Cardiac Rehabilitation Guideline[1]

1

KNGF-guidelines for physical therapy in cardiac rehabilitation

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Clinical practice guidelines for physical therapy in

cardiac rehabilitation

EMHM Vogels,I RJJ Bertram,II JJJ Graus,III HJM Hendriks,IV R van Hulst,V HJ Hulzebos,VI H Koers,VII

T Jongert,VIII F Nusman,IX RHJ Peters,X B Smit,XI S van der Voort.XII

I Lisette Vogels, MSc, physical therapist / social scientist, Department of Research and Development, Dutch Institute of Allied Health

Professions, Amersfoort, The Netherlands

II Rob Bertram, physical therapist, rehabilitation center Beatrixoord, Haren, The Netherlands

III Jean Graus, physical therapist, rehabilitation center Hoensbroek, The Netherlands

IV Erik Hendriks, PhD, physical therapist / clinical epidemiologist and guidelines coordinator, Department of Research and Development,

Dutch Institute of Allied Health Professions, Amersfoort, The Netherlands

V Rob van Hulst, physical therapist, Deventer Hospital, Deventer, The Netherlands

VI Erik Hulzebos, MSc, physical therapist / human movement scientist, University Medical Center Utrecht, Utrecht, The Netherlands

VII Hessel Koers, physical therapist / manual therapist, Groene Hart Hospital, Gouda, The Netherlands

VIII Tinus Jongert, MSc, exercise physiologist, TNO-PG, Leiden, The Netherlands

IX Frank Nusman, physical therapist, Isala Klinieken, Zwolle, The Netherlands

X Roelof Peters, physical therapist, Sint Antonius Hospital, Nieuwegein, The Netherlands

XI Bart Smit, physical therapist, Sint Lucas Andreas Hospital, Amsterdam, The Netherlands

XII Simon van der Voort, physical therapist, Zonnestraal, Hilversum, The Netherlands

IntroductionThese clinical guidelines describe the application of

physical therapy in cardiac rehabilitation. They were

developed by the Royal Dutch Society for Physical

Therapy (KNGF) and follow up the Cardiac

Rehabilitation Guidelines 1995/1996 produced by the

Dutch Cardiology Association and the Dutch Heart

Foundation. In essence, the guidelines provide a

summary of the information contained in the second

section of this document, entitled “Review of the

evidence”, in which the choices made in deriving

guideline recommendations are presented separately.

The guidelines and the review of the evidence can be

read individually. An explanation of the abbreviations

used and the definitions of some important terms and

concepts are given in an appended list of

abbreviations and definitions and a glossary. These

KNGF guidelines on physical therapy in cardiac

rehabilitation are for the use of physical therapists

who work with cardiac patients in rehabilitation

phases I and II.

The (Dutch) physical therapists involved will have

also knowledge of the multidisciplinary Cardiac

Rehabilitation Guidelines 1995/1996 and of a

supplementary publication entitled “Physical therapy

in cardiac rehabilitation”.

Considerations of treatment quality in cardiac

rehabilitation are discussed below in the review of the

evidence.

Cardiac rehabilitation phases:

Phase I: during hospital admission;

Phase II: in the polyclinic rehabilitation setting

(both clinical and polyclinic patients);

Phase III: post-rehabilitation and aftercare phases.

These clinical guidelines describe the goals of

treatment and the end criteria in phase I and the

diagnostic and therapeutic processes in phase II.

Aftercare, which comprises phase III, is not covered

by the guidelines.

Defining cardiac rehabilitation

These KNGF clinical guidelines have been devised for

the implementation of physical therapy in patients

who have had an (acute) myocardial infarction, or

who have undergone a coronary artery bypass

operation, percutaneous transluminal coronary

angioplasty, a heart valve operation, or operative

correction of a congenital heart disorder.

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Acute phase

Physical therapy goals End criteria Evaluation method

Surgical treatment: Physical therapy: Monitoring mucus clearance

• Provide preoperative • No objectively observed and ventilation

pulmonary guidance; pulmonary problems.

• Monitor mucus clearance,

ventilation and treatment Medical:

(if necessary). Post-operative treatment:

• No excess mucus retention

Non-surgical treatment: and no atelectasis;

• Monitor mucus clearance, • Patient is hemodynamically

ventilation and treatment stable;

(if necessary). • No severe rhythm disorders

or conduction abnormalities.

Non-surgical treatment:

• Patient is hemodynamically

stable;

• Enzyme levels decreasing;

• No severe rhythm disorders

or conduction abnormalities.

Mobilization phase

Physical therapy goals End criteria Evaluation method

Surgical treatment and Physical therapy: History-taking2;

non-surgical treatment: • Patient can function at the Risk factor checklist;

• Ensure patient can function intended level of activities of Objective determination of the

at the intended level of daily living; patient’s level of activities

activities of daily living; • Patient has moderate aerobic of daily living by evaluating

• Ensure patient has sufficient capacity (≥ 3 MET’s1); activities.

information to start • Patient has knowledge about

phase II or to proceed heart disease and surgery and

independently, which means can cope adequately with

that the patient: the information;

- can cope sensibly with • Patient has knowledge

the heart disease; of risk factors;

- has knowledge about • Patient can cope adequately

the disease’s nature, with symptoms.

surgery and risk factors;

and

- can react adequately to

any symptoms that might

occur.

Table 1. Goals of therapy, end criteria and methods of evaluation applicable during the acute and mobilization

phases of rehabilitation phase I.

1 1 Metabolic Task Equivalent (MET’s) = 3.5 ml of oxygen per kg per minute. Supplement 3 to the review of the evidence gives the metabolic

equivalence (i.e., MET’s values) of different activities.

2 Preferably using a structured questionnaire.

Risk factors and prognostic factors

Coronary heart disease risk factors can be split into

two groups: influenceable and non- influenceable risk

factors. Influenceable factors include smoking, lipid

imbalance (e.g., hypercholesterolemia and

hyperlipidemia), hypertension, obesity, physical

inactivity and diabetes mellitus. Non-influenceable

factors include hereditary tendencies, age and sex.

Prognostic factors that influence recovery after acute

myocardial infarction include the residual function of

the left ventricle and the size and location of the

infarct. The patient’s psychological condition,

including factors such as exhaustion, fear and

depression, and the presence of any co-morbid

conditions, such as physical limitations or a

cerebrovascular accident, can have a negative

influence on recovery.

Secondary or tertiary prevention

Preventing the progression of coronary heart disease

depends on modifying the above-mentioned risk

factors. These risk factors include bio-psychosocial

factors, which can limit adaptive potential and can,

therefore, influence balance and ability to increase

load capacity (see Glossary).

Rehabilitation phase I

Activities associated with cardiac rehabilitation

during hospital admission take place in two parts: the

acute phase and the mobilization phase. These phases

occur after treatment, whether an operation was

involved or whether treatment was conservative. The

goals of physical therapy, the end criteria used for

assessing the achievement of these goals, and the

applicable methods of evaluation in these two

subphases are presented in Table 1.

Rehabilitation phase II

Before beginning rehabilitation in the polyclinic (i.e.,

rehabilitation phase II), all patients are screened by

the rehabilitation team after physician referral. The

referral documentation must include, as a minimum,

the information listed in Table 2. The rehabilitation

team consists, at a minimum, of a physician, a

physical therapist, a social worker and a nurse. The

physician in the team, who is usually a cardiologist,

has the final responsibility for treatment.

The exercise capacity of the patient are estimated by a

cardiologist and are classified as either low, medium

or high.

It is recommended that rehabilitation screening is

carried out before, or shortly after, hospital discharge.

Patients are screened by the rehabilitation team on

the basis of questions posed in five areas of enquiry

relating to the patient’s physical, psychological and

social functioning and to the presence of

influenceable risky behavior (see Table 3). Physical

therapy diagnosis forms part of the screening.

Answers to questions in the five areas of enquiry are

obtained by using objective measuring instruments,

by clinical observation, and from the patient’s

testimony, which is supplemented by the use of a

self-administered questionnaire, if necessary.

The symptom-limited exercise test (ergometric) is an

objective measuring instrument that can be used to

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• Medical diagnosis;

• Relevant cardiac information, as decided by the physician, including details of:

- hemodynamic stability;

- the location and extent of the infarction and the extent of any left ventricular dysfunction;

- exercise testing results including ECG findings (e.g., the presence of ischemia); and

- heart rhythm disorders or conduction abnormalities.

• Co-morbid conditions;

• Risk factors;

• Medicine use; and

• The cardiologist’s estimate of exercise capacity (i.e., low, medium or high1) and prognosis.

Table 2. Minimum referral information given by the physician to the rehabilitation team.

1 For more information, see Table 11 in the review of the evidence.

provide answers to the questions posed in area I

above. Physical, psychological and social functioning,

covered in areas II, III and IV, can be determined

objectively using screening questionnaires, which are

currently being developed. Some of these

questionnaires can be used for rehabilitation

screening as well as for evaluating treatment. A risk

factor checklist can be used to determine risk factors

objectively and to relate them to the patient’s

lifestyle, to help answer questions in area V.

Diagnosis The objectives of the physical therapy diagnostic

process are to investigate the severity and nature of

the health problem in relation to functional

movement and to identify any influenceable

prognostic factors. Of central importance are the

patient’s concerns and goals. The physical therapist

will assess the patient’s health status and identify the

most important disorders, the desired health

condition, any existing influenceable and non-

influenceable risk factors, and the patient’s need for

information. The diagnostic process makes use of the

referral, history-taking, assessment, analysis and the

formulation of a treatment plan. The recommended

measuring instruments are described and explained

in Supplement 2 to the review of the evidence.

History-taking

In history-taking, information is obtained partly by

the rehabilitation team, and includes referral data

from the cardiologist, and partly from the patient

himself or herself. History-taking involves:

• recording the patient’s concerns and goals,

including his or her desired level of activity;

• assessing the patient’s level of activity before the

present health situation developed;

• assessing the overall health situation, including

taking details of:

- the nature and severity of any impairments,

disabilities and problems with social

participation;

- the start and course of the condition;

- any factors that led to the condition (e.g., poor

circulation);

- prognostic and risk factors;

• recording the present situation, including noting

details of:

- any current impairments, disabilities and

problems with social participation associated

with the heart disease;

- present general health status, including

information on functioning, and levels of

activity and participation;

- present treatment, including medications used

and medical treatment received;

- personal factors;

- the patient’s motivation; and

- the patient’s need for information.

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I. Has physical aerobic capacity been reduced objectively, in terms of the patient’s ability to work and carry

out domestic and leisure activities? Are there any motor limitations that restrict the patient’s functional

abilities?

II. Has physical aerobic capacity been reduced subjectively because of anxiety about aerobic capacity

(including sexual capabilities) or because the patient feels very handicapped?

III. Is there a problem with emotional balance? Does the patient deal with the sickness in a dysfunctional

manner? In other words: What is the difference between the patient’s present and optimal psychological

functioning?

IV. Is there a problem with social functioning? What is the prognosis for the patient’s return to a normal

social role in relation to work, leisure and family relationships? What is the quality and extent of the

patient’s social network?

V. Are there any influenceable risky behaviors, involving, for example, smoking, diet (e.g., leading to

obesity or lipid disorders), physical inactivity, or non-compliance with therapy?

Table 3. Questions in the five areas of enquiry used in rehabilitation screening, taken from the Cardiac

Rehabilitation Guidelines 1995/1996:

The patient’s most important complaints, including

any activity problems, can be determined using a

specially designed questionnaire, called the patient-

specific complaint questionnaire, and a visual

analogue scale for assessing activity level. The risk

factor checklist should be used to identify risk factors.

Assessment

Functional human movement can be expressed in

terms of physical load and aerobic capacity but is also

affected by the presence of any functional

impairments. Assessment involves observation,

functional evaluation and, if necessary, palpation.

Basically, assessment centers on determining the

levels of functional impairment, activity limitation

and problems with participation, all of which

influence the choice of exercises used in the

rehabilitation program. Activities may be limited in

terms of their nature, duration or quality. In dealing

with psychosocial functioning, the physical therapist

adopts a signaling function. During activity

evaluation, the physical therapist should pay

attention to how the patient deals with the health

problem. For example, does the patient have a fear of

movement? The following measuring instruments or

techniques can be used during assessment: the Borg

scale, an ergometer, MET’s units, the specific activity

scale, the six-minute walking test, and the fear,

angina pectoris and/or dyspnea scale. If indicated by

the physician, heart rate and blood pressure can also

be monitored.

Analysis

Analysis is based on assessment and evaluation. The

physical therapist must obtain answers the following

questions:

1. What is the patient’s health status in terms of

impairments, disabilities and participation

problems? How much can the patient currently

handle, physically, mentally and socially?

2. Are there physical problems that limit increases in

the patient’s physical, mental and social

performance? These may be:

- related to a cardiac disorder (e.g., myocardial

infarction or chronic heart failure); or

- related to other sicknesses or disorders,

including other physical complaints.

3. Are there any other factors that have a negative

influence on exercise capacity? For example:

- fear, depression, mental handicap or sleep

problems;

- stress or exhaustion;

- lifestyle, involving, for example, smoking,

physical inactivity or eating problems;

- medication use; or

- social problems.

4. How does the patient envisage his or her future

performance of daily activities, leisure activities,

work and hobbies (i.e., the patient’s goals and

expectations)?

5. Is the desired level of performance attainable,

according to the information obtained in

answering questions 2 and 3?

- can any negative factors be influenced?

- if so, negative factors should be reduced or

eliminated and exercise capacity increased;

- if not, the situation should be optimized and

the patient should learn to accept it.

6. Can physical therapy help ameliorate the health

problem? In terms of:

- reducing impairments;

- reducing disabilities;

- reducing participation problems; or

- improving functions, activities and the level of

participation.

In addition to the above-mentioned problem areas,

patients may experience other health problems that

may or may not be related to heart disease. On

occasion, additional physical therapy may be

indicated. These problems are not covered by these

guidelines.

Treatment plan

The rehabilitation team will decide if there are

discrepancies between the patient’s present condition

and the desired level of functioning and determine

whether there is an indication for further

rehabilitation (see the flow chart in Figure 3 in the

review of the evidence). The rehabilitation team,

together with the patient, will formulate therapeutic

goals with help from the answers given to questions

in the five areas of enquiry used in rehabilitation

screening, which were taken from the Cardiac

Rehabilitation Guidelines 1995/1996. These goals are

translated into an individual rehabilitation plan that

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consists of a number of different modules. If

necessary, these modules can be implemented with

individual guidance. The rehabilitation team decides

when the rehabilitation program will start and which

module the patient should use first. The Cardiac

Rehabilitation Guidelines 1995/1996 describe four

modules: short and long exercise modules (FIT), an

information module (INFO), and a psychoeducational

preparation module (PEP). The KNGF guideline working

group advises the addition of a fifth module, on

relaxation instruction (RELAX). The information given

in these guidelines is divided into exercise programs.

Table 4 provides an overview of the data held by the

rehabilitation team that is relevant to physical

therapists.

Patients who have to employ physical training to

achieve their most important goal must undergo a

symptom-limited aerobic capacity test using an

ergometer to provide relevant information for

therapy.

The following are the six specific goals for physical

therapy (the numbers in square brackets refer to the

goals listed in the Cardiac Rehabilitation Guidelines

1995/1996):

1. Learning to find one’s own physical limits [1].

• The goal is to enable the patient to go about

daily life and to manage at a physical level. By

coming up against objective boundaries, the

patient learns what his or her personal exercise

capacity is and where his or her physical limits

lie.

2. Learning to deal with physical limitations [2].

• The goal is to confront the patient with his or

her physical disabilities and to help him or her

learn how to deal with different physical

situations and types of movement. Acceptance

is essential. It is important to encourage the

patient’s active involvement in discovering his

or her level of physical capability.

3. Finding the optimum aerobic capacity level [3].

• The goal is to enable the patient to reach a

desired level of physical capability. Capabilities

are improved up to a level at which the patient

can function better in performing normal daily

activities, work, sports and hobbies.

4. Diagnosis: evaluating aerobic capacity level and

correlating symptoms with objective disorders [4].

• The goal is to assess the patient’s exercise

capacity on a number of occasions. It is

important to find correlations between

symptoms and objective disorders, and to

determine which disabilities the patient has

problems with in daily life. The results of the

diagnostic process provide an insight into the

patient’s exercise capacity and identify

opportunities for increasing these capabilities.

5. Reducing fear of movement [5].

• The goal is to enable the patient to experience

movement, with the hope that, through

experience, fear for movement will decrease.

6. Developing and attaining a physically active

lifestyle [14].

• The goal is to help the patient enjoy

exercising. Providing guidance that enables the

patient to be active at home will reduce the

risk factors associated with an inactive lifestyle.

