CARDIAC REHABILITATION

Prepared By: Floriza P. de Leon

GOALS OF CARDIAC REHABILITATION Increasing functional capacity of the

patient Changing natural history of the disease

to reduce morbidity and mortality

EPIDEMIOLOGY Leading cause of morbidity and

mortality in the adult population in the US

CAD is the number one cause of mortality in men age 45 yrs old and in women aged 75 and older

RISK FACTORS FOR CADIRREVERSIBLE RISKS REVERSIBLE RISKS

Male gender Cigarrete Smoking

Past history of CAD Hypertension

Family History ofPremature CAD (before age 55 year in a parent orSibling

Low HDL Cholesterol (<0.9 mmmol/L (200 mg/dL))

Past history of occlusive PVD High Lipoprotein A

Past history of CVD Abdominal Obesity

Hypertriglyceridemia (>2.8 mmol/L (250 mg/dL))

Hyperinsulinemia

Diabetes Mellitus

Sedentary Lifestyle

EXERCISE PHYSIOLOGYPT needs to understand the cardiac

response to exercise and the effects of aerobic training in order to design a safe and effective rehabilitation program for any given patient

EXERCISE PHYSIOLOGYAerobic Capacity Physiological term used to measure the

work capacity of an individual Represented by the maximum oxygen

consumption (VO2 Max)

Table shows relationship between O2 and intensity of work being performed

EXERCISE PHYSIOLOGYCardiac Output Increases with increasing work In early exercise, CO increases due to

augmented stroke volume via the Frank-starling mechanism

Relationship between CO and oxygen consumption

EXERCISE PHYSIOLOGYHeart Rate Increases in a linear manner when

plotted against the VOS or other measures of physical work

Limited by the person’s age Even with regular exercise there is a

linear decrease in the maximum HR with age

MHR = 220 - age

EXERCISE PHYSIOLOGYStroke Volume Represents the quantity of blood

pumped with each heartbeat Major determinant of SV is the diastoling

filling volume, which is inversely related to the HR

EXERCISE PHYSIOLOGYMyocardial Oxygen Consumption Actual oxygen consumption of the heart as opposed

to the VO2, which represents the oxygen consumption of the whole body (mainly due to skeletal mm)

Angina threshold: point where the myocardial oxygen demand exceeds the ability of coronary circulation to meet the demand

Activities performed with the LE as opposed to LE generate a higher MVO2

Activities performed supine as opposed to upright generate a higher MVO2 at low intensities and a lower MVO2 at higher intensities

Activities that have an isometric component generate a higher MVO2, than a similar activity at the same VO2, without an isometric component

EXERCISE PHYSIOLOGYMyocardial Oxygen Consumption

UE

AEROBIC TRAININGRefers to an exercise program that involves

dynamic exercise with large mm groups and of a sufficient intensity, duration, and frequency to alter the cardiopulmonary response to exercise

Major contributors to Physical Fitness:1. Strength2. Endurance3. Coordination4. Flexibility5. Speed 6. Power

PRINCIPLES OF AEROBIC TRAINING For cardiopulmonary patient, cardiorespiratory

endurance is emphasized for maintenance of health and rehabilitation of individuals

Aerobic activity- Rhythmical- Sustained for prolonged periods of time- Uses large mm group High impact activities (running and jumping) are not

generally recommended for promoting cardiorespiratory endurance because of the increased risk of injury

Low impact/non weight bearing activities have a lower incidence of injury and are generally recommended for cardiopulmonary px

As in all types of training, to be most effective, it must be specific

DETERMINANTS OF AN AEROBIC EXERCISE PROGRAM INTENSITY DURATION FREQUENCY MODE

INTENSITY Overload principle Specificity principle Quantifying intensity

Heart Rate VO2 Max Rating of Perceived Exertion

Overload- Stress on an organism is greater than the one

regularly encountered during daily life- Exercise must be above the training stimulus

threshold for adaptation to occur- Stimulus threshold stimulus that elicits a training or

conditioning response

Specificity - Adaptations in metabolic and physiologic systems depending on the imposed d

INTENSITYHeart Rate Maximum Heart Rate

220-age Karvonens Formula

THR= RHR + (MHR - RHR) (60-80%)Deconditioned – 40-50%Cardiopulmonary disease – 40 – 60%Healthy individuals – 60 – 80%

For UE workMHR = 220 – age - 11

INTENSITYRating of Perceived Exertion Useful for patients with heart rate

suppressors e.g. Beta blockers

Original Revised

INTENSITYRating of Perceived Exertion Original version ( 6-20 )

Remember only the ODD numbers

12- 60% HR range

13- 65 – 70% HR range 16- 85% HR range

7 – VERY VERY9 - VERY11 - LIGHT13 – SOMEWHAT HARD 15 - HARD17 - VERY 19 – VERY VERY

INTENSITYRating of Perceived Exertion Revised version ( 0-10 )0 – nothing at all0.5 – VERY VERY (just noticeable)1- VERY2 - WEAK3 – MODERATE4 - SOME - WHAT5 - STRONG (heavy)7 – VERY10 VERY VERY

