an individual patient's needs.
• Exercise treatments usually are scheduled 3 times a week.
• Constant medical supervision is provided, including exercise
electrocardiograms (ECGs), as well as supervision by a nurse and
exercise specialist.
• In addition to exercise, counseling, and education about stress
management, smoking cessation, nutrition, and weight loss also are
incorporated.
• This phase of rehabilitation may last 4-6 months.

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Exercise Testing
The Cardiovascular Response to Exercise
• A stress test, sometimes called a treadmill test or
exercise test, helps a doctor find out how well your
heart handles work.
• As the body works harder during the test, it requires
more oxygen, so the heart must pump more blood.
The test can show if the blood supply is reduced in the
arteries that supply the heart.

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Two forms of exercise tests are performed in patients

following an acute cardiac event:
Submaximal exercise testing
• Predictive tests are submaximal tests that are used to
predict maximal aerobic capacity. Performance tests
involve measuring the responses to standardized physical
activities that are typically encountered in everyday life.
Symptom-limited exercise testing.
• Symptom-limited exercise testing causes sustained
diastolic dysfunction in patients with coronary disease
and low effort tolerance. Exercise stress testing is
routinely used for the noninvasive assessment of coronary
artery disease and is considered a safe procedure.
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A) Submaximal exercise testing

• The test protocols do not reach the maximum of the
respiratory and cardiovascular systems. Submaximal tests
are used because maximal tests can be dangerous in
individuals who are not considered normal healthy subjects.

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B) Symptom-limited exercise testing

• Graded exercise testing is used to observe the dynamic

relationship between exercise workload and the integrated
cardiovascular, pulmonary, musculoskeletal, and
neuropsychological systems .
• Protocols require a systematic and linear increase in
exercise intensity over time until the individual is unable to
maintain or tolerate the workload. Selected cardiovascular,
pulmonary, and metabolic variables are collected during
the test to evaluate exercise tolerance and represent the
efficiency in which the cardiovascular system is able to
deliver oxygenated blood to working skeletal muscle and
the ability of muscle to utilize oxygen.

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Symptoms to stop the exercise

• Unusual discomfort – Chest pain, Angina
• Nausea
• Extremely heavy breathing
• Severe shortness of breath
• Severe fatigue
• Extreme sweating
• Abnormal heart rate responses
• Unexplained low heart rate
• Heart rate dramatically higher than target heart rate
• Abnormal blood pressure
• Blood sugar below 80 mg/dl or 250mg/dl
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• Dizziness
• Muscle cramp
• Premature ventricular beats
• ST segment depression
• Bradycardia
• Exertion hypotension (blood pressure drops below pre – exercise
level)
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Exercise Tolerance Test

• ETT consists of exercising on a treadmill following a defined
protocol, the Bruce protocol, over approximately 20
minutes. The test begins gently and gradually the level of
intensity is increased through a combination of increased
treadmill speed and incline.
• Intensity of exercise is measured in metabolic equivalents
(METs) where 1 MET is the amount of energy expended at
rest or 3.5 ml oxygen per kilogram per minute.
• The test is divided into seven stages of three minutes and
there is also a less strenuous version called the modified
Bruce.
• ECG is recorded throughout and blood pressure measured
intermittently.
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Treadmill – Bruce protocol

• The Bruce protocol is a standard test in cardiology and is

comprised of multiple exercise stages of three minutes each. At
each stage, the gradient and speed of the treadmill are
elevated to increase work output, called METS. Stage 1 of the
Bruce protocol is performed at 1.7 miles per hour and a 10%
gradient. Stage 2 is 2.5 mph and 12%, while Stage 3 goes to 3.4
mph and 14%.

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Bruce Protocol

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MODIFICATIONS:

• There is a commonly used Modified Bruce protocol, which

starts at a lower workload than the standard test, and is
typically used for elderly or sedentary patients.
• The fist two stages of the Modified Bruce Test are performed at
a 1.7 mph and 0% grade and 1.7 mph and 5% grade, and the
third stage corresponds to the first stage of the Standard Bruce
Test protocol.

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Exercise prescription
Phase 2 of a cardiac rehabilitation program is initiated based on the
result of the exercise testing, and the exercise prescription is
individualized. Three main components of an exercise training
program are as follows:
• Frequency: The minimum frequency for exercising to improve
cardiovascular fitness is 3 times weekly
• Time: 30-60 minutes for each session, which includes a warm-up
of at least 10 minutes
• Intensity: The intensity prescribed is in relation to one's target
heart rate.
• Patients usually should exercise at an RPE of 13-15

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• The Karvonen method resting heart rate (HRrest) to calculate

target heart rate (THR), using a range of 50–85% intensity:
THR = (HR max − HR rest) × % intensity) + HR rest
• Example for someone with a HRmax of 180 and a HRrest of 70:
• 50% Intensity: ((180 − 70) × 0.50) + 70 = 125 bpm
• 85% Intensity: ((180 − 70) × 0.85) + 70 = 163 bpm
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Strength training
• Recent addition to the traditional program
• AACVPR, American heart association, American college of sports
medicine – advocate the importance of strength training in cardiac
rehab.
• Safe & effective to improve strength and cardiovascular endurance
and modifying risk factors and enhancing self efficacy in low risk
cardiac patients.
• Light weights (1-3 lb), 12-15 repetitions.
• Strength training should not begin until the patient has been in CR
program for at least 3 wk in general, 5wk – post MI, 8wk – Post
CABG.
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Cardiac rehab: maintenance phase

Phase 3 (AACVPR)

• Designed for lifetime. The exercise sessions - 3 times a week.

• Activities such as walking, bicycling, or jogging.
• ECG monitoring & supervision usually is not necessary.
• The main goal of phase 3 is to promote habits that lead to a healthy
and satisfying lifestyle.
• Exercises can be done at the community

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Psychosocial Care
• Reduce fear and anxiety

• Assist with adjustment

• Promote positive attitude

• Facilitate behaviour change

• Identify need for further support

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Life style modifications

• Lifestyle:
1. Diet and weight management
2. Smoking cessation
3. Physical activity and exercise
4. Secondary prevention
5. Education
• Long-term management strategy
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References:
1. Dean, E. & Frownfelter. K. (2012). Principles and practice of
cardiopulmonary physical Therapy. USA: Mosby. 5th edition.
2. Webber, B.A. & Pryor J.A. (1993). Physiotherapy for
respiratory and cardiac problems UK: Longman Group.
3. Patricia A. Downie. (1987). Cash's Textbook of Chest, Heart
and Vascular conditions for physiotherapists. Jaypee brothers,
New Delhi. 4th edition.