The patient will learn to integrate exercises

into his or her lifestyle. The idea is that the

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• The physician’s diagnostic and prognostic referral data and information about the patient’s exercise

capacity (See Table 2 above);

• Individual aerobic capacity goals and reasons for any aerobic capacity limitations, such as fear or a

dysfunctional way of coping with heart disease;

• Physical therapist’s diagnosis.

If necessary:

• information about work rehabilitation and prognosis;

• information on the patient’s family.

Table 4. Data held by the rehabilitation team that is relevant for physical therapy:

patient will make exercise a normal daily

activity and will, therefore, progress to

rehabilitation phase III.

The physical therapist can also have an influence on

the achievement of other goals, such as achieving

secondary prevention [12–16], acquiring emotional

balance [6], and learning how to deal with heart

disease in a functional manner [7]. Each patient

usually has a combination of goals. If improving

aerobic capacity is not indicated, then goal 1 or 2, or

both, are recommended. If improving aerobic

capacity is indicated, then goal 1 or 3, or both, are

recommended. If there is a subjective decrease in

aerobic capacity, treatment should focus on goal 1 or

5, or both. The problem areas covered by goals 1 and

5 are usually the initial focus of treatment. For

example, the patient must first reduce the level of

fear or learn what his or her personal limits are before

being ready for training. If there is no clear objective

reduction in aerobic capacity, then goal number 4 is

recommended.

It is important that patients are divided into groups

with high, medium or low exercise capacity, as

estimated by the cardiologist and rehabilitation team,

before deciding on an exercise program. It is also

important that the patient’s motor capabilities and

degree of motivation for carrying out activities are

also taken into consideration. Patients who have little

motivation need an exercise program in which the

main exercises can be incorporated into normal daily

activities. This is more enjoyable and ensures better

functioning during exercise.

An exercise program may consist of exercises that

focus on improving health or exercises that focus on

improving performance, or both.

Exercises aimed at improving health involve

practicing skills and activities, and training is less

intensive. Exercises aimed at improving performance

involve physical training. Attention must always be

paid to helping patients enjoy the exercises.

TherapyThe application of physical therapy is based on

individual rehabilitation schemas, which are drawn

up by the rehabilitation team. If rehabilitation

screening occurs shortly before hospital discharge,

the patient can immediately enter rehabilitation

phase II in the same hospital where screening was

carried out. If rehabilitation screening is carried out

and indications for therapy are determined at the end

of rehabilitation phase I but the patient does not

immediately progress to phase II (for example,

because rehabilitation only starts four weeks after

hospital discharge) or the patient is referred from

another hospital, the physical therapist will repeat

the diagnostic process before therapy starts. During

the therapeutic process, the physical therapist will

evaluate individual goals systematically (see

description of evaluation given below). The

therapeutic process is divided into the following areas

for descriptive purposes: informing and advising,

patient-orientated exercise program, and relaxation

instruction.

In cardiac rehabilitation, the patient’s physical

functioning is of central concern, not his or her

sporting abilities.

Informing and advising

Providing information and advice, and supporting

the patient are both part of physical therapy and fall

under the general category of providing guidance.

The patient’s need for information, advice and

coaching, which becomes apparent during diagnosis,

forms the basis for the patient information plan.

Consultation with practitioners of other disciplines is

important.

The provision of patient education is divided into

four tasks: informing, instructing, educating and

guiding. In practice, these four tasks overlap. Each

task involves a different approach, which depends on

the time and educational aids available, and on the

therapist’s experience. The physical therapist coaches

the patient and helps him or her to make the desired

behavioral adjustments by providing education, by

giving positive feedback, and by enabling the patient

to have positive movement experiences.

The goals of patient education are:

• To provide an insight into the disorder and

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subsequent rehabilitation – the physical therapist

informs the patient about the nature and course

of heart disease, surgery, rehabilitation (including

its goals, therapeutic content and estimated

duration), risk factors and prognosis;

• To improve compliance and increase trust in

therapy – the learning process involves extending

and incorporating the activities and behaviors

learned during treatment into the patient’s daily

life. The patient has to learn to ‘feel’ how to deal

with heart disease;

• To encourage an adequate way of coping with the

condition – the patient should learn what

symptoms mean and how to control them. The

learning process may be based, for example, on

reducing fear of movement. The physical therapist

ensures that the patient does not receive any

unclear or conflicting information. For example,

reassuring information can counteract a negative

view of the cardiac condition and can, therefore,

help prevent unnecessary invalidity. If the

patient’s partner is worried, it is important that

the partner as well as the patient is provided with

information.

Patient-oriented exercise programs

In developing a patient-oriented exercise program, it

is important to take into consideration the patient’s

goals and desires, the patient’s exercise capacity, and

the individual goals and choices made regarding (a)

the priorities of the exercise program, (b) the types of

exercise to be used, and (c) training variables and

loading. If the exercise program is directed at

improving objective aerobic capacity, the choices

made in selecting training variables should be based

on physiological training concepts, such as

specificity, overloading, supercompensation, reduced

output, and reversibility.

(a) Exercise program priorities

The different exercise program priorities are described

below along with the general goals to be achieved

and with individual goals listed in parentheses:

1. Practicing specific skills, with the goal of

increasing general aerobic capacity and strength

during motor activities (goals 1, 2, 3, 5 and 6).

Result: improved performance of the skills and

activities practiced, a higher level of activities of

daily living, a reduction in risk factors, and

improved postoperative mobility.

2. Aerobic exercise (goals 1, 2 and 3). Result:

increased general aerobic capacity, reduced blood

pressure and heart rate through submaximal

exercise, decreased myo-cardial oxygen uptake,

and a reduction in risk factors.

3. Strength and aerobic exercise (goals 1, 2 and 3).

Result: increased strength and aerobic capacity,

and a higher level of daily activity in housework,

occupational work, sports and hobbies.

4. Learning how to enjoy exercise by practicing

specific functions and activities (goals 5 and 6).

Result: patient enjoys exercising and integrates

exercises into his or her normal lifestyle.

5. Training to reduce risk factors, such as

hypertension, hyperlipidemia, diabetes mellitus,

obesity, inactivity and emotional factors. Result:

increased energy, weight loss, blood pressure

control, controlled insulin responses, and an

active lifestyle.

The treatment used in cardiac rehabilitation is not all

given at the same level. The therapeutic approach can

vary from professional sports training to learning the

most efficient way to tie shoelaces.

(b) Types of exercise

Cardiac rehabilitation involves a wide range of

activities, such as practicing basic skills and daily life

activities, and sports training. Therapy can take the

form of fitness or aerobics exercises, swimming, or

exercises in water. The therapeutic approach chosen

must provide the most appropriate and specific way

of increasing the patient’s daily activities. If therapy is

focused on physical training, use of an ergometer and

sports training are involved. ECG and blood pressure

monitoring are carried out if indicated by the

rehabilitation team.

Ergometers are mostly used during training in high-

risk patients whose ECG recording, blood pressure

and heart rate are being monitored.

(c) Training variables and loading

Examples of training variables are the intensity,

frequency and duration of training, and the length of

the rest intervals. However, training structure is also

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important. General indications of training variable

values according to exercise program priorities, as

noted above, are:

1 and 4.

Practicing specific functions, skills and activities

while encouraging the patient to enjoy exercise:

training frequency should be 2–3 times a week.

2. Aerobic exercise: training intensity should be at

40–85% of maximum oxygen uptake and at 11–16

on the Borg scale; training should consist of a

warm-up period, aerobic training, and a cooling-

down period, and should last 20–60 minutes;

training frequency should be 3–7 days a week.

3. Strength and aerobic exercise: training intensity

should be at 40–50% of maximum strength; each

training session should comprise 1–3 sequences of

10–15 repetitions with pauses lasting 1–2 minutes;

resistance should increase with time, both

relatively and absolutely; training frequency

should be 2–3 times a week. Circuit training

should last for 20–30 minutes and should consist

of a warm-up period, strength training, and a

cooling-down period.

4. Reduction of risk factors: exercises that have a

longer duration, lower intensity and higher

frequency are recommended for patients with

obesity, hypertension, diabetes mellitus (type-II),

and lipid disorders.

Individual exercise programs are devised using the

results of tests of maximum symptom-limited aerobic

capacity. Table 5 shows the relationship between

exercise intensity, percentage maximum heart rate

(HR-max), heart rate reserve (HR-reserve) or

maximum oxygen uptake (VO2-max), and Borg scale

score. The reserve heart rate, which is defined as the

maximum heart rate minus the heart rate in a resting

state, is used during training when VO2-max is

unknown. The Karvonen formula is used to derive

the heart rate during training, as follows:

heart rate during training = heart rate in the resting

state + (X/100 x HR-reserve),

where X = target percentage VO2-max.

Relaxation instruction

Progressive relaxation, autogenic training and deep-

breathing therapy are the approaches to relaxation

used during instruction. The important elements of

these methods were used to develop the relaxation

instruction approach used in the Cardiac

Rehabilitation Guidelines 1995/1996. The specific

type of instruction given is formulated to meet the

patient’s needs and to suit the patient’s current

situation. Relaxation instruction takes place during

exercise, as active relaxation, and during rest periods,

as passive relaxation, or it could form part of warm-

up or cooling-down activities. Relaxation instruction

can also be provided by itself in a separate treatment

session. The need for relaxation instruction

determines therapy frequency. Two or three sessions

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Relative intensity (%) Borg scale score Exercise intensity

HR-max* VO2-max * or

HR-reserve*

< 35% < 30% < 10 very light

35–59% 30–49% 10–11 light

60–79% 50–74% 12–13 medium

80–89% 75–84% 14–16 heavy

> 90% > 85% > 16 very heavy

* HR-max = maximum heart rate; VO2-max = maximum oxygen uptake; HR-reserve = HR-max - resting

heart rate.

Table 5. Determining exercise intensity, and hence aerobic capacity level, in a training session lasting 20–60

This table has been reproduced with permission from WB Saunders Company. Source: Pollock ML, Wilmore JH. Exercise in health and disease:

evaluation and prescription for prevention and rehabilitation. Second edition. Philadelphia: WB Saunders; 1990. © 2000

are necessary to determine whether instruction can

be given in a group setting or individually. There are

very few patients in whom this amount of instruction

is enough to learn relaxation methods, usually more

than five or six sessions are required. Evaluation

carried out after more than five or six sessions

indicates that most patients can relax successfully

without follow-up sessions. However, a small number

of patients will still need individual relaxation

instruction. These are usually patients who have

difficulty following instructions or relaxing. It is

important that the physical therapist also pays

attention to psychosocial factors.

Evaluation

In addition to carrying out continuous evaluation

during treatment, thorough evaluations should take

place every four weeks during treatment, or more

frequently if necessary, and at the end of therapy.

Table 6 outlines the final evaluation criteria and Table

7 describes the desired end result for each goal along

with the recommended means of evaluating the

achievement of these goals.

Evaluating the effects of therapy must be carried out

during treatment as well as at the end. The evaluation

method chosen depends on the individual goal.

Reporting

The rehabilitation team evaluates the rehabilitation

process during and at the end of treatment by using

information about the treatment process and

treatment results and gives advice on aftercare. The

rehabilitation team decides if rehabilitation is still

needed or if it should be ended. Reporting is carried

out in accordance with KNGF guidelines on reporting.

Aftercare

The patient is given information that encourages

activity after rehabilitation. This could be

information on, for example, continuing

independently with training, such as walking or

cycling, or joining a gym. It is important that the

patient chooses a sport or activity that he or she

enjoys to ensure that it will be continued for a long

time. Patients and their partners can also be given

information about local heart patient clubs (e.g.

Heart-in-Movement and Heart Care Federation clubs

in the Netherlands) and heart rehabilitation programs

(e.g., Corefit).

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• The patient has achieved the specified goals.

• The patient has partially achieved the specified goals and it is expected that the patient will achieve all

the goals by himself or herself and be self-sufficient in performing activities.

• The patient has not met the specified goals but it is thought that the patient’s maximum capacity has

already been reached. (The patient is sent back to the rehabilitation team.)

Table 6. Final evaluation criteria

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Goal End result Means of evaluation When used in the program

1. Learn about Patient knows own • the top five problem Beginning and end

physical limits physical limits and areas are identified

activity levels achievable and scored using

a questionnaire

2. Learn to cope with Patient can cope with • activity problems are

physical limitations physical limitations identified and scored

using the fear,

dyspnea and/or angina

pectoris scale

• Borg scale scores on

exhaustion, chest pain

and shortness of breath

are obtained

• if necessary, heart rate

and blood pressure are

monitored

3. Optimize aerobic Aerobic capacity is • questionnaire Beginning and every

capacity level optimum for the patient (as in goals 1 and 2) four weeks

• ergometer

• MET’s units, specific

activity scale, six-

minute walking test

4. Make a diagnosis There is insight into the • all methods used in Continuous monitoring

patient’s capabilities evaluating goal 3 during rehabilitation

• scoring before, during

and after movement

activities, Borg scale

score (see goals 1 and 2)

5. Overcoming fear of Patient is no longer • history-taking and Beginning and end

reduced aerobic afraid to perform physical observation

capacity activities

6. Developing an active Patient has an active • history-taking Beginning and end

lifestyle lifestyle • start of rehabilitation

phase III activities

7. Attaining knowledge Patient has knowledge

about secondary about secondary

prevention prevention • risk factor checklist Beginning and end

8. Learning to relax Patient has knowledge • questionnaire During and at the end

about relaxation and can • flow chart

use this information

to relax

Table 7. Physical therapy goals and means of evaluating the achievement of these goals.

General introductionThe guidelines on cardiac rehabilitation issued by the

Royal Dutch Society for Physical Therapy (KNGF)

provide a guide to the physical therapy of patients

who are eligible for cardiac rehabilitation. The

guidelines describe a methodical approach to the

diagnostic and therapeutic processes involved in

providing physical therapy.

The guidelines were developed by the Dutch Physical

Therapy Association for Cardiac and Vascular Diseases

(NVFH), the Royal Dutch Society for Physical Therapy

(KNGF) and the Dutch Institute of Allied Health

Professions (NPi). They are consistent with the Cardiac

Rehabilitation Guidelines 1995/1996 developed by

the Dutch Cardiology Association (NVVVC) and the

Dutch Heart Foundation (NHS).1,2 The guidelines are

multidisciplinary and interdisciplinary and have been

developed for rehabilitation therapists who are

directly involved with the practical treatment of

patients who require cardiac rehabilitation in

rehabilitation phase II. The rehabilitation team

consists, at a minimum, of a physician, a physical

therapist, a social worker and a nurse. The physician

in the team, who is usually a cardiologist, has the

final responsibility for treatment. If necessary,

information on the patient is discussed by the team

and it is decided whether practitioners of other

disciplines should be involved, such as a nutritionist,

a psychologist, a rehabilitation physician, a primary

care physician, or an occupational physician. The

rehabilitation process should be designed to meet the

individual patient’s needs, as expressed in the

Individual Rehabilitation Plan concept. These clinical

guidelines have been developed for circumstances in

the Netherlands.

Definition

KNGF guidelines are defined as “a systematic

development from a centrally formulated guide,

which has been developed by professionals, that

focuses on the context in which the methodical

physical therapy of certain health problems is applied

and that takes into account the organization of the

profession”.3,4

Objective of the KNGF guidelines on cardiac

rehabilitation

The objective of the guidelines is to describe the

optimal physical therapy, in terms of effectiveness,

efficiency and tailored care, for patients who are

eligible for cardiac rehabilitation and who have had

an acute myocardial infarction, or who have

undergone coronary artery bypass grafting,

percutaneous transluminal coronary angioplasty, a

heart valve operation, or operative correction of a

congenital heart disorder. Guideline

recommendations are based on current scientific

knowledge and the physical therapy provided should

result in a decrease in symptoms and in

improvements in the patient’s functions and levels of

activity participation.

In addition to the above-mentioned objectives, KNGF

guidelines are explicitly designed:

• to adapt the care provided to take account of

current scientific research and to improve the

quality and uniformity of care;

• to provide some insight into, and to define, the

tasks and responsibilities of the physical therapist

and to stimulate cooperation with other

professions; and

• to aid the physical therapist’s decision-making

process and to assist in the use of diagnostic and

therapeutic interventions.

To promote implementation of the guidelines,

recommendations have been made concerning the

levels of professionalism and expertise needed to

ensure that treatment is carried out in accordance

with the guidelines.

Main clinical questions

The group that formulated these guidelines set out to

answer the following questions:

• How many patients are eligible for cardiac

rehabilitation in the Netherlands, in terms of

incidence and prevalence?

• Which health problems can be described in this

group of patients?

• Which risk factors and prognostic factors are

known and can be influenced by physical

therapy?

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Review of the evidence

• What is the normal course of development in

patients eligible for cardiac rehabilitation?

• Which parts of the physical therapy approach to

treatment and prevention are valid in this group

of patients and what are the effects of different

forms of treatment, such as movement programs

(e.g., exercises), relaxation instruction,

psychoeducational interventions, and the

provision of advice and information?