INTENSITY Exercising at a high intensity elicits a

greater improvement of the VO2 max

The higher the intensity, the longer the exercise intervals, the faster the training effect

Exercising at high intensities increases the risk for CV complications and musculoskeletal injury

INTENSITYGoal Achievement of intensity 60-90% MHR

OR 50-85% VO2 Max Beginners: 50-60% VO2 Max Average: 60-70% VO2 Max Fit: 75-85% VO2 Max Maximum oxygen consumption (VO2

Max) BEST measure of exercise intensity

DURATIONDependent on Total work performed Intensity Frequency Fitness level

HIGH intensity SHORT duration

LOW intensity LONG duration

DURATION Poor functional capacity

5 - 10 minutes Beginners

10 - 20 minutes Average

15 - 45 minutes Fit

30 – 60 minutes

DURATIONModerate to Minimal intensity 20 – 30 minutesHigh intensity 10 – 15 minutes

Exercise longer than 45 minutes increases the risk for musculoskeletal complications

FREQUENCY Dependent on the health and age of the

individual

LOW intensity HIGH frequency

HIGH intensity LOW frequency

FREQUENCY POOR

Daily Beginner

Every other day Optimal frequency

3-4 times a week 2 times a week does not generally evoke CV

changes for well population Increase in frequency beyond optimal range,

increases risk for musculoskeletal complications

30-45 mins 3x a week protects against CV disorders

FREQUENCY3 – 5 sessions / week Greater than 5 METS

Daily or multiple daily sessions Less than 5 METS

MODE Large muscles Rhythmic Long duration Lower extremity versus Upper extremity

exercise

MODELower extremity Upper extremity

Larger muscle mass Higher VO2 max HR increases linearly

as a function of increased workload / VO2 max

HR plateaus just before maximal VO2 max

Systolic BP increases Diastolic BP remains

the same

Smaller muscle mass

Lower VO2 max than LE exercise

HR higher Stroke volume

lower Systolic AND

Diastolic BP higher

Warm-upAerobic exercise period

Cool-down

EXERCISE PROGRAM

WARM-UP Muscle temperature NCV Vasodilation Adaptation of respiratory centers Venous return

WARM-UP 2 components Graduated low intensity warm-up (5-10

minutes) of total body movementHR increase 20bpm

Flexibility exercises

WARM-UP Should NOT cause fatigue Decreases

Risk for ECG changes (arrythmias)Musculoskeletal disorder

AEROBIC EXERCISE Continuous Interval Circuit Circuit-interval

CONTINUOUS Submaximal and sustained Achievement of the steady state Duration; 20 – 60 minutes Intensity: 60 – 85% VO2 Max Most effective in increasing endurance

for healthy individuals

CONTINUOUSTwo types: Intermediate Slow Distance

20-60 minutes continuous exerciseMost commonly used for managing weight

Long Slow DistanceLonger than 60 minutes for athletic trainingProvided after 6months of successful ISD

INTERVAL Designed to improve strength and

power more than endurance Incorporates recovery after continual

exercise Useful for beginners Work – rest - work

INTERVAL Exercise period is followed by rest

intervalRest relief (Passive recovery)Work relief (Active recovery)

Work recovery ratio1:1 to 1:5

1 : 1.5 work interval allows the succeeding exercise interval to begin before recovery is complete

INTERVALAerobic Interval Training For patients with poor CV fitness 2-15 minutes at 50-80% functional

capacity

Anaerobic Interval Training For patients with high CV fitness 30 sec – 4 minutes at 85-100%

functional capacity Usually results in greater lactic acid

concentrations

CIRCUIT Series of exercise activities Several exercise modes Improves both strength and endurance

CIRCUIT INTERVAL Stresses both aerobic and anerobic

systems Delays the need for glycolysis and lactic

acid production

COOL-DOWN Prevents

Pooling of bloodPost-exercise syncope Ischemia, arrythmias, and other

complications Increases oxidation of metabolic waste Length of cool-down phase proportional

to intensity and length of the conditioning phase

Typical 30-40 aerobic exercise periodWarrants a 5-10 minute cool-down phase

CORONARY ARTERY DISEASE In-patient phase Out-patient phase Maintenance phase

PHASE I (IN-PATIENT PHASE/ICU/CCU PHASE) In px groups: uncomplicated myocardial

infarctions, post-operative CV, pulmonary, PVD and any others that may benefit from such services while in the hospital

Includes supervised ambulatory therapy Staff to px ratio – 1:1 ECG monitoring equipment must be available for

determining appropriate exercise response and an emergence team should be available on the premises

1-2 METS in CCU; 3-4 METS in ward Begins in the CCU once the px is medically stable 1-2 wks in duration  