• Which diagnostic and evaluative measuring

instruments are useful?

Formation of the monodisciplinary working group

In May 1998, a monodisciplinary working group of

professionals was formed to find answers to these

clinical questions. In forming the working group, an

attempt was made to achieve a balance between

professionals with experience in the area of concern

and those with an academic background. Patients’

desires and preferences were expressed via the Dutch

Heart Foundation. All members of the working group

stated that they had no conflicts of interest in

participating in the development of these guidelines.

Guideline development took place from May 1998

until June 2000.

Monodisciplinary working group procedure

The guidelines were developed in accordance with

concepts outlined in a document entitled “A method

for the development and implementation of clinical

guidelines”.3–6 This document includes practical

recommendations on the strategies that should be

used for collecting scientific literature. Below, in this

review of the evidence for these guidelines, details are

given of the specific terms used in literature searches,

the sources searched, the publication period of the

searched literature, and the criteria used to select

relevant literature. The recommendations made on

therapy are almost entirely based on scientific

evidence. If no scientific evidence was available,

guideline recommendations were based on the

consensus reached within the working group or

between professionals working in the field. External

experts commented on guideline recommendations.

Once the draft guidelines were completed, they were

sent to a secondary working group comprising

external professionals or members of professional

organizations, or both, so that a general consensus

with other professional groups or organizations and

with any other existing monodisciplinary or

multidisciplinary guidelines could be achieved.

The members of the working group individually

selected and graded the documentation collected on

the basis of the quality of the scientific evidence.

Even though the scientific evidence was collected by

individuals or smaller subgroups, the results of the

process were presented to and discussed by the whole

working group. Thereafter, a final summary of the

scientific evidence, which included details of the

amount of evidence available, was made. In addition

to scientific evidence, other important considerations

were taken into account in formulating

recommendations, such as: the achievement of a

general consensus, cost-effectiveness, the availability

of resources, the availability of the necessary expertise

and educational facilities, organizational matters, and

the desire for consistency with other

monodisciplinary and multidisciplinary guidelines.

Validation by intended users

Before they were published and distributed, the

guidelines were systematically reviewed, for the

purpose of validation, by the target group that would

use the guidelines in the future. The draft KNGF

guidelines on cardiac rehabilitation were tested in

daily practice by members of the working group who

were working in different environments in order to

provide an overall appraisal of the guidelines. The

working group included nine physical therapists who

tested the guidelines in their own working

environments, with their own teams, or with other

professionals working in their field. The comments

and criticisms made by the physical therapists were

recorded and discussed by the working group. If

possible or desirable, they were taken into account in

the final version of the guidelines. The final

recommendations on practice, then, are derived from

the available evidence and take into account the

other above-mentioned factors and the results of the

guideline evaluation carried out by intended users

(i.e., physical therapists).

During the period 2001–2003, a prospective cohort

study was conducted that involved cardiac

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rehabilitation patients who were treated according to

the guidelines. Before the start of the study,

documentation and reporting forms were developed

for distribution at the end of the study. Patients’

opinions were sought during the study and an

attempt was made to identify organizational aspects

of treatment that could be improved, for example, by

obtaining information about the cost implications of

applying guideline recommendations. Another goal

was to identify criteria for ascertaining whether

guidelines are being followed (i.e., process indicators),

for determining the results of therapy (i.e., outcome

indicators), and for determining the extent of care

(i.e., benchmarks). The results of this prospective

cohort study will be included in the first revision of

the guidelines.

Composition and implementation of the

guidelines

The guidelines comprise three parts: the practice

guidelines themselves, a schematic summary of the

most important points of the guidelines, and a review

of the evidence. Each part can be read individually.

Immediately after publication of the guidelines and

their distribution among members of the Dutch

Physical Therapy Association for Cardiac and Vascular

Diseases (NVFH), a prospective cohort study was

started, which involved implementation of the

guidelines in eleven hospitals and rehabilitation

centers. In addition, the guidelines were

implemented in accordance with the standard

method of implementation, which has been

described elsewhere.3–7

Introduction to these guidelinesThis section describes the choices made in arriving at

the recommendations given in the KNGF guidelines on

physical therapy in cardiac rehabilitation. The

guidelines are based on Dutch Cardiac Rehabilitation

guidelines,1,2 United States guidelines9–12 and recent

scientific literature on cardiac rehabilitation, since

1994. Literature was collected using the Cochrane

Library 1999 Issue 2, MEDLINE (November 1994 to

1999) and CINAHL (September 1994 to 1999). The

following terms were used in literature searches: heart

disorder, (acute) myocardial infarction (AMI), coronary

artery bypass graft (CABG), percutaneous transluminal

coronary angioplasty (PTCA), heart valve operation,

and operative correction of congenital heart

disorders, together with the additional terms: exercise

therapy, movement therapy, physical therapy,

postoperative care, cardiac rehabilitation, clinical

trial, randomized clinical trial, protocol, meta-

analysis, and reviews (in both Dutch and English).

Literature was also provided by working group

members.

Rehabilitation phases I, II and III

Cardiac rehabilitation involves actions that take place

in the following phases: during hospital admission

(phase I), during rehabilitation in the polyclinic

(phase II), and after rehabilitation and during

aftercare (phase III).1,13 KNGF guidelines focus on

phase II, as do the multidisciplinary guidelines. The

details of rehabilitation in phase I are given in

summary form because the period of hospital

admission has been increasingly shortened and

rehabilitation treatment in this phase consequently

reduced. Rehabilitation in phase III does not take

place in the institutional healthcare sector and is not,

therefore, covered by these guidelines. Phase III

focuses on individual sporting and recreational

activities. In the Netherlands, physical therapists in

primary healthcare sectors are involved in treatment

related to sport and recreation, which may include

Heart-in-Movement and Heart Care Federation clubs,

the Corefit heart rehabilitation program, and physical

therapy sports centers.

Defining cardiac rehabilitation

“Cardiac rehabilitation involves the rehabilitation of

normal activities after a cardiac incident.

Rehabilitation focuses on optimizing physical,

psychological and social activities, so that the patient

can regain a normal place in society, and on

influencing risk factors.”14 The KNGF guidelines are

based on this definition with the addition of the

following: “Cardiac rehabilitation involves strategic

training and education to promote adequate coping

behavior and optimal functioning in normal daily

life, such that the patient’s quality of life is improved,

and individual limitations and participation problems

are reduced”.15

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Impairments, limitations and participation

problems

The physical therapist describes health problem in

cardiac patients in terms of impairments (functional

or structural), disabilities (affecting activities), and

participation problems. These terms are defined in

the International Classification of Impairments,

Disabilities and Handicaps (ICIDH-2 Beta-2 1999).16

Quality of life is also assessed during the evaluation

of paramedical and medical treatments. Quality of

life involves physical, psychological and social

components, which are related to the patient’s

perception of whether treatment is having an effect

on his or her daily life. The treatment goal of

improving quality of life is especially important for

those patients in whom full recovery is not possible.

Defining cardiac rehabilitation patients

The KNGF clinical guidelines on physical therapy in

cardiac rehabilitation have been developed for

patients who have had an (acute) myocardial

infarction, or who have undergone coronary artery

bypass grafting, percutaneous transluminal coronary

angioplasty, a heart valve operation, or operative

correction of a congenital heart disorder.

Rehabilitation in all these types of patient is

practically identical. This target group coincides with

that described in (Dutch) Multidisciplinary Cardiac

Rehabilitation Guidelines.2 Additional screening is

necessary for patients suffering from angina pectoris,

chronic heart failure, hypertrophic obstructive

cardiomyopathy that has not been treated surgically,

heart rhythm disorders (for example, after ablation

therapy) and atypical thoracic complaints, and for

those with a pacemaker or an implantable

cardioverter-defibrillator, or who have had a heart

transplant.1

Pathogenesis

After a cardiac incident, both objective and subjective

aerobic capacity may be reduced. The patient’s

aerobic capacity level ‘objectively’ depends on motor

characteristics such as strength, speed, flexibility,

perseverance and coordination, as well as on the

potential application of these characteristics in

normal daily activities, sport, work and hobbies.

Other impairments and limitations can also have an

influence on functioning. Aerobic capacity may be

reduced subjectively by fear, invalidity, depression or

a limited social life.1 Emotional disturbances and

social factors may also lead to disorders. Fear,

aggressiveness and depression can predominate and

are often associated with sleeping difficulties,

exhaustion, emotional lability, libido problems, and

eating, memory and concentration disorders.1

Acceptance of a reduced social life can also have an

influence.1 It is possible that a patient may deal with

his or her heart disease inappropriately. Negative or

overpowering reactions from a partner or from the

patient’s environment can unnecessarily limit or

stress the patient. Problems with fulfilling social roles

are usually secondary consequences of physical

limitations or psychological difficulties. However,

elements in the patient’s environment, such as an

unhelpful employer, can inhibit the return to optimal

social functioning.1,2

Epidemiology

In 1997 in the Netherlands, there were 14,274 deaths

related to cardiac infarctions: 8,064 men and 6,210

women. In that same year, 27,199 hospital

admissions were directly related to cardiac

infarctions. In general, the women affected were

older than the men. Men had an average hospital

stay of 10 days, and women stayed for 11.5 days on

average.17 In 1995, 14,709 open-heart operations

were completed in the Netherlands.18 Cardiac

rehabilitation generally takes place in specialized

clinics and almost never in the primary healthcare

sector.1,19 In 1999, the Dutch Heart Foundation

reviewed the availability of cardiac rehabilitation in

the Netherlands.20 The results showed that, in 1998,

98 locations provided group rehabilitation in

polyclinics (rehabilitation phase II). In that same

year, 17,000 patients attended polyclinic cardiac

rehabilitation programs. The largest subgroups of

these patients had suffered from acute myocardial

infarctions (46%) or had had coronary artery bypass

graft operations (30%). Smaller subgroups received

cardiac rehabilitation after percutaneous transluminal

coronary angioplasty (11%), valve operations (7%) or

chronic heart failure (3%), or after receiving a

diagnosis of angina pectoris or heart rhythm disorder

(3%). (The percentages given are all approximate.)

Exercise therapy, which was given in groups with

physical therapy guidance, appeared to be more

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specialized than in 1993. In 1998, institutions

generally provided more than two exercise programs,

in which patients were categorized as having a

physically good condition or a physically poor

condition. Around 85% of all institutions offered

relaxation instruction, usually as part of the exercise

program (81%), but sometimes individually (48%).20

Risk factors and prognostic factors

The cause of almost all coronary heart disease is

arteriosclerosis. Arteriosclerotic processes and damage

to coronary arteries depend on existing risk factors.

Influenceable risk factors include smoking, lipid

disorders (e.g., hypercholesterolemia and

hyperlipidemia), hypertension, obesity, depression,

diabetes mellitus, stress and physical inactivity.2 Non-

influenceable risk factors include hereditary

tendencies, age and sex.

The most important prognostic factors determining

the chance of survival and quality of life after the

acute phase of a myocardial infarction are left

ventricular function and the amount of vascular

damage in the coronary system.25 Other prognostic

factors that are important for recovery are the

patient’s psychological state, which may be affected

by exhaustion, fear or depression, and co-morbid

conditions, such as physical limitations or a

cerebrovascular accident. Taking part in a

rehabilitation program after a myocardial infarction

increases the patient’s quality of life. This is especially

the case for those whose quality of life is low or

whose level of cardiovascular risk is low.26

Secondary and tertiary prevention

The prevention of coronary heart disease involves

adopting measures that focus on behavioral change,1

stopping smoking, and increasing regular physical

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DefinitionsLipid imbalance: There are different forms of imbalance such as hyperlipidemia (i.e., high blood levels of

triglycerides and cholesterol) and hypercholesterolemia (i.e., a high blood cholesterol level).15 A cholesterol

level between 5 and 6.5 mmol/l is slightly high, between 6.5 and 8 mmol/l high, and greater than 8 mmol/l

very high. (Source: Dutch cholesterol consensus document).16

Hypertension: Hypertension is defined as a systolic blood pressure (SBP) of 140 mmHg or more or a diastolic

blood pressure (DBP) of 90 mmHg or more, or both, in persons not taking medications for high blood

pressure.17 For adults over 18 years of age, the following hypertension categories are used:17

• grade 1 (mild hypertension): SBP of 140–159 mmHg or DPB of 90–99 mmHg;

• grade 2 (medium hypertension): SBP of 160–179 mmHg or DBP of 100–109 mmHg;

• grade 3 (severe hypertension): SBP > 180 mmHg or DBP > 110 mmHg.

Obesity: The most commonly used method for assessing body weight is the Quetelet index (QI), which is

also referred to the body mass index (BMI). To obtain the QI, body weight in kilograms is divided by body

height in meters squared. The World Health Organization proposed the following weight classification for

adults on the basis of the QI:18

• normal weight: QI = 18.5–24.9 kg/m2;

• overweight (level I): QI = 25.0–29.9 kg/m2;

• obesity (level II): QI = 30.0–39.9 kg/m2;

• morbid obesity (level III): QI > 40 kg/m2.

People with obesity are at a higher risk of physical inactivity, hypertension and hypercholesterolemia

because they are overweight.1

Diabetes mellitus: In diabetes, there is absolute (type-I diabetes) or relative (type-II diabetes) insulin

deficiency, which leads to hyperglycemia. People with diabetes area t a higher risk of developing

retinopathy, nephropathy, vascular diseases and neuropathy.15

activity. Healthy eating habits have a positive

influence on such risk factors as being overweight,

hypercholesterolemia, and hypertension. Additional

instruction is necessary for patients who find it

difficult to take medications or to develop trust in

therapy.2

Physical therapist’s role

The physical therapist’s specific role in the

rehabilitation team concerns the patient’s functional

movement. On the basis of history-taking and

functional assessment, the physical therapist analyses

the patient’s movement capabilities and limitations,

identifies influenceable risk factors, and develops a

treatment plan. The main goal of physical therapy is

to influence the patient’s movement capabilities

positively so that his or her participation in society is

optimized. The patient’s interests are central in

devising the treatment plan, and the patient and

physical therapist must work well together as a

team.27

Physical therapy qualifications

Physical therapists working with patients in cardiac

rehabilitation have knowledge and experience that

they acquired while obtaining their physical therapy

qualifications. In the Netherlands, they will know

about publications such as the “Cardiac

Rehabilitation Guidelines 1995/1996” and “Physical

therapy in cardiac rehabilitation”. They must have

adequate knowledge and experience of behavior-

orientated principles, the methodical provision of

patient information, group training techniques, and

guiding exercise. Patients can work towards several

goals using one or more exercises and the physical

therapist must adjust activities, as appropriate.2

Dutch physical therapists who provide instruction on

relaxation therapy in groups must follow a basic

course entitled “Relaxation instruction”, which is

provided by the Dutch Heart Foundation. Providing

individual therapy involving deep-breathing and

relaxation techniques necessitates specialized

education in subjects such as haptic therapy, the

Feldenkrais method, deep-breathing therapy and

psychosomatic therapy.

Rehabilitation phase IOnce a diagnosis has been made and surgery carried

out, therapy in this phase involves the provision of

appropriate medical treatment, early mobilization,

and giving information on heart disease, on any

associated surgery and on risk factors and prevention.

Referral data should include the diagnosis, the dates

of the infarct and operation, details of any

complications, and the reasons for referral.

Additional referral information detailing the patient’s

current level of mobility and the cardiologist’s advice

may be necessary. Table 8 provides an overview of

information the cardiologist may provide.

Diagnosis

History-taking provides the physical therapist with

information about: the patient’s concerns; the

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Quality criteria for physical therapy facilities28

• Emergency procedures must exist for incidents affecting personnel or infrastructure;

• Telephones must be available in all treatment areas;

• A resuscitation team with experience in advanced life support must be available (during rehabilitation,

there must be, on location, a minimum of two trained individuals who are experienced in basic life

support);

• A physician must be available during rehabilitation;

• The treatment area must be multifunctional, for example, including an exercise gym where group

therapy can also be given;

• Treatment areas must be provided with equipment (e.g., a treadmill, an exercise bicycle or a rowing

machine) that can be used with an ergometer;

• There must be alarms in exercise, shower and changing areas;

• There must be areas for private conversations;

• There must be a meeting area.

activity level needed for normal functioning in daily

life; health problems before, during and after the

infarction; risk factors; co-morbid complaints; the

patient’s way of coping with the infarction and the

subsequent operation; the patient’s need for

information; the patient’s work, living and family

situations; and sporting, hobby and recreational

activities.

Therapy

The actions taken during cardiac rehabilitation are

divided into (a) actions taken after conservative

treatment and (b) actions taken after surgical

treatment.

(a) Rehabilitation after conservative treatment

The duration of rehabilitation phase 1 depends on

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Non-surgical

• medical condition on admission

• thrombosis: yes/no

• reperfusion: yes/no

• size of myocardial infarction:

- creatine kinase and creatine kinase

(MB fraction)

- levels

- echographic wall-motion score

- left ventricular resting function

• myocardial infarction location

• complications:

- rhythm disorders

- cardiac decompensation

- post-infarct angina pectoris

- NYHA grading

- cardiac aneurysm

• cardiac history

• test results:

- thorax X-ray

- ejection fraction

- coronary angiography

- ergometric tests*

- thallium scintigraphy

- lung function

• relevant laboratory results: hemoglobin and

cholesterol levels

• medication

• diagnosis

• reasons for referral

• psychological information

• work rehabilitation information and prognosis

• family information

* For more information, see Table 14

Surgical

• type of operation:

- number of bypasses

- arterial or venous grafts

• valve:

vtype of valve operation

• left ventricular function

• cardiac complications (e.g., rhythm disorders,

pericardial fluid, pleural fluid or decompensation)

• non-cardiac complications (e.g., atelectasis,

infiltration, wound problems or cerebrovascular

accident) and co-morbid conditions

• cardiac history

• test results:

- thorax X-ray

- echography

- ergometric tests*

- lung function

• medication

• diagnosis

• reasons for referral

• psychological information

• work rehabilitation information and prognosis

• family information

Table 8. Cardiac information that may be provided by a cardiologist. Reproduced, in an adapted form, from a

report on a 1994 symposium on cardiac rehabilitation.29 NYHA = New York Heart Association classification.

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the size of infarct and any complications that arise

within five to ten days, on average. During the acute

phase, the patient will be in hospital for cardiac care

and will stay there for a few days. For patients with

pulmonary problems, such as chronic obstructive

pulmonary disease, physical therapy focuses on

monitoring mucus clearance and ventilation. The end

criterion for physical therapy is that there are no

longer any objective signs of pulmonary difficulty.

The acute phase ends when the patient meets the

following criteria: there is hemodynamic stability, the

relevant enzyme levels have been reduced, there are

no serious rhythm disturbances or conduction

disorders, and all pulmonary complications have

been eliminated.

After the acute phase, the patient is moved to another

hospital ward where mobilization can begin. During

this mobilization phase, the physical therapist helps

the patient achieve the desired level of daily activity

(see Table 9). It is also the physical therapist’s

responsibility to inform the patient about heart

disease, coping with symptoms, medical treatment,

risk factors and the level of activity desirable during

rehabilitation at home. The optimum levels of

physical activity and stress to be applied during

treatment depend on the patient’s current exercise

capacity. The end criteria for physical therapy are: the

patient can function at the desired level of activities

of daily living; the patient’s aerobic capacity level has

improved, both subjectively and objectively, to

greater than 3 MET’s; the patient has knowledge

about heart disease and can deal responsibly with the

condition; the patient has knowledge about risk

factors; and the patient understands how he or she

can deal appropriately with symptoms. To achieve

these, the physical therapist must, therefore,

determine the patient’s normal level of activities of

daily living and identify any risk factors.

During rehabilitation, the physical therapist should

be alert to signs of patient distress and overloading

(see Table 10). Vascular problems are indicated when

angina pectoris, dyspnea or exhaustion occurs during

Functional class I

- sitting up in bed with

assistance;

- carrying out activities

associated with personal

hygiene;

- sitting with assistance;

- sitting in a chair for 15–30

minutes two or three times a

day.

Functional class II

- sitting up in bed without

assistance;

- standing without assistance;



hygiene while sitting in the

bathroom;

- walking within the bedroom

and to the bathroom, with or

without assistance.

Functional class III

- sitting and standing without

assistance;



hygiene while sitting or

standing in the bathroom;

- walking short distances

(15–30 m) in the hallway with

assistance approximately

three times a day.

Table 9. Functional classification of patient activities during the mobilization phase.

Functional class IV



hygiene and bathing;

- walking short distances

(45–60 m) with minimal

assistance three or four times

a day.

Functional class V

- walking in the hallway

without assistance for a

distance of 75–150 m three or

four times a day.

Functional class VI

- walking without assistance

3–6 times a day.

This table has been reproduced with permission from the American College of Sports Medicine (ACSM). Source: American College of Sports

Medicine. ACSM guidelines for exercise testing and prescription. Philadelphia and Baltimore: Lippincott William & Wilkins; 2000. © 2000.

low-level exercise. Dyspnea is an important symptom

of serious stenosis of the left coronary artery or the

frontal descending coronary artery. Abnormally high

blood pressure is a systolic pressure above 250 mmHg

and a diastolic pressure above 120 mmHg. A diastolic

pressure that is more than 25 mmHg higher than in

the resting state can indicate coronary heart disease.

The occurrence of hypotension or low blood pressure

at higher levels of exertion can indicate left

ventricular difficulty. This is usually seen in patients

with serious ischemic heart disease or chronic heart

failure. Supraventricular rhythm disorders can occur

in heart disease, or may be secondary to endocrine or

metabolic factors, or may result from the use of

certain medicines. Ventricular rhythm disorders may

be associated with mitral valve prolapse, with

hypertrophic and idiopathic cardiomyopathies (i.e.,

heart muscle disorders), and with heart valve

disorders.10

(b) Rehabilitation after surgical treatment

Rehabilitation phase 1 includes preoperative and

postoperative phases. In the preoperative phase, the

patient is prepared for the operation. The treatment

goal in this phase is to inform the patient about

previous lung disorders and other potential problems

(e.g., paralysis, muscle disease or Bechterew’s disease)

that could have a negative effect on postoperative

recovery. Preexisting lung disorders are treated if

indicated by a physician or pulmonologist.

Preoperative pulmonary therapy consists of:

explaining the goals of physical therapy, teaching

techniques for improving ventilation, teaching about

methods of mucus clearance, and advising

patients.30,31 The postoperative phase is split into two

phases: the first immediately follows the operation

when the patient is in the intensive care unit and

lasts, on average, one or two days; the second, the

mobilization phase, lasts 4–10 days in the recovery

ward. The goals of physical therapy in intensive care

are to identify problems with mucus clearance and

ventilation and, if necessary, to teach techniques for

coughing, blowing and breathing (see Figure 1). In

the mobilization phase, the treatment goals are

identical to those following myocardial infarction,

with additional information being given about the

operation. The physical therapist should provide the

patient with information about the pain occurring in

the operated areas and about wound care. Guidelines

developed by Dutch clinical physical therapy

rehabilitation teams in university hospitals, and

entitled “Guidelines for peri-operative physical

therapy of the lung with abdominal and heart

surgery”,30 advise the following: provide appropriate

breathing exercises that concentrate on maximizing

inspiration and that involve holding deep breaths for

a few seconds. Teaching effective coughing, blowing

and forced expiration techniques is useful for helping

mucus clearance. Particular attention should be paid

to encouraging the patient to become self-reliant

during mobilization as early as possible.

Rehabilitation phase IIThe need for rehabilitation in the polyclinic is

indicated in the physician’s referral documentation.

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• angina pectoris;

• left ventricular systolic disfunctions;

- shortness of breath;

- excessive exhaustion for the level of physical activity;

• rhythm disorders;

- faster than expected heart rate for the level of physical activity;

- irregular heart rate, alterations in normal rhythm;

• abnormally high or low blood pressure;

• fainting;

• dizziness;

• orthosympathetic responses (e.g., sweating or pallor).

Table 10. Symptoms of overloading during exercise.


Analysis

Combination of preoperative and postoperative:

higher risk

Treatment plan

higher risk

1. Improve ventilation: 3. Advice:

- maximum inspiration Patient:

- chronic obstructive pulmonary disease, - maximum inspiration

pressed-lip breathing five time per hour

Physician:

2. Improve mucus removal: - painkillers

- effective coughing and blowing - mucolytics

- manual compression Nurse:

- forced expiration techniques - change position in bed

- mobilization

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Risk assessment

• nature of operation:

- complexity

- duration

- complications

• time on respirator

• clinical information:

- temperature

- blood gas analysis

- thorax X-ray

• medication:

- painkillers

- mucolytics

Physical therapy assessment

1. History-taking:

- pain

- mucus production

- shortness of breath

2. Assessment:

- breathing pattern

- coughing and blowing techniques

- ability to follow instructions

- degree of consciousness

Diagnosis

TherapyNo risk

Treatment period:

• monitor on first postoperative day

and continue as long as needed,

depending on clinical improvement

depending on clinical

High risk

Treatment period:

• start on the day of the operation

and continue as long as needed,

depending on clinical improvement

Treatment frequency:

• day 0: 1 per day

• day 1: 1 or 2 per day

• day 2: 1 per day

• day 3: depending on clinical improvement

Evaluation

Clinical information: Other factors:

• fever (> 38°C) • mucus production

• positive mucus laboratory results • pain

• abnormal thorax X-ray • slow mobilization phase

• abnormal blood gas concentrations • moderate ability to follow

• abnormal blood oxygen saturation instructions

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Additional screening is carried out by the

rehabilitation team to ascertain indications for

therapy.2 Referral information should, at a minimum,

include the physician’s diagnosis, relevant

cardiological diagnostic information, details of any

heart rhythm or conduction disorders, details of any

risk factors, and details of medicine usage. The

cardiologist will appraise the patient’s exercise capacity

and estimate the level of risk using all diagnostic

information available (see Table 11). A low risk level is

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Risk level Characteristics

Low • normal left ventricular function (i.e., ejection fraction > 50%);

• absence of complex arrhythmias while resting and during aerobic capacity exercises;

• no complications during the clinical phase (i.e., absence of chronic heart failure and

symptoms of ischemia);

• hemodynamic stability while resting and during aerobic capacity exercises;

• no symptoms (e.g., absence of angina pectoris during aerobic capacity exercises);

• functional capacity greater than 7 MET’s1;

• absence of depression.

For a patient to be classified as low-risk, it is assumed that all the characteristics in this category are present.

Medium • moderate limitation of left ventricular function (i.e., ejection fraction = 35–49%);

• symptoms, including angina pectoris, occur during or after exercising at a medium

aerobic capacity level (i.e., 5–6.9 MET’s).

All patients who do not fit into the low-risk or high-risk categories are classified as medium risk.

High • poor left ventricular function (i.e., ejection fraction < 35%);

• status after successful resuscitation;

• complex ventricular arrhythmias while resting and during aerobic capacity exercises;

• myocardial infarction or heart operation with complications such as cardiac shock,

congestive heart failure or symptoms of repeated or persistent ischemia;

• hemodynamic instability during aerobic capacity exercises, especially systolic blood

pressure reduction or chronotropic incompetence with increasing exercise;

• symptoms, including angina pectoris, occur during or after light aerobic capacity

exercises

(< 5 MET’s);

• functional capacity less than 5 MET’s2;

• clinically significant depression.

For a patient to be classified as high-risk, it is assumed that at least one of the characteristics listed in this

category is present.

1 metabolic task equivalent (MET’s) = 3.5 ml of oxygen per kg per minute.

2 If a functional capacity measurement is not available, the variable is not included in risk factor

determination.

* the working group made the following changes: < 50% was changed to > 50%; 40–49% was changed to

35–49%; < 40% was changed to < 35%; and “previous myocardial infarction or sudden death” was

changed to “status after successful resuscitation”.

Table 11. Guidelines for determining level of risk.

This table has been reproduced with permission from the American Association of Cardiovascular and Pulmonary Rehabilitation. Guidelines for

cardiac and secondary prevention programs, 3rd edition. Champaign, IL: Human Kinetics; 1999.(51)

associated with a high degree of physical capability,

and vice versa.

The rehabilitation team screens patients by means of

questions on five areas of enquiry relating to the

patient’s physical and social functioning and to the

presence of risky behavior (see Table 12). Evaluation

criteria provide a guide to the patient’s present and

future functional status. Screening is carried out by

means of a clinical assessment, a maximum symptom-

limited aerobic capacity test, and a psychological

assessment. If these objective measures coupled to

clinical judgement fail to provide sufficient

information to answer screening questions, it is

necessary to use a questionnaire to obtain additional

information about the patient’s physical, psychological

and social functioning, about risk factors and about

the lifestyle choices made by the patient. In this

situation, screening is distinct from evaluation. The

decision on which questionnaire to use can be made

with the aid of the “Leiden Screening Questionnaire

for Heart Patients (LSVH)”33 and the “Maastricht

Screening Questionnaire for Heart Patients (MSVH)”.34

These screening questionnaires both include elements

that are used in rehabilitation evaluation. For example,

the “Quality of Life after Myocardial Infarction

Instrument (QLMI)’35 forms part of the “Leiden

Screening Questionnaire for Heart Patients”. Moreover,

the questionnaires cover physical, psychological and

social factors as well as quality of life. The “Medical

and Psychological Questionnaire for Heart Patients

(MPVH)”,36 the “Maastricht Questionnaire on

Exhaustion and Depression (MV)” and the “Cardio Fear

Test (HAT)” together give an assessment of the patient’s

level of life satisfaction. A checklist of risk factors is

used to assess risky lifestyles objectively (question V in

Table 12). It can also be useful to look at specific

characteristics of the patient, such as the patient’s

personality and whether the patient’s partner is being

overprotective.37,38 The physical therapist’s diagnosis

forms part of the screening process carried out by the

rehabilitation team.

Diagnosis

In diagnosis, the goals of physical therapy are to

determine the severity and cause of any health

problems affecting the patient’s mobility and whether

it is possible to influence them. The starting point is

the patient’s concerns and needs. The physical

therapist will investigate the patient’s health

problems and symptoms, the health state the patient

wishes to attain, the existence of any factors that

hinder or promote recovery, and the patient’s

information needs. The diagnostic process involves

history-taking, assessment and analysis.

History-taking

In history-taking, information is obtained partly by

the rehabilitation team, and includes referral data

from the cardiologist, and partly from the patient

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I. Has aerobic capacity been reduced objectively, in terms of the patient’s ability to work and carry out

domestic and leisure activities? Are there any motor limitations that restrict the patient’s functional

abilities?

II. Has aerobic capacity been reduced subjectively because of a fear of physical activity (including sexual

activity) or because the patient is highly aware of being disabled?

III. Has the patient’s emotional balance been threatened? Does the patient cope with the condition

inadequately? In other words: Is there a relationship between present and optimal psychological

functioning?

IV. Is social functioning threatened? What is the prognosis for the patient’s return to a normal social role in

relation to work, leisure and family relationships? What is the quality and extent of the patient’s social

network?

V. Are there any influenceable risky behaviors, involving, for example, smoking, diet, physical inactivity, or

non-compliance with therapy?

Table 12. Questions in the five areas of enquiry used in rehabilitation screening, taken from the Cardiac

Rehabilitation Guidelines 1995/1996:(1,2)

himself or herself. See Table 13 for details.

The clinical guidelines advise using a standard

questionnaire during history-taking, especially for

those carrying out history-taking for the first time. In

addition to the assessment techniques described

above in the introduction to rehabilitation phase II,

use can also be made of the “Patient-specific

complaints” questionnaire, of specific visual analogue

scales, and of “numerical rating scales” for

quantifying the nature, duration and extent of

activity problems. For details, see Supplement 2 on

measuring instruments.

Assessment

The physical therapist should determine the patient’s

aerobic capacity level using the maximum symptom-

limited exercise test and estimate of the skill level

needed by the patient to carry out the motor

functions involved in his or her normal daily

activities. The physical therapist must taken into

account coordination, movement efficiency, muscle

strength, flexibility and the patient’s psychological

state. The patient’s psychological state indicates to

the physical therapist which course of treatment

should be followed. The working group advises that

measuring instruments should be used during

assessment, for example: the MET’s method, which

quantifies the activities the patient finds most

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Investigating the patient’s concerns:

• Which activities are most problematic?

• What is the desired level of activity?

• How does the patient experience the consequences of heart disease and what are his or her expectations

of treatment, including physical therapy?

Investigating the patient’s level of activity before the present health problem, and the course of the

health problem and its prognosis:

• Which impairments, limitations and problems with social participation does the patient experience as a

result of heart disease?

• Which physical disorders were caused by the heart disease?

• Which emotional disorders were caused by the heart disease?

• Briefly describe how the patient’s symptoms relate to the onset and progression of the condition.

• Which underlying factors contributed to the disorder?

- disease course (e.g., poor circulation)

- prognostic and risk factors:

- local: e.g., left ventricular function or coronary artery condition (one, two or three vascular

disorders?)

- general: risky behavior such as an inactive lifestyle, smoking, stress (e.g., sleep problems), fear or

depression.

- treatment and the effects of treatment.

Investigating the present situation:

• Which impairments, limitations and problems with social participation does the patient experience as a

result of heart disease?

• What is the patient’s present level of activity in terms of functioning, activities and social participation?

• Personal information:

- social information: family situation, occupation and family health history;

- what demands does the patient’s environment place on him or her?

• How well-motivated is the patient?