PHASE I (IN-PATIENT PHASE/ICU/CCU PHASE) Goals: Provide additional medical surveillance To return px to activities of daily living To offset the deleterious physiological

and psychological effects of bed rest Prepare px and families for stages of

cardiac rehabilitation and life at home that will follow

PHASE I (IN-PATIENT PHASE/ICU/CCU PHASE) Role of PT: Evaluating the physiological response to

exercise Supervising the exercise and ambulation Accurately charting and recording

patients progress and responses preparing the patient for discharge and remaining phases of rehabilitation program

PHASE I (IN-PATIENT PHASE/ICU/CCU PHASE) In-Patient Exercise Prescription Methods1-3 Days post MI: low intensity activities (2-3 METS) Reduce the risk of thrombi Self care activities, selected arm and leg exercises Lying to sitting to standing Orthostatic stress Protective chair posture (high back rest and low seat) which reduces

cardiac output by 10% compared to supine Increased duration of sitting Use of bedside commode which loads the heart with only up to 3

METS unlike bed pan which increases load up to 4.7 METS PROM – 1.5 METS only AROM – 1.7 METS only for the UE and 2 METS only for the LE 3-5 days Post MI Walking, treadmill, cycle ergometer 5-10 mins of exercise session Most of the time exercise intensity is low and session so short that

warm up and cool down are not applicable Calisthenics, self-care, early ambulation around the bed

PHASE I (IN-PATIENT PHASE/ICU/CCU PHASE) Stress Test for Prognostic Stratification Should be submaximal Pxs with more than 40 years of age;

limit HR to 130 bpm and workload to 5 METS

Pxs with less than 40 years of age; limit HR to 140 bpm and workload to 7 METS

PHASE II (OUT-PATIENT) Should begin immediately after dismissal from the

hospital: 2nd or 3rd wk after MI or open heart surgery Important time for continued medical surveillance as well

as beginning intervention programs for lifestyle changes Outpatient versus home or community based facility 4-7 METS Highly supervised 0-3 mos in duration   Goals: Improve functional or exercise capacity Enhance cardiac functions Promote early return to normal activity Promote positive lifestyle changes Decrease risk factors

PHASE II (OUT-PATIENT) Activities: Interval conditioning Circuit conditioning Circuit interval conditioning Continuous training   Intensity: with functional capacity of greater than 5 METS>

prescriptive techniques using heart rate and RPE Frequency: 3-4 sessions per day Duration: 10-15 mins and progress to 30-60 mins Progression rate: 1 MET/2 wks Discharge planning: Aerobic capacity of at least 5 METS Px’s ability to self monitor his or her exercise program Stability of px(absence of contraindication to exercise) Psychologic and emotional status of the px

PHASE II (OUT-PATIENT) Stress Testing Should be maximal Treadmill or bicycle ergometer

Criteria for Terminating Stress Test Px is exhausted Px has dyspnea Px is experiencing cramps(leg fatigue) Px has pain over LE mm Excessive chess pain Circulatory insufficiency ECG changes

PHASE II (OUT-PATIENT) Contraindications for Stress Testing Acute MI Unstable angina pectoris Acute myocarditis/pericarditis Coronary artery lesion Stenosis HPN (225/110 mm Hg) Acute systemic illness Congestive heart failure

PHASEIII (COMMUNITY EX PROGRAM PHYSICAL CONDITIONING/MAINTENANCE) Participants: 6-12 wks post hospital discharge Clinically stable or decrease angina Medically controlled dysrhythmias Knowledge of symptoms Ability to self-regulate their exercise Minimum functional capacity of 5 METS   During the 1st 3-6 mos Intensity is 50-85% of functional capacity Duration: 45 mins Frequency: 3-4 sessions/wk

PHASEIII (COMMUNITY EX PROGRAM PHYSICAL CONDITIONING/MAINTENANCE)

Goals: Maintenance of function Compliance of exercise program Risk factor education and modification Promote long term fitness   Physical Training: includes recreational

activities

PHASEIII (COMMUNITY EX PROGRAM PHYSICAL CONDITIONING/MAINTENANCE Physiological Effects: Decreased HR Increased SV Decreased CO at each submaximal work level Increased ability to extract O2 from the blood Increased size and number of mitochondria Increased myoglobin Decreased O2 utilization by myocardial cells Improved contractility of heart mm  

PHASEIII (COMMUNITY EX PROGRAM PHYSICAL CONDITIONING/MAINTENANCE

Clinical Effects: HR decreases at rest Workload performed at a maximal level

would be increased Heavier workload, increased endurance   Criteria for discharge: same as Phase II,

with the functional capacity of individual, consistent with vocational and recreational requirements/goals of the individual

SEX Those who can tolerate 5 METS or more Orgasm expenditure = 5 METS Px who can climb 2 flights of stairs can

return to sexual activities