• What is the patient’s need for information?

Table 13. Details of history-taking.

difficult because of duration, quality, fear or dyspnea;

the Borg scale, which can quantify exhaustion, chest

pain and shortness of breath (heart rate and blood

pressure can also be monitored); the Specific Activity

Scale; and the six-minute walking test. For more

information, see Supplement 2 on measuring

instruments.

Analysis

Analysis involves assessment and evaluation. The

physical therapist must obtain answers to the

following questions:

1. What is the patient’s health status in terms of

impairments, limitations and problems with social

participation? How much can the patient

currently handle, physically, mentally and

socially?

2. Are there physical problems that limit increases in

the patient’s physical, mental and social

performance? Are these:

• related to a cardiac disorder (e.g., myocardial

infarction); or

• related to other diseases or disorders, including

other physical complaints?

3. Are there any other factors that have a negative

influence on exercise capacity?

• fear, depression, mental handicap or sleeping

problems;

• stress or exhaustion;

• smoking, physical inactivity or eating

problems;

• medication use; or

• social problems.

4. How does the patient envisage his or her future

performance of daily activities, leisure activities,

work and hobbies (i.e., the patient’s goals and

expectations)?

5. Is the desired level of performance attainable?

• can any negative factors be influenced?

• if so, negative factors should be reduced or

eliminated and exercise capacity increased;

• if not, the situation should be optimized and

the patient should learn to accept it.

6. Can physical therapy help ameliorate the health

problem? In terms of:

• reducing impairments;

• reducing limitations;

• reducing participation problems; or

• improving functional activities and the level of

participation.

In addition to the above-mentioned problem areas,

patients may experience other health problems

related to heart disease. On occasion, additional

physical therapy may be indicated. These problems

are not covered by these guidelines.

Treatment plan

The rehabilitation team will decide if there are

discrepancies between the patient’s present condition

and the desired level of functioning and determine

whether there is an indication for rehabilitation. The

rehabilitation team, together with the patient, will

formulate therapeutic goals with help from the

answers given to questions in the five areas of

enquiry used in rehabilitation screening, which were

taken from the Cardiac Rehabilitation Guidelines

1995/1996. These goals are translated into an

individual rehabilitation plan that consists of a

number of different modules. If necessary, these

modules can be implemented with individual

guidance. The rehabilitation team decides when the

rehabilitation program will start and which module

the patient should use first. The Cardiac

Rehabilitation Guidelines 1995/1996 describe four

modules: a short exercise module, a long exercise

module, an information module, and a

psychoeducational preparation module. The KNGF

guideline working group advises the addition of a

fifth module, on relaxation instruction.

The physical therapist must receive all relevant

referral information from the rehabilitation team

before the first treatment session. The referral

information should include: the medical diagnosis

and prognosis; an estimate of the patient’s exercise

capacity; individual goals for physical aerobic

capacity; details of possible influenceable factors,

such as fearfulness or inappropriate coping strategies;

and the physical therapy diagnosis. Extra information

may include details of the patient’s occupation,

family and environment.

For patients who are referred for ‘physical training’, it

is necessary to obtain relevant diagnostic and

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prognostic information using the symptom-limited

exercise test (i.e., using an ergometer). Therapeutic

goals then depend on cardiac capacity, the maximum

symptom-limited heart rate, maximum aerobic

capacity, and maximum acceptable exercise

duration.2 The maximum symptom-limited exercise

test for cardiac patients indicates maximum oxygen

consumption (peak VO2) and, thereby, maximum

aerobic capacity.2 Table 14 outlines the information

that can be obtained from ergometric tests.

There are six specific goals of physical therapy, which

correspond to goals specified by multidisciplinary

guidelines (the numbers in square brackets refer to

the goals listed in the Cardiac Rehabilitation

Guidelines 1995/1996):1,2

1. Learning to find one’s own physical limits [1].

2. Learning to deal with physical limitations [2].

3. Finding the optimum aerobic capacity level [3].

4. Diagnosis: evaluating the aerobic capacity level

and correlating symptoms with objective disorders

[4].

5. Reducing fear of movement [5].

6. Developing and attaining a physically active

lifestyle [14].

The physical therapist can also have an influence on

the achievement of other goals, such as achieving

secondary prevention [12–16], acquiring emotional

balance [6], and learning how to deal with heart

disease in a functional manner [7]. Each patient

usually has a combination of goals. If improving

aerobic capacity is not indicated, then goals 1 and 2

are recommended. If improving aerobic capacity is

indicated, then goals 1 and 3 are recommended. If

there is a subjective decrease in aerobic capacity,

treatment should focus on goals 1 and 5. The

problem areas covered by goals 1 and 5 are usually

the initial focus of treatment. For example, the

patient must first reduce the level of fear or learn

what his or her personal limits are before being ready

for training. If there is no clear objective reduction in

aerobic capacity, then goal number 4 is

recommended.1

Goals must be clearly formulated at the beginning of

treatment. For example, it is preferable to formulate

goals such as “the patient should able to cycle” or

“the patient should able to continue with sexual

activities” rather than “the patient has overcome fear

of movement”. A goal such as “improving lifestyle

activities” is better formulated as “the patient should

able to walk twice a day for 30 minutes”.2

On the basis of information obtained during

diagnosis, the patient can be allocated to an exercise

group in which rehabilitation exercises match the

patient’s exercise capacity. Corstjens et al.39

developed three exercise groups:

1. an exercise group for, usually young, patients with

high exercise capacity;

2. a less-intensive exercise group for less physically

capable patients; and

3. a functional exercise group for, usually elderly,

patients with poor exercise capacity.

It is important when allocating patients to exercise

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• the patient’s current exercise capacity, expressed in terms of VO2, MET’s units or watts, as derived from

symptom-limited tests;

• the protocol in use;

• the cardiologist’s estimate of aerobic capacity level based on cardiograms made before, during and after

physical exertion (there are criteria for cardiac ischemia and rhythm disorders and the practical

consequences of these conditions);

• resting heart rate, maximum achievable heart rate, and heart rate after recovery;

• blood pressure while resting, during exertion and during recovery;

• reasons for not completing the tests;

• medication use before and during testing;

• the patient’s subjective symptoms during testing (e.g. angina pectoris or dyspnea).

Table 14. Information recorded during ergometric testing.

groups to bear in mind that high-frequency programs

are more effective in counteracting psychological

complaints40 and low-frequency programs are more

effective in encouraging self-sufficiency and self-

confidence.37

TherapyThe physical therapy approach is based on individual

rehabilitation schemas, which are drawn up by the

rehabilitation team. If rehabilitation screening occurs

shortly before hospital discharge, the patient can

immediately enter rehabilitation phase II in the same

hospital where screening was carried out. If

rehabilitation screening is carried out and indications

for therapy are determined at the end of

rehabilitation phase I but the patient does not

immediately progress to phase II (for example,

because rehabilitation only starts four weeks after

hospital discharge) or the patient is referred from

another hospital, the physical therapist will repeat

the diagnostic process before the start of therapy.

Below, the effects of specific treatments used in

cardiac rehabilitation are described along with their

implications for the guidelines. The evidence used in

developing guideline recommendations comes from

United States 1995 clinical practice guidelines

number 17 on cardiac rehabilitation9 and from

scientific literature published between 1994 and

1999. In the present clinical practice guidelines,

conclusions are based on systematic reviews. The

standard of scientific evidence is regarded as being at

one of three levels: level A, in which conclusions

have been based on scientific data from randomized

clinical trials and on statistical results; level B, in

which conclusions have been based on observational

studies or on randomized clinical trial with less

consistent results; and level C, in which conclusions

have been based on the consensus view of

experienced and knowledgeable experts. The target

group for these clinical guidelines includes the target

group for KNGF guidelines. The guidelines have also

been developed for patients with angina pectoris and

chronic heart failure, and for those who have

received heart transplants.

Effects of cardiac rehabilitation programs

Cardiac rehabilitation programs that focus on

physical training, developing a healthy lifestyle, and

relaxation techniques help patients to recover and

increase aerobic capacity, slow down atherosclerotic

processes, and reduce the risk of further cardiac

events.1,2,28,41–43

Oldridge et al.44 and O’Connor et al.45 showed using

meta-analyses that total and cardiovascular mortality

rates in patients who had had myocardial infarctions

were 20–25% lower in those who followed cardiac

rehabilitation programs than in control groups.

However, the number of non-fatal recurrent

infarctions was not lowered significantly by these

programs. According to the authors of both meta-

analyses, no definite conclusions can be drawn about

the effects of physical therapy in rehabilitation

because most studies involved other measures in

addition to physical training. Kugler, Seelbach and

Krüskemper46 showed that physical therapy

rehabilitation programs also have positive effects on

fear and depression. Meta-analyses of multifactorial

cardiac rehabilitation programs tend to focus on

improving physical functions, providing information

about healthy lifestyles, and increasing quality of life.

These analyses show that there were favorable

impacts on cardiovascular mortality, recurrent

infarction, blood pressure, cholesterol levels, and

eating behavior.9,47–49 Cost-effectiveness analyses

show that cardiac rehabilitation decreases medication

use.2

Training effects and aerobic capacity

Training that focuses on the recovery, maintenance

and improvement of aerobic capacity provides

objectively improved aerobic capacity without

causing significant cardiovascular complications or

other negative effects (scientific evidence: level A).

Aerobic training that improves aerobic capacity and

leads to adaptations in cardiac and peripheral

musculature is the most effective.9 Recently, this

conclusion has been confirmed by Dugmore et al.50

and Stahle et al.51 In the randomized clinical trial

published by Dugmore et al.,50 acute myocardial

infarction patients were given guided aerobic training

three times a week for 12 months. The effects in these

patients were compared with those in a control group

in which patients did not receive any training. After a

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follow-up period of five years, improvements were

observed in cardiorespiratory status, psychological

well-being and quality of life. There was also a

reduction in the risk of early death and

improvements in work and occupational

performances. Stahle et al.’s51 randomized trial

compared the physiological effects of aerobic training

and giving exercise advice in a group of elderly

patients (> 65 years old) with those of a program

providing only exercise advice. Significant

improvements in aerobic capacity and well-being

were found in the group of patients who took part in

the aerobic training program. Table 15 outlines the

effects of aerobic training on the cardiorespiratory

system.

Effects of strength training

Strength training improves muscle strength and

muscle aerobic capacity in patients who have

clinically stable coronary heart disease and has

positive effects on the performance of daily life

activities and work (scientific evidence: level B).9 In a

review, Verrill et al.53 showed that high-resistance

training increases muscle circumference by means of

hypertrophic changes. Circuit training at a lower

level of resistance improves muscle strength, bone

density, mineral balance and aerobic capacity. This

was confirmed by a study carried out by Brechue and

Pollock.54 More research is needed to determine the

safety and effectiveness of strength training in other

groups of coronary and cardiac patients.9,53 Verrill et

al.53 advise patients to take part in strength training

programs to screen for cardiovascular complications

and for specific medical conditions. They give the

following exclusion criteria for intensive muscle

strength training: abnormal hemodynamics or

ischemia noted on ECG recordings during aerobic

activities, poor left ventricular function (i.e., an

ejection fraction of less than 30%), unstable angina

pectoris, acute heart failure, malignant hypertension,

uncontrolled rhythm disorders, and serious aortic

stenosis or aneurysm. Verrill et al. recommend

strength and resistance exercises for patients with

functional capacities of 6 MET’s or more. Low-risk or

medium-risk patients (see Table 11 above) who have

functional capacities of less then 6 MET’s should use

low-resistance exercises.

A randomized controlled study55 that assessed high-

intensity strength training programs, at 80% of

maximum, showed that they were safe and that they

were effective in increasing muscle strength and in

improving physical condition. The exclusion

criterion for these programs was that the patient was

not able to participate fully in an aerobic training

program, for example, because of uncontrolled

rhythm disorders (see the exclusion criteria described

above). In addition, Beniamini et al.55 concluded that

high-intensity muscle strength training under

medical supervision can be well-tolerated when given

as a supplement to aerobic training or to a cardiac

rehabilitation program, and that it results in

increased muscle strength and aerobic capacity,

thereby enabling daily activities to be carried out

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• lowers heart rate;

• increases heart pump output volume;

• increases heart minute volume during maximum-intensity exercise;

• increases blood volume and hemoglobin level;

• increases artery-vein oxygen differential;

• lowers blood pressure;

• increases VO2-max;

• increases anaerobic threshold;

• increases maximum respiratory minute volume;

• increases ventilation;

• increases lung diffusion capacity;

• increases lung volume and capacity.

Table 15. Effects of aerobic training on the cardiorespiratory system. Source: Jongert et al.(52)

more easily. Table 16 outlines the effects of strength

training on skeletal muscle.

Other effects of exercise

• Less angina pectoris in patients with coronary

heart disease, and fewer symptoms of chronic

heart failure in patients with left ventricular

systolic dysfunction (scientific evidence: level B).

The symptoms of angina pectoris are also reduced

by psychological and education interventions,

counseling, and behavioral change (components

of multifactorial rehabilitation).9

• In the past, exercise programs, with or without

psychological and educational preventative

measures and stress management, have been

shown to have positive effects on psychological

functioning.41,46,56 However, these findings have

not been supported by more recent

research.49,57,58 These inconsistencies have had

the result that additional screening is now carried

out in heart patients in order to ensure good

healthcare, to ensure that personal goals are met,

and to assess the relationships between different

components of exercise programs and the results

achieved.49

• Positive effects on social functioning (scientific

evidence: level B). Exercise programs improve

social functioning.9

• Exercise programs combined with educational and

psychological interventions also influence:

smoking (scientific evidence: level B),

hyperlipidemia (scientific evidence: level B),

obesity (scientific evidence: level C) and

hypertension (scientific evidence: level B). Cardiac

rehabilitation involving only exercise programs

has a smaller effect on these risk factors.9 In a

randomized clinical trial, Vergès et al.59 showed

that patients with chronic heart disease who

completed intensive rehabilitation programs,

which included educational components, reacted

better to hyperlipidemia treatment than patients

who did not undergo cardiac rehabilitation. The

educational component of the program promotes

secondary prevention by providing knowledge

about low-lipid diets and by increasing trust in

therapeutic recommendations concerning diet

and medication use.

• Cardiac rehabilitation in patients who have had a

myocardial infarction or who have received a

coronary artery bypass graft leads to increased

participation in exercise after rehabilitation

(scientific evidence: level B). The effect is short

lived, however, and it is, therefore, advisable to

provide further cardiac rehabilitation on a long-

term basis to encourage both exercise and the

adoption of an active lifestyle. It is important to

encourage patients to find a form of exercise that

they enjoy and that they find easy to continue.9

Pathophysiological effects9

• Exercise programs administered in combination

with extensive dietary control and any necessary

hyperlipidemia medications slow the progression

of coronary arteriosclerosis, as observed

angiographically, and are, therefore,

recommended. Rehabilitation that involves only

an exercise program has been shown to be less

effective (scientific evidence: level A/B).

• There is no evidence showing that exercise

programs influence the development of a

collateral coronary circulation or cause consistent

changes in cardiac hemodynamic measurements

made during cardiac catheterization. Exercise

programs for patients who have chronic heart

failure and, therefore, also reduced ventricular

ejection fractions, result in positive changes in the

peripheral musculature and are, therefore,

recommended for improving muscle function

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• functional hypertrophy;

• increased mitochondrial numbers (mitochondrial hypertrophy);

• increased capillary circulation;

• increase in muscle enzymes;

• increased energy-rich phosphate level.

Table 16. Effects of strength training on skeletal muscle. Source : Jongert et al.(52)

(scientific evidence: level B).

• Exercise programs reduce myocardial ischemia


• Exercise programs have small positive effects on

the ventricular ejection fraction and on

abnormalities in ventricular wall motion.

However, they are not recommended for

improving ventricular systolic function. Exercise

programs have different effects on left ventricular

function in patients who are recovering from

frontal infarctions, who exhibit Q waves in their

ECGs and who have left ventricular dysfunction


• Exercise programs have no consistent effects on

ventricular rhythm disorders (scientific evidence:

level B).

Effects of relaxation instruction

At present, more then twenty studies demonstrate

that relaxation therapy is effective in patients with

coronary heart disease. Most of these studies are

randomized clinical trials. About half of the research

is on the beneficial effects of supplementing

rehabilitation that involves exercise modules in

polyclinics.60,61 Research covers a large variety of

methods and there is a large variation in results. Table

17 outlines the results of these studies. The use of

relaxation therapy after exertion has received the

most research interest – resting cardiac oxygen

consumption is reduced by relaxation. This is

confirmation that relaxation increases physiological

aerobic capacity. For this reason, it is important that

all patients have the opportunity to learn relaxation

methods. It is possible that relaxation helps

physiological adaptations consolidate the effects of

training. In other words, relaxation therapy can lead

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Type of improvement Number of studies showing effects of relaxation therapy

Positive effects No effects

Changing from ergotrophic to trophotrophic situations – physiological:

• reduction in heart rate at rest 7 3

• systolic blood pressure reduction 5 5

• diastolic blood pressure reduction 6 3

• reduction in myocardial ischemia 3 0

• fewer arrhythmias 3 1

• reduction in respiratory rate 3 0

Changing from ergotrophic to trophotrophic situations – psychological:

• less fear 5 4

• increased well-being 3 1

• less depression 5 0

Coping adequately with stress in daily life:

• fewer cardiac complaints 3 0

• fewer physical complaints 3 1

• return to work and normal activities 5 0

Recurrent complaints and long-term risk factors

• fewer additional cardiac problems, such as infarction,

the need for a coronary artery bypass graft, or death 3 0

• less smoking 0 3

Table 17. Overview of the effects of relaxation therapy. The second and third columns give the number of studies

in which the improvement in the group receiving relaxation therapy was greater than or equal to, respectively,

that in the control group.(60,61)

to an increase training intensity. A few studies have

investigated myocardial ischemia, by looking at ST

depression and by using thallium scintigraphy, and

rhythm disorders. In these studies, positive effects

were also found.

It is more difficult to assess the effects of learning

how to deal with physical limitations and activity

limitations. It has been shown that learning to deal

with stress in daily life improves symptoms and

promotes recovery, in terms of returning to work and

to a normal activity level. The small amount of

research that has been carried out confirms that

positive effects exist. A few studies have

demonstrated positive effects on recurrent long-term

complaints but a negative effect on stopping

smoking. It is not yet clear which particular method

should be used to improve prognosis.

Implications for the guidelines

The role of physical therapists in cardiac

rehabilitation programs is to develop and implement

exercise programs for patients, to provide

information and advice, and to provide relaxation

instruction. Consultation with practitioners of other

disciplines is also important. Exercise program

priorities are set according to the patient’s wishes and

exercise capacity.24 Therapy may include:

• practicing skills that increase strength or aerobic

capacity through motor activities;

• increasing (total) aerobic capacity;

• increasing (local) strength;

• practicing specific functions and activities that

help the patient enjoy exercising;

• practicing specific exercises that help reduce the

effects of risk factors, such as hypertension,

hyperlipidemia, diabetes mellitus, obesity,

physical inactivity and emotional factors.

There follow detailed descriptions of how

information and advice, exercise programs, and

relaxation instruction are provided in practice.

Providing information and advice

Important components of rehabilitation are providing

appropriate information for cardiac patients and

helping to build trust in therapy.62–64 In providing

patient information, the goals may be: to provide

information about the disorder and rehabilitation, to

influence compliance, and to help the patient adopt

an adequate way of coping with the condition, which

may involve dealing with fear. For more information,

see Supplement 1 on patient education.

Behavior-orientated principles

Today, increasing attention in physical therapy is

being paid to integrating physical, psychological and

external factors, such as pain, stress and fear. These

categories often overlap, however.65 For example, it

may possible to deal successfully with biomechanical

factors that cause symptoms while the patient’s daily

life limitations remain the same or even increase,

perhaps because of psychosocial factors. Behavior-

orientated principles can be applied in the

rehabilitation of patients who are not able to deal

adequately with the consequences of coronary heart

disease. In effect, these principles represent the

integration of behavioral science and rehabilitation.

In this approach, the focus is on the situation in

which the behavior appears, not on the under lying

pathology.65 Behavior-orientated rehabilitation also

involves:

• using tests to determine why the patient is

functionally limited and to identify the causes of

symptoms. Tests are repeated to help guide and

evaluate treatment;

• active patient participation;

• helping patients acquire adequate coping skills

during treatment that will enable them to deal

better with the condition (e.g., motor and

relaxation skills);

• using a time-dependent approach to treatment, in

which treatment follows a time line.

In behavior-oriented approaches to rehabilitation, it

is important to include the patient’s partner,

employer and occupational physician and the

practitioners of any other disciplines involved as

much as possible during rehabilitation.

Tailored exercise programs

Exercise programs can comprise exercises that focus

on improving performance or exercises that focus on

improving health, or both. Exercises that focus on

improving performance involve physical training,

increasing (total) aerobic capacity, strength training,

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and reducing the effects of risk factors. Exercises that

focus on improving health involve practicing specific

skills and activities and helping patients learn to

enjoy exercise. In the latter, training is less intense

than in physical training. Attention should always be

paid to encouraging patients to enjoy exercising.

If the aim of the exercise program is to increase

objective aerobic capacity, it is essential to adhere to

certain physiological training principles to help bring

about the desired physiological changes. These

physiological training principles have the following

characteristics:2

• specificity: the effects of training are highly

specific to the type of exercise used and to the way

training load is built up. This means that motor

performance must be developed in the context of

specific motor activities;

• progressive load build-up: the training load must

increase as the patient’s physical condition

improves;

• overloading: the training load should be the

minimum needed to produce the desired effect of

training (e.g., a physiological change);

• supercompensation: it is important that enough

rest is taken during recovery after training.

Insufficient rest limits physiological change and

‘supercompensation’, which form the basis of

effective training;66

• relationship between physical condition and

training load: as the patient’s physical condition

improves, the effect of constantly increasing the

training load is reduced;

• Reversibility: to sustain the effects of training, it is

essential that the patient enjoys exercising,

thereby ensuring its continuation.

In order to reduce subjective limitations on

movement, it is important that use is made of

behavior therapy and social learning theory during

treatment administration.67 For more information on

the principles of behavior therapy and social learning

theory, the Dutch reader is referred to the Cardiac

Rehabilitation Guidelines 1995/1996.2

Not only must a choice be made in deciding the

priorities of the exercise program, but also in selecting

the movements and training variables that are used.

Activities

Cardiac rehabilitation can involve a large range of

different activities, such as those necessary for

practicing basic skills and those involved in normal

daily life, sport and recreation. Use can also be made

of fitness and aerobics exercises, swimming, and

exercises in water. The activities chosen must have a

relationship with the patient’s normal daily activities

so that training can be as specific as possible. If the

aim of training is to improve the patient’s physical

condition, an ergometer should be used, and track-

and-field, sporting and recreational training should

be carried out. The use of an ergometer during

training is recommended when patients are at an

increased risk or when additional monitoring is

needed, such as ECG, or blood pressure or heart rate

measurement. If indicated by the rehabilitation team,

training should be monitored using an ECG or blood

pressure measurement, or both.

Training variables and training load

Training variables are items such as the intensity,

frequency and duration of training and the length of

the rest intervals. The way in which training load is

built up is also important. Training load is a function

of the magnitude of the load, and the duration and

frequency of its application. The duration of loading

depends strongly on the patient’s physical condition,

the goals of training, and training intensity. How

frequently the load is applied depends on the

patient’s physical condition and the magnitude of

previous loads.

The general indications of target values for training

variables given in the clinical practice guidelines are

derived from the multidisciplinary Cardiac

Rehabilitation Guidelines 1995/1996,2 the American

College of Sports Medicine guidelines,10,24,68 exercise

standards defined by the American Heart

Association,12 and the guidelines developed by the

American Association for Cardiovascular and

Pulmonary Rehabilitation.11 Table 18 summarizes the

training variable values recommended for patients

with cardiovascular problems by these different

guidelines. The American Heart Association and the

American Association for Cardiovascular and

Pulmonary Rehabilitation also quote minimum

values for training parameters whereas the American

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College of Sports Medicine gives a range of values.

The Cardiac Rehabilitation Guidelines 1995/19962

recommend that patients should train at 50–60% of

their reserve heart rate in the first half of movement

training modules and at 60–80% in the second half.

Static strength exercises are effective when training is

carried out at 30–40% of maximum voluntary muscle

strength. Optimal effects are achieved at 50–60% of

maximum. Above 70% of maximum, effectiveness

begins to level off.2

The training variable values recommended for

reducing the effects of specific risk factors are:24

• Hypertension: training intensity of 50–85% of HR-

max or 40–70% of VO2-max or 11–13 on the Borg

scale; training duration of 30–60 minutes; training

frequency of 3–7 days a week; strength training is

given with many repetitions and low resistance.

• Diabetes: training intensity of 50–90% of HR-max

or 50–85% of VO2-max (a lower intensity may be

necessitated by complications or chronic

diabetes); training duration of 20–60 minutes;

training frequency of 4–7 days a week.

• Obesity: training intensity of 50–70% of peak

VO2; training duration of 40–60 minutes (or two

20–30 minute sessions a day); training frequency

of 5 days a week; more important to build up

duration than intensity.

• Hyperlipidemia: 40–70% of peak VO2 or 11–16*

on the Borg scale; training duration of 40

minutes; training frequency of 1–2 sessions, 5–7

days a week; more important to build up duration

than intensity.

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Aerobic Capacity training:

Frequency

Intensity

Duration

Method

Strength training:

Method

Frequency

American College of

Sports

Medicine guidelines (10)

3–5 times/week

55–90% of HR-max or

40–80% of VO2-max or

HR-reserve

20–60 minutes

continuously

aerobic or intermittent

activities

minimum one set, 10–15

repetitions, large muscle

groups, start with low

resistance

2–3 times/week

American Heart

Association exercise

standards (12)

3 times/week minimum

50%–75% of VO2-max or

HR-reserve

20 minutes minimum

healthy physical activity

one set, 10–15 repetitions,

8–10 exercises, large

muscle groups

2–3 times/week

American Association for

Cardiovascular and

Pulmonary Rehabilitation

guidelines (11)

3–5 times/week

50% VO2-max minimum

20–60 minutes

healthy physical activity

one set, 12–15 repetitions,

8–10 exercises, large

muscle groups before

small muscle groups

2–3 times/week

Table 18. Summary of training variable values recommended for patients with cardiovascular problems by

guidelines developed by different organizations.

Calculating the intensity of aerobic capacity

exercises

The intensity of individual exercises can be calculated

using information from a maximum or symptom-

limited aerobic capacity test. The reserve heart rate

(HR-reserve), which equals maximum heart rate

minus resting heart rate, is used during training when

VO2-max is unknown. The Karvonen formula is used

to derive the heart rate target during training, as

follows:2,69

heart rate during training = heart rate in the resting

state + (X/100 x HR-reserve),

where X = target percentage VO2-max.

Calculating the intensity of strength exercises

Using the pyramid diagram shown in Figure 2, an

estimate of maximum muscle strength can be made

without having to determine directly the maximum

weight a patient can pick up only once. The patient

should choose a weight that he or she can lift about

10 times and it should then be determined how

many times he or she can repeatedly lift the weight

in practice. The total number of repetitions the

patient can make is related to a percentage on Figure

2. The weight, in kg, is multiplied by the percentage

to obtain an estimate of maximum muscle strength.

Figure 2. Pyramid diagram relating the number of

times a patient can repeatedly lift a specified weight to

maximum muscle strength.70

Continuous training and intermittent training

In continuous training, the patient exercises at a

specified training load for a relatively long period of

time without stopping. There are two levels of

intensity: extensive continuous training, which is

characterized by a relatively long duration and

relatively low intensity, and intensive continuous

training, which is characterized by a relatively short

duration and relatively high intensity. The minimum

training duration required for training to have a

central effect on maximum aerobic capacity is 20–30

minutes. Therefore, to achieve an effect, it is

necessary, first, to build up to the minimum training

duration and, then, to increase training intensity. As

the patient’s physical condition improves, the focus

of the exercise program changes from extensive

continuous training to intensive continuous training.

If the patient is severely overweight, or suffers from

extreme hypertension, diabetes mellitus or

hypercholesterolemia, the total training duration can

be increased while the intensity is kept at a low level.

In this way, the main focus of training is on

metabolizing fat.52

In intermittent training, periods of intensive training

are alternated with periods of rest or less intensive

training. By choosing the right duration and intensity

of intermittent training, it is possible to influence

different metabolic systems, such as alactic anaerobic,

lactic anaerobic or aerobic metabolism.2 Intermittent

training enables patients to prepare themselves for

the desired training intensity and duration.

Intermittent training is particularly recommended for

patients with peripheral arterial disease and

intermittent claudication.24

Effects of medication on heart rate, blood pressure, ECG

and exercise capacity

Supplement 4 summarizes the effects of different

medications on heart rate, blood pressure, the ECG

and exercise capacity.10

Beta-blockers52 affect both heart rate and contraction

force. They are administered for high blood pressure,

angina pectoris and certain rhythm disorders. Beta-

blockers can be used effectively on a long-term basis.

They influence exercise capacity, reduce symptom

duration and affect heart rate. In patients taking beta-

blockers, heart rate increases in parallel with

increasing load and VO2-max even though the

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medication significantly reduces the maximum heart

rate. The magnitude of the reduction in maximum

heart rate depends on the dose and type of beta-

blocker. The nature of beta-blocker administration

determines the relationship between exercise load

and heart rate. Therefore, the dose, intake time and

type of beta-blocker must be the same for all tests

carried out during the rehabilitation program. A

change in one of these three parameters can lead to a

change in heart rate during exercise. In order to

provide effective maximum aerobic training for

patients taking beta-blockers, the heart rate must be

relatively high during training, in terms of percentage

maximum heart rate. It is advisable to keep training

intensity at a level at which the heart rate is 70–90%

of the maximum measured while the patient is taking

the beta-blocker. The results of training are usually

good in patients using beta-blockers. However, those

who take beta-blockers because of hypertension have

poorer results.24 The results of training in patients

taking other forms of medication, such as ACE

inhibitors, calcium antagonists and diuretics, are also

good.71

Relaxation instruction

It is recommended that every cardiac patient learns

about or experiences relaxation exercises.2 The aims

of these exercises are: to enable patients to learn

about their physical limits, to improve aerobic

capacity, to help patients regain an emotional

balance, and to help them find a practical way of

dealing with heart disease. There are many ways in

which relaxation instruction can contribute to

cardiac rehabilitation. Being able to relax has a

positive effect on recovery and can enable patients to

exercise without stress. Becoming aware of stress and

learning to sense the position of one’s body in space

enables patients to understand their physical

limitations. The sense of inner peace that comes

about during relaxation can reduce feelings of fear

and depression. Moreover, learning to deal with stress

in daily life improves social functioning. Together

these factors influence psychological balance and

help patients find a practical way of dealing with

heart disease. There are even positive effects over the

long term.

During exercise, patients are given information about

and an explanation of stress and relaxation, and how

to incorporated relaxation into an exercise program.

If instructing the patient in a group does not have the

required effect, the patient can be given individual

relaxation instruction. Individual sessions are

recommended for patients who are likely to be

receptive to relaxation therapy and who are willing to

accept change, and for those who did not receive

enough information during relaxation instruction to

enable it to be effective. For all these patients, it is

important that attention is paid to the existence of

any underlying psychological factors. If any are

present, patients should be referred for guided

conversation therapy.72 For more information on

relaxation instruction, Dutch readers should refer to

the Cardiac Rehabilitation Guidelines 1995/19962

and the published conclusions of a workshop entitled

“Relaxation instruction in cardiac rehabilitation”.72

Evaluation

In addition to carrying out continuous evaluation

during treatment, thorough evaluations should take

place every four weeks during treatment and at the

end of therapy. The choice of evaluation instrument

made by the physical therapist depends on the

specific goals of therapy. Table 19 describes the

desired end result for each goal along with the

recommended means of reliably evaluating the

achievement of these goals. In the final evaluation, it

is determined whether: (a) the patient has achieved

the specified goals; (b) the patient has partially

achieved the specified goals and it is expected that he

or she will achieve the treatment subgoals by

independently continuing treatment activities at

home; or (c) the patient has not achieved the

specified goals but is thought to have reached his or

her maximum capacity. In the last case, the patient is

sent back to the rehabilitation team. A description of

the measuring instruments used is given in

Supplement 2. The first evaluation should be carried

out after four to six group relaxation sessions. The

flow chart in Figure 3 provides an explanation of the

processes involved in evaluating relaxation therapy.

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Table 19. Physical therapy goals and measuring instruments used for evaluating the achievement of these goals.

Goal

1. Learn about physical

limits

2. Learn to cope with

physical limitations

3. Optimize aerobic

capacity level

4. Make a diagnosis

5. Overcoming fear of

reduced aerobic capacity

6. Developing an active

lifestyle

7. Attaining knowledge

about secondary

prevention

8. Learning to relax

End result

Patient knows own

physical limits and

activity levels achievable

Patient can cope with

physical limitations

Aerobic capacity is

optimum for the patient

There is insight into the

patient’s capabilities

Patient is no longer

afraid to perform

physical activities

Patient has an active

lifestyle

Patient has knowledge

about secondary

prevention

Patient has knowledge a-

bout relaxation and can use

this information to relax

Measuring instruments

• the top five problem

areas are identified

and scored using a

questionnaire (visual

analogue scales could

also be used)

• activity problems are

identified and scored

using the fear,

dyspnea and/or

angina pectoris scale

• Borg scale scores on

exhaustion, chest

pain and shortness of

breath are obtained

• if necessary, heart rate

and blood pressure

are monitored

• questionnaire (as in

goals 1 and 2)

• ergometer

• MET’s units, specific

activity scale, six-

minute walking test

• all instruments used

in evaluating goal 3

• scoring before, during

and after movement

activities, Borg scale

score (see goals 1 and 2)

• history-taking and

observation

• history-taking

• start of rehabilitation

phase III activities

• risk factor checklist

• questionnaire

• flow chart

When used in the program

Beginning and end

Beginning and every four

weeks

Continuous monitoring

during rehabilitation

Beginning and end

Beginning and end

Beginning and end

During and at the end

Ho

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Figure 3. Flow chart explaining the process of evaluating relaxation instruction throughout therapy.

Ending therapy and reporting

The rehabilitation team is informed about the

treatment process and about treatment results during

and at the end of treatment. In addition, advice is

given on aftercare. It is decided in consultation with

the rehabilitation team whether rehabilitation should

continue or end. For more information on reporting,

the Dutch reader is referred to KNGF guidelines on

reporting.73

Aftercare

During rehabilitation, the patient must receive

information that encourages the continuation of

rehabilitation activities after discharge. For example,

information can be given on walking, cycling, or

joining a gym. It is important that patients choose

exercises that they enjoy and can continue for a long

time. Patients and their partners can be referred to

local heart patient clubs (e.g. Heart-in-Movement and

Heart Care Federation clubs in the Netherlands) and

to heart rehabilitation programs such as Corefit.

Corefit is a fitness program in the Netherlands in

which patients can work on their physical condition.

CORE stands for Cardiopulmonary, Osteoporosis,

Recreation and Education.74

Legal significance of the guidelinesThese guidelines are not statutory regulations. They

provide knowledge and make recommendations

based on the results of scientific research, which

healthcare workers must take fully into account if

high-quality care is to be provided. Since the

recommendations mainly refer to the average patient,

healthcare workers must use their professional

judgement to decide when to deviate from the

guidelines if that is required in a particular patient’s

situation. Whenever there is a deviation from

guideline recommendations, it must be justified and

documented.4,5 Responsibility, therefore, resides with

the individual physical therapist.8

Guideline revisions

These KNGF guidelines are the first such clinical

guidelines to be developed for diagnosis, treatment

and prevention in patients requiring cardiac

rehabilitation. Subsequent developments that could

lead to improvements in the application of physical

therapy in this group of patients may have an impact

on the knowledge contained in these guidelines. The

prescribed method for developing and implementing

guidelines in general proposes that all guidelines

should be revised a maximum of three to five years

after the original publication.4,5 This means that the

KNGF, together with the working group, will decide

whether these guidelines are still accurate by 2006 at

the latest. If necessary, a new working group will be

set up to revise the guidelines. These guidelines will

no longer be valid if there are new developments that

necessitate a revision.

Before any revision is carried out, the recommended

method of guideline development and

implementation should also be updated on the basis

of any new knowledge and to take into account any

cooperative agreements made between the different

groups of guideline developers working in the

Netherlands. The details of any consensus reached by

Evidence-Based Guidelines Meetings (i.e., the EBRO

platform), which are organized under the auspices of

the (Dutch) Collaborating Center for Quality

Assurance in Healthcare (CBO), will also be taken into

account in any updated version of the method of

guideline development and implementation. For

example, the stipulation that uniform and

transparent methods are necessary for determining

the amount of evidence needed and for deriving

practice recommendations would constitute an

important improvement.

External financingThe production of these guidelines was subsidized by

the (Dutch) Ministry of Public Healthcare, Welfare

and Sport (VWS) within the framework of a program

entitled “A quality support policy for allied health

professions (OKPZ)”. The interests of the subsidizing

body have not influenced the content of the

guidelines nor the resulting recommendations.

AcknowledgmentsFor their help in producing these KNGF guidelines,

special words of gratitude are in order to members of

the secondary working group: ELD Angenot PhD

(rehabilitation physician, Amsterdam Rehabilitation

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Center), M Berkhuysen PhD (movement scientist), J

van Dixhoorn PhD (physician, Amersfoort and

Haarlem), T van Elderen PhD (psychologist,

Rijksuniversiteit Leiden), AM Erdman PhD

(psychologist, Rotterdam University Hospital), HACM

Kruijssen PhD (cardiologist, NVCC) and A Vermeulen

PhD (cardiologist, NVCC). Also words of gratitude are

in order to the referents: GE Bekkering MSc (NPi),

ATM Bernards MSc (NPi), YF Heerkens PhD (NPi), HJ

Lasonder-Veldhuizen MSc (KNGF) and ALJ Verhoeven

MSc (KNGF). Last but not least, thanks to Ms JA Smit

for her secretarial work.

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The patient education plan forms part of the overall

physical therapy treatment plan. The development of

the patient education plan starts, during history-

taking, with carrying out an analysis of the patient’s

need for education. How much knowledge does the

patient presently have about his or her condition and

its treatment? Are the patient’s coping strategies

effective? Does the patient know how to improve

these strategies? What do the patient and his or her

partner expect from treatment? Attention must be

paid to every area of difficulty. This approach also

provides information about the reasons for any lack

of trust in therapy.

Dekkers75 divided patient education into four

categories: information, instruction, education and

guidance. This division is hierarchical in that the

provision of information requires least involvement

by the physical therapist whereas giving guidance

requires most.

1. Information: providing factual information about

the condition, its treatment, and patient self-care.

2. Instruction: providing guidelines or instructions

that enable patients themselves to have a positive

influence on treatment.

3. Education: providing information about and an

explanation of the condition and its treatment so

that patients have some background information

about the condition, understand the implications

of the condition, and gain knowledge about the

nature of the condition. The result should be the

achievement of sense of control and the

development of a sense of independence.

4. Guidance: providing emotional support so that

patients can cope with their disorders.

In practice, these four categories overlap. However, it

is important that activities are split into the four

categories during patient education to make sure

goals are understood. The practical characteristics of

activities carried out in the four categories are

different, in terms of the time required, and the

educational aids and skills employed. Education is

more didactic and involves more sophisticated

educational aids than providing information. When a

patient shows signs of denial or non-acceptance of

the condition, current patient expectations become

important in providing guidance. It is recommended

that this type of situation is discussed by the

rehabilitation team as a whole.

Steps in the patient education plan

Van der Burgt and Verhulst76 provide an overview of

the different educational models used in different

healthcare sectors, which they have adapted for

specific use in paramedical healthcare. The authors

integrate the Attitude, Social Influence and Personal

Efficacy model77 with van Hoenen et al.’s78 Education

Ladder Model. The Attitude, Social Influence and

Personal Efficacy model is based on the assumption

that the patient’s willingness to change current

behavior is determined by a combination of attitude

(i.e., how the person himself or herself views the

behavioral changes), social influence (i.e., how others

view the behavioral changes), and the patient’s

perception of his or her own efficacy (i.e., whether

the patient expects the changes to be effective or

not). According to van Hoenen et al., the Education

Ladder Model comprises the following steps: being

open, understanding, wanting, and doing. For

application in paramedical healthcare practice, van

der Burgt and Verhulst added two more steps: being

able, and keeping on doing. An additional step was

added, in which the patient’s individual

characteristics were determined. Van der Burgt and

Verhulst approach patient education as a process in

which behavioral change is the final step. This final

step is not attainable if the other steps have not been

completed first. In total, six steps have to be

completed, as shown in Table 20.

It is important that attention is paid to any

difficulties the patient may have during each step in

the process. This approach provides information

about the reasons for any lack of trust in therapy.

Scientific research shows that most information is

provided during the second treatment session. In

patient education, it is important that information is

given in a balanced way throughout all treatment

sessions. This enables attention to be given

systematically to all aspects of patient education

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Supplement 1: Patient education plan

without the patient receiving too much information

at one time.79

During each step in patient education, it is important

that certain characteristics of the patient (i.e., personal

factors) are taken into consideration, such as:

• Locus of control: the degree of influence the

patient believes he or she has over the situation.

• Attribution: the factors that the patient believes

are having an influence on his or her life

situation.

• Coping: how the patient reacts to important

incidents in his or her life.

• Emotional state: the patient’s current emotional

state may temporarily prevent him or her being

open to new information. Emotional state may

also determine the way the patient deals with the

situation.

A professional approach to providing patient

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1. Being open

The physical therapist adapts the methods used to suit the perceptions, expectations, questions and

concerns of the patient. Important questions are: What are the patient’s main concerns? Which concerns

limit the patient’s ability to be open to new information and to behavioral change?

2. Understanding

Information must be presented in such a way that the patient will understand it and remember it. It is

important: not to provide too much information at one time; to decide which information is needed first

and what can be saved for later; to repeat the message (in another form, if necessary); and to use educational

aids, such as leaflets and videos. The physical therapist should monitor whether or not the patient has

understood the information provided.

3. Wanting

The physical therapist should determine what motivates the patient to act. Here it is important: to

determine how significant performing the exercises is to the patient; to find out whether individuals in the

patient’s environment encourage or discourage the patient; and to determine whether the patient feels that

he or she can influence the situation. The physical therapist offers support and provides information about

different options and alternatives. Achievable goals are set.

4. Being able

The patient must be able to perform the desired behavior. Functional skills must be practiced. It is important

that the physical therapist determines which practical problems the patient expects and decides how they

will be overcome.

5. Doing

This step covers the actual performance of the new behavior. The physical therapist makes a clear, concrete

and realistic agreement with the patient and sets concrete goals. If possible, positive feedback is given.

6. Keeping on doing

The patient must to continue to perform the learned behavior after treatment has ended. During therapy,

the physical therapist will discuss with the patient whether continuation is possible. It is important to know

what the possibilities are, what encourages the patient, and whether there are any short-term or long-term

gains. The physical therapist should determine what helps the patient get back on track after a ‘dip’ in

motivation.

Table 20. The six steps in patient education, as suggested by van der Burgt en Verhulst.(76)

education involves understanding all factors that can

have a positive or negative influence on bringing

about the desired behavioral change.

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I. Checklist of influenceable risk factors

Use of this risk factor checklist makes it possible to

identify risk factors that the patient can influence,

such as:

� physical inactivity;

� smoking;

� obesity;

� hypertension;

� lipid disorders, such as hypercholesterolemia and

hyperlipidemia;

� diabetes mellitus;

� depression;

� long-lasting stress.

Non-influenceable risk factors include hereditary

tendencies, age and sex.

II. Visual analogue scale for assessing activity level

Patients can use visual analogue scales to identify the

nature of the activities that have been most

problematic during the previous few weeks and to

estimate their duration and severity. The visual

analogue scale is a line measuring 0–100 mm. Visual

analogue scales can be used to evaluate a variety of

abstract concepts. Usually they are used for

measuring pain, but they can also be used to

determine the patient’s activity level.80,81 The visual

analogue scale provides a valid, reliable and

responsive way of measuring pain and the level of

activities of daily living. In practice, it can be

administered quickly.82,83 The Disability Rating

Index80 and the Verbal Rating Scale are similar

measuring instruments.

III. ‘Patient-specific complaint’ questionnaire81

This instrument can be used to determine the

patient’s functional status. In practice, the patient

selects between three and five of the most important

symptoms affecting physical activity. The

questionnaire is also used, for example, by patients

with rheumatism. To date, there is no information on

the reliability of this measurement method. However,

the questionnaire has been found to be responsive in

patients with back complaints.

IV. Dyspnea scale10

This instrument enables the observed level of

dyspnea to be estimated. Use of the New York Heart

Association (NYHA) cardiology scale is recommended

for quantifying the severity of dyspnea.85

V. Angina pectoris scale10

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Supplement 2: Measuring instruments

(To be filled in by the physical therapist)

Patient code :

Physical Therapist :

Date :

The aim of this scale is to obtain knowledge about how the patient performs various activities. After each

question, the patient must draw a vertical line on the horizontal line. If the vertical line is placed to the far

left, the patient has no difficulty in performing the activity. If placed to the far right, the patient has a lot of

difficulty. All questions must be answered.(86)

Climbing stairs (for example):

No difficulty whatsoever impossible

Table 21. Example of the visual analogue scale as used for assessing activity level.

VI. Borg scale

The Borg scale is a subjective index that is used to

assess the patient’s degree of exhaustion or reaction

to participating in activities. Use of the Borg scale

helps patients learn how to match their daily

activities to their current exercise capacity.85 In

practice, the patient indicates the level of exhaustion

and the extent of any dyspnea or chest pain

experienced during activity on a scale from 6 to 20.

Patients quickly learn how to apply the Borg scale to

their daily activities. For example, the patient can

learn how to exert himself or herself up to a certain

level during the performance of normal daily

activities or while participating in a sport.2 The Borg

scale score can be used in combination with heart

rate measurements made while resting, at maximum

exertion, and during recovery to provide feedback to

the patient on normal and abnormal symptoms.

VII. Six-minute walking test

Scientific research has been carried out on the use of

the six-minute walking test in patients with chronic

heart failure. The research shows that this test is safe

and applicable in these patients.88 Heijblom et al.89

concluded from their research that the six-minute

walking test provides reliable results in patients with

chronic heart failure and that the results correlate

with cardiac information.

VIII. The MET Method

The MET’s method can be used to estimate aerobic

capacity levels and makes it possible to evaluate the

metabolic demands of motor activities without

having to take into account the individual’s body

size. One MET’S unit is equal to the basic metabolic

level of the particular individual while resting. The

number of MET’s units needed to perform a specific

motor activity depends on the ratio of the amount of

energy used during the activity and that used in

resting state. The numbers of MET’s units needed to

perform a large range of activities have been

determined.90 For more details, see Supplement 3.

The energy used by the patient in resting state

corresponds to an oxygen uptake, or VO2, of 3.5 ml

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Level Description

+1 Mild, noticed by the patient but not others

+2 Mild, minor problems, noticed by observers

+3 Moderate problems, it is possible to continue activity

+4 Serious problems, patient must stop activity

Reproduced with permission from the American College of Sports Medicine. Source: American College of Sports Medicine guidelines for exercise

testing and prescription. Philadelphia, Baltimore: Lippincott William & Wilkins; ©2000.

Table 22. Dyspnea scale.

Level Description

1+ Light, hardly noticeable

2+ Moderate, uncomfortable

3+ Serious, very unpleasant

4+ Most horrific pain ever felt

Reproduced with permission from the American College of Sports Medicine. Source: American College of Sports Medicine guidelines for exercise

testing and prescription. Philadelphia, Baltimore: Lippincott William & Wilkins; ©2000.

Table 23. Angina pectoris scale

per kg per minute. By using the MET’s method, the

physical therapist can correct differences between the

patient’s actual and desired performance by using an

appropriate rehabilitation program.

• It must be remembered that the patient’s ability to

perform an activity not only depends on his or

her aerobic capacity level, but also on his or her

fears, movement efficiency, and motor behavior,

which are all equally important.

• The number of MET’s units quoted for each

activity is an average. It is important to take

different levels of skill into consideration. For

more information, see the Cardiac Rehabilitation

Guidelines 1995/1996.2

IX. The specific-activity scale91

X. Evaluating relaxation instruction2

It is of the utmost importance not only that the

patient receives relaxation instruction but also that

the effects of relaxation instruction on daily life are

evaluated. To date, no reliable measurement

instruments are available. Measurement methods 1

and 2a shown below are highly recommended. The

third measurement method requires more time but

results in more detailed information.

Three measuring instruments for evaluating

relaxation instruction:

In this method, the patient is asked to score the result

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Borg scale score Scale A (15 points) Scale B (15 points)

6 no feeling of exertion

7 extremely light extremely light

8

9 very light very light

10

11 fairly light light

12

13 fairly heavy fairly heavy

14

15 heavy heavy

16

17 very heavy very heavy

18

19 extremely heavy extremely heavy

20 maximum exertion

Table 24. Borg scale for estimating aerobic capacity on the basis of subjective observation. Sources: Borg (85,86)

and Pollock and Wilmore.(87)

Does the therapist have the impression that the patient has learned how to relax?

1 = yes, clearly: The patient can demonstrate the ability to carry out the instructions and, after doing so,

feels a positive benefit.

2 = not clearly: The patient can scarcely, or not at all, demonstrate the ability to carry out the instructions

and no change is experienced.

3 = no: The patient does not carry out the instructions and either no change or an unpleasant

change is experienced.

Method 1: Therapist’s opinion.

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1. Can you walk down a single flight of stairs (i.e. more than eight steps) without stopping?

2a. Can you carry something in your

arms while walking downstairs?

Or can you:

• work in the garden?

• dance (e.g., foxtrot)?

• walk at 6.4 km/h on a level

surface?

3a. Can you shower without having

to stop?

Or can you:

• make up a bed?

• hang up the laundry?

• walk at 4 km/h?

• take part in golf or bowling?

• mow the lawn?

2b. Can you carry a 12-kg weight up

the stairs?

Or can you:

• carry heavy objects (> 40 kg)?

• shovel snow or rake the garden?

• take part in an active recreation

such as skiing, squash, basketball,

soccer or handball?

• can you jog at 9 km/h?

3b. Do you have to stop to rest while

getting dressed and undressed?

Or do you have symptoms while:

• eating or standing?

• sitting down or lying?

YES

YES

YES

YESYES

NO

NO

NO

NO

NO

(CLASS 1) (CLASS 2) (CLASS 3) (CLASS 4)

Figure 4: The Specific Activity

Figure reproduced with permission from Circulation.(91) Source: Goldman L et al. Comparative reproducibility and validity of systems assessing

cardiovascular functional class: advantages of a new specific-activity scale. Circulation 1981;64(6):1227-34. Copyright 2000.

of following each relaxation instruction on a matrix.91 The matrix can be filled in before the exercise is

completed, as suggested in the Cardiac Rehabilitation Guidelines 1995/1996.2 Each instruction can be repeated

four times, after each of which the patient scores the result on the following dimensions: (C) completion, (F)

feeling, and (A) appreciation, as explained below. The higher the percentage of instructions that receive three

pluses, the better the patient’s ability to relax.

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1a. Have you found an exercise method that you can use yourself at home and is it one you practice

repeatedly?

2 = yes (completely adequate)

1 = yes (somewhat adequate)

0 = no

1b. If yes, which exercises do you prefer?

2a. Do the relaxation exercises you practice at home have an effect?

2 = yes (definitely)

1 = yes (to some extent)

0 = no

2b. Which effects do you notice?

3. Do you expect to continue relaxation exercises in the future?

2 = yes, certainly

1 = yes, perhaps

0 = no

A total score of 5 or 6 points indicates that relaxation exercises have had a positive influence; a total score of

0 or 1 indicates that there has been no effect.

Additional questions:

4. Do you feel the need to continue with relaxation exercises?

� yes, certainly

� yes, perhaps

� no

5. If yes, what type of instruction would you prefer?

� group

� individual

Method 2: Patient self-assessment.

2a. Questions asked at the end of treatment.

2b. Matrix method.

Method 3: Questionnaire on applying relaxation instruction.

This method was developed by van Dixhoorn to assess cardiac patients.92 The Dutch questionnaire evaluates

exercise frequency, relaxation while resting and during activities, and the positive and negative effects of

conscious relaxation. Scores on all these factors have a high level of reliability.93

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C (completion)

+ completed; easy, good

0 completed; unclear

- not completed

F (feeling)

+ clear experience

0 vague experience

- no experience

A (appreciation)

+ positive, felt good

0 mixed feelings

- negative, felt bad

Instruction C F A C F A C F A C F A

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Supplement 3: Metabolic equivalence of professional,

leisure and sporting activities

Table 25. Metabolic equivalence of a range of professional, leisure and sporting activities.

Power

(watt)

0

1.5

20

40

60

Metabolic

equivalen

ce (MET’s

units)

1

1.5

2

3

4

Daily activities

sitting quietly, eating

washing, shaving,

dressing, washing

dishes, writing

driving a car,

cooking, brushing

hair, moping the

floor, dusting

making beds,

hoovering, ironing,

waxing furniture,

grocery shopping,

gardening

showering, washing

windows, scrubbing

floors, walking down

stairs, mowing lawns

(electric mower),

weeding, trimming

plants, sexual

activities (own

partner)

Professional

activities

light office work

(e.g., typing),

handicraft

radio, TV or car

repair, working as a

bank teller, light

welding, working as

a doorman, light

janitorial work,

operating machinery,

working as a

seamstress or

shoemaker

factory work (< 20

kg), screwing in

screws, electrician’s

work, bricklaying,

painting, driving a

light truck, garage

work

Leisure activities

sleeping

watching TV, playing

cards, sewing

playing music (e.g.,

piano or guitar),

light wood work,

fishing, playing

billiards

bowling, playing golf

(using golf cart),

painting, flying in an

airplane, washing

the car, archery

slow dancing,

horseback riding

(horse walking)

Leisure and

sporting activities

standing up for 15

minutes

light cycling,

walking at 2.5 km/h

cycling at 8 km/h,

walking at 3–4

km/h, light

gymnastics

cycling at 10 km/h,

walking at 5 km/h,

playing volleyball,

table tennis,

badminton or golf,

swimming (breast

stroke)

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80-90

110

140

160-170

190–200

5

6

7

8

9

grocery shopping

with a heavy bag,

sexual activities (new

partner), digging in

the garden, mowing

the lawn (non-

electrical mower)

walking up stairs,

digging holes

shoveling powdery

snow, chopping

wood, walking in

gentle hills while

carrying less than 5

kg

shoveling wet snow,

cutting down trees,

scrubbing floors,

hillwalking with a

10-kg weight

hillwalking with a

10–20 kg weight at

one’s own tempo

heavy office work,

wall-papering, using

a wheelbarrow,

making footpaths,

mixed labor

involving digging, la-

ying stones or land-

scaping, feeding

animals

digging, plowing by

hand, using a

manual screwdriver,

transporting a load

of 20–29 kg, mixed

construction

activities, mining,

mechanical work

sawing wood,

railroad work,

transporting a load

of 30–38 kg

sawing by hand,

heavy digging using

a pick-axe, moving

40-kg weights,

cleaning out stables

working in high-

temperature ovens,

garden construction

work, throwing hay

bails

dancing, fishing in

fast-flowing water,

hunting, playing golf

(carrying own bag)

horseback riding

(galloping), low-

impact aerobics

fast dancing (e.g.,

swing)

high-impact aerobics

cross-country

running

cycling at 12 km/h,

walking at 5.5 km/h,

horseback riding

(trotting), playing

tennis doubles,

playing badminton,

rowing

walking at 6.5km/h,

playing tennis

singles, canoeing,

skiing, ice skating,

playing basketball or

non-competitive

soccer

cycling at 15 km/h,

walking at 7.5 km/h,

walking up gentle

hills, fencing, skiing

at 4–9 km/h

cycling at 19 km/h,

jogging at 8 km/h,

cross-country skiing

on the level, swim-

ming (front crawl) at

35 m/min,

horseback riding

(racing), playing

hockey

skipping at a rate of

70–80/min,

swimming (front

crawl) at a fast pace

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220

240

260–270

290

300-340

>350

10

11

12

13

14-15

>16

carrying a weight of

more than 30 kg,

hillwalking with a 8-

kg weight at 6 km/h

carrying a weight of

up to 50 kg

carrying 10 kg up a

16% slope at 6 km/h

working in high-

temperature ovens,

heavy steel work

cutting wood at a

high tempo using an

axe

judo

rugby

cycling at 23 km/h,

playing squash,

hand-ball or paddle

ball, rowing,


125/min, high-

jumping, swim-ming

(back stroke) at a

very fast pace


145/min, running at

10 km/h

cycling at 25 km/h,

running at 12 km/h,

swimming at 3 km/h

(i.e., 1 km in 20

minutes)

running at 15 km/h

running at 17 km/h

competitive sports,

cycle-racing,

running at 18 km/h,

using barbells

weighing more than

13 kg

Table reproduced with permission from Bohn Stafleu Van Loghum. Source: Vanhees L. Cardiac rehabilitation. In: Physical Therapy/Kinesiology

Therapy Year book 1999. Den Dekker J, Aufdemkampe G, van Ham I, Smits-Engelsman BCM, Vaes P (editors). Houten, the Netherlands: Bohn

Stafleu Van Loghum; 1999:66-95. © 2000.

52 V-08/2003/US

Supplement 4: Effects of medications on heart rate,

blood pressure, ECG responses and exercise capacity

Medications Heart Rate Blood Pressure ECG Exercise Capacity

ß-Blockers (including ↓ (R and E) ↓ (R and E) ↓ HR (R) ↑ in patients with angina;carvedilol, labetalol) ↓ ischemia (E) ↓ or ↔ in patients without

angina

II. Nitrates ↑ (R) ↓ (R) ↑ HR (R) ↑ in patients with angina;↑ or ↔ (E) ↓ or ↔ (E) ↑ or ↔ HR (E) ↔ in patients without angina

↓ ischemia (E) ↑ or ↔ in patients with con-gestive heartfailure (CHF)

III. Calcium channel blockersAmlodipine ↑ or ↔ HR (R and E)Felodipine ↓ ischemia (E) ↑ in patients with angina’Isradipine ↔ in patients without anginaNecardipine ↑ or ↔ (R and E)NifedipineNimodipineNisoldipine ↓ (R and E)Bepridil ↓ HR (R and E)Diltiazem ↓ (R and E) ↓ ischemia (E)Verapamil

IV. Digitalis ↓ in patients with ↔ (R and E) May produce nonspe- Improved only in patients withatrial fibrillation cific ST-T wave atrial fibrillation or inand possibly CHF change (R) patients with CHF

Not significantly altered May produce ST seg-in patients with sinus ment depression (E)rhythm

V. Diuretics ↔ (R and E) ↔ or ↓ (R and E) ↔ or PVCs (R) ↔,except possibly in patients ´ May cause PVCs and with CHF

“false positive” testresults if hypoka-laemia occurs

May cause PVCs in hy-pomangnesemia oc-curs (E)

VI. Vasodilators, nonadren- ↑ or ↔ (R and E) ↓ (R and E) ↑ or ↔ HR (R and E) ↔,except ↑ or ↔ in patients ergic with CHFACE inhibitors ↔ (R and E) ↓ (R and E) ↔ (R and E) ↔,except ↔ ↑ or ↔ in patients

with CHF�-Adrenergic blockers ↔ (R and E) ↓ (R and E) ↔ (R and E) ↔Antiadrenergic agents ↓ or ↔ (R and E) ↓ (R and E) ↓ or ↔ HR (R and E) ↔without selective blockade

VII. Antiarrhythmic agents All antiarrhythmic agents may cause new or worsened arrhtyhmias (proarrhythmic effect)Class I

Quinidine ↑ or ↔ (R and E) ? or ↔ (R) ↑ or ↔ HR (R) may ↔Disopyramide ↔ (E) May prolong QRS and

QT intervals (R)Quinidine may result in

“false negative” testresults (E)

Procainamide ↔ (R and E) ↔ (R and E) May prolong QRS and ↔QT intervals (R)

May result in “falsepositive” test results (E)

PhenytoinTocainide ↔ (R and E) ↔ (R and E) ↔ (R and E) ↔MexiletineFlecainideMoricizine ↔ (R and E) ↔ (R and E) May prolong QRS and ↔

QT intervals (R) ↔ (E)

Propafenone ↓ (R) ↔ (R and E) ↓ HR (R) ↔↓ or ↔ (E) ↓ or ↔ HR (E)

Class IIß-Blockers (see I.)

Class IIIAmiodarone ↓ (R and E) ↔ (R and E) ↓ HR (R) ↔

↔ (E)Class IV

Calcium Channel Blockers (see III.)

}

}

}

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Medications Heart Rate Blood Pressure ECG Exercise Capacity

VIII. Bronchodilators ↔ (R and E) ↔ (R and E) ↔ (R and E) Bronchodilators ↑ exercise capacity in patients limitedby Bronchospasm

Anticholinergic agents ↑ or ↔ (R and E) ↔ ↑ or ↔ HR May produce PVC’s

(R and E)Sympathomimetic agents ↑ or ↔ (R and E) ↑, ↔ or ↓ (R and E) ↑ or ↔ HR (R and E) ↔Cromolyn sodium ↔ (R and E) ↔ (R and E) ↔ (R and E) ↔Corticosteroids ↔ (R and E) ↔ (R and E) ↔ (R and E) ↔

IX. Hyperlipidemic agents Clofibrate may provoke arrhythmias, angina in patients with prior myo-cardial infarction

Nicotinic agents may ↓ BPAll other hyperlipidemic agents have no effect on HR, BP, and ECG

X. Psychotropic medicationsMinor tranquilizers May ↓ HR and BP by controlling anxiety: no other effectsAntidepressants ↑ or ↔ (R and E) ↓ or ↔ (R and E) Variable (R)

May result in ‘false positive’test results (E)

Major tranquilizers ↑ or ↔ (R and E) ↓ or ↔ (R and E) Variable (R)May result in ‘false positive’ or

‘false negative’ test results (E)Lithium ↔ (R and E) ↔ (R and E) May result in T wave changes

and arrhythmias (R and E)

XI. Nicotine ↑ or ↔ (R and E) ↑ (R and E) ↑ or ↔ HR ↔, except ↓ or ↔ inMay provoke ischemia, patients with anginaArrhythmias (R and E)

XII. Antihistamines ↔ (R and E) ↔ (R and E) ↔ (R and E) ↔

XIII. Cold medications with Effects similar to those described in sympathomimetic agents, ↔Sympathomimetic agents although magnitude of effects is usually smaller

XIV. Thyroid medications ↑ (R and E) ↑ (R and E) ↑ HR ↔, unless angina worsenedMay provoke arrhythmias

Only levothyroxine ↑ ischemia (R and E)

XV. Alcohol ↔ (R and E) Chronic use may May provoke ↔have role in ↑ BP arrhythmias (R and E)(R and E)

XVI. Hypoglycemic agents ↔ (R and E) ↔ (R and E) ↔ (R and E) ↔Insulin and oral agents

XVII. Dipyridamole ↔ (R and E) ↔ (R and E) ↔ (R and E) ↔

Anticoagulants ↔ (R and E) ↔ (R and E) ↔ (R and E) ↔

XIX. Antigout medications ↔ (R and E) ↔ (R and E) ↔ (R and E) ↔

XX. Antiplatelet medications ↔ (R and E) ↔ (R and E) ↔ (R and E) ↔

XXI. Pentoxyfiline ↔ (R and E) ↔ (R and E) ↔ (R and E) ↑ or ↔ in patients limitedby intermittent claudication

XXII. Caffeine Variable effects depending upon previous useVariable effects on exercise capacityMay provoke arrhythmias

XXIII. Anorexiants/diet pills ↑ or ↔ (R and E) ↑ or ↔ (R and E) ↑ or ↔ (R and E)

Key: ↑ = increase; ↔ = no effect; ↓ = decrease; R = rest; E = exercise; HR = heart rate; PVC’s = premature ventricular contractions

* ß-Blockers with ISA lower resting HR only slightly.

+ May provide or delay myocardial ischemia.

XVIII.

AbbreviationsECG electrocardiogram

HR-max maximum heart rate

HR-reserve heart rate reserve

ICIDH International Classification of Impairments, Disabilities and Handicaps

MET’s metabolic equivalent unit

VO2-max maximum oxygen uptake

GlossaryActivity Execution of a task or action by an individual

Borg scale Subjective scale that patients can use to indicate how they experience difference loads

Ergometer Standardized instrument for measuring work capacity

Functions Physiological functions of body systems (including psychological functions)

Impairment Problem with body function or structure, such as a significant deviation or loss

Limitation Difficulty in performing an activity; activities may be limited in nature, duration or

quality

Load The physical, mental or social demands on an individual

Load capacity The load an individual can handle

Muscular function Muscle strength, speed of movement, flexibility and coordination

Optimal functioning The level of functioning at which the patient can return to full participation in society

Participation Involvement in a life situation

Prevention The sum of all the measures taken to bring about behavioral change aimed at

preventing heart disease progression; in 1995, the (Dutch) Rehabilitation Commission

used the term secondary prevention, whereas epidemiologists refer to it as tertiary

prevention

Training Providing a physical exercise plan to force the body to adapt to a higher level of

functioning

Training capacity The individual’s scope for adapting his or her body to a higher level of functioning

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List of abbreviations, glossary and definitions

1 Revalidatie Commissie (NHS/NVVVC). Richtlijnen hartrevalidatie:

Deel I. ’s-Gravenhage, the Netherlands: Nederlandse

Hartstichting; 1995.

2 Revalidatie Commissie (NHS/NVVVC). Richtlijnen hartrevalidatie:

Deel II. ’s-Gravenhage, the Netherlands: Nederlandse


3 Hendriks HJM, Reitsma E, van Ettekoven H. Centrale richtlijnen

in de fysiotherapie. Ned Tijdschr Fysiother 1996;106:2-11.

4 Hendriks HJM, van Ettekoven H, Reitsma E, Verhoeven ALJ, van

der Wees PJ. Methode voor centrale richtlijnontwikkeling en

implementatie in de fysiotherapie. Amersfoort, the Netherlands:

KNGF/NPi/CBO; 1998.

5 Hendriks HJM, Bekkering GE, van Ettekoven H, Brandsma JW,

van der Wees PJ, de Bie RA. Development and implementation

of national practice guidelines: A prospect for continuous quality

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Cardiac Rehabilitation Guideline[1]

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