Download Cardiac rehabilitation II

Cardiac rehabilitation II
Dr/ Rehab F. Gwada
Contraindication to exercise program
 Unstable angina.
 Hypertension, ( B.P ≥ 200/100
at rest) .
 Moderate to severe aortic
stenosis.
 Orthostatic blood pressure drop
of > 20 mmHg.
 Uncontrolled ventricular or
atrial arrhythmia.
 Uncontrolled sinus tachycardia
(> 120 b/min.)
 Decompensated heart failure .
 S-T segment displacement
more than 3 mm.
 3rd degree of A - V block.
 Acute systemic illness.
 Acute pericarditis, myocarditis
or endocarditis.
 Thrombophlebitis.
 Recent embolism.
 Other disorder that may be
aggravated by exercise (Severe
orthopedic problems.
Effects of Exercise
Cardio protective
Effects
Antiatherosclerotic
Psychologic
Anti-
Anti-
Anti-
thrombotic
ischemic
arrhythmic
Myocardial O2
demand
Depression↓
Lipids
↓ adiposity
↑insulin sensitivity
↓ inflammation
Stress↓
↑Social support
Platelet adhesiveness
↓ fibrinogen
↓ blood viscosity
Coronary flow
↓ endothelial
dysfunction
↓ adrenergic activity
Risk Stratification
• American Association of
Cardiovascular &pulmonary
Rehabilitation
(AACVPR)
(Card Clin 2001; 19: 415-431)
– Lowest Risk
– Moderate Risk
– High Risk
• American Heart Association
(Circulation 2001; 104:1694-1740)
–
–
–
–
Class A
Class B
Class C
Class D
Risk Stratification for Exercise
according to AHA
Class D: unstable disease for whom exercise is
contraindicated.
Class C: moderate or high risk of cardiac complications (multiple myocardial
infarctions or cardiac arrest, NYHA class III or IV, Exercise capacity of < 6 METs, or
significant ischemia on the exercise test
Class B: established CHD that is clinically stable.
Overall low risk of cardiovascular complications
of vigorous exercise
Class A: apparently healthy and no
clinical evidence of increased
cardiovascular risk of exercise.
Risk Stratification for Exercise
according to (AACVPR)
LOW RISK
MODERATE
RISK
HIGH RISK
• if ALL low risk
factors are
present(indicated
for CR)
• if they meet neither
High Risk nor Low
Risk standards
• if ANY ONE OR
MORE of the high
risk factors are
present
Risk factors
Left ventricular
ejection fraction
Complex
ventricular
dysrhythmias
Ex. Induced cardiac
ischemia
hemodynamics
with exercise
Maximal functional
capacity
Clinical data
low
Moderate
high
<50%
40-50%
>40%
No(at rest or during
exercise)
at rest or with
exercise
Yes
no
at moderate level of ex.
5-6.9 METs
Or in recovery
flat or decreasing SBP
or HR with increase
load
Normal
at least 7.0 METs
-Uncomplicated MI,
CABG, angioplasty,
- Absence of CHF or
signs/symptomsindicating
post-event ischemia
NYHA class II
Yes
at low level of
ex.<5METs
Or in recovery
5-6.9 METs
less than 5.0 METs
NYHA class II MI or cardiac surgery
complicated by
cardiogenic shock, CHF,
and/or signs/symptoms
of post-procedure
ischemia
NYHA class III_IV
New York Heart Association Functional
Classification
NYHA
Class
Symptoms
I
Cardiac disease, but no symptoms and no limitation in
ordinary physical activity, e.g. no shortness of breath
when walking, climbing stairs etc.
II
Mild symptoms (mild shortness of breath and/or angina)
and slight limitation during ordinary activity.
III
Marked limitation in activity due to symptoms, even
during less-than-ordinary activity, e.g. walking short
distances (20–100 m).
Comfortable only at rest.
IV
Severe limitations. Experiences symptoms even while at
rest. Mostly bedbound patients.
Cardiac Rehab Phases
Phase III- maintenance program – long term-in
which physical fitness and additional risk-factor
reduction are emphasized -
Phase II- (supervised ambulatory outpatient
program spanning 6-12 weeks or more) exercise, risk
factor reduction,
reduce morbidity/mortality, improve function and
quality of life and build confidence
Phase 1: Inpatient Rehab - A program that delivers
preventive and rehabilitative services to
hospitalized patients following an index CVD event
Phase I Cardiac
Rehabilitation
Objectives of Phase I
Cardiac Rehabilitation
• 1) To initiate early physical therapy activities
to :
• a) Return to the activities of ADL.
• b) To offset the prolonged bed rest effects.
• c) To decrease anxiety and depression.
• d) To determine the effects of prescribed
medications during activities.
The deconditioning effects of
prolonged bed rest
 pulmonary complications: Decrease in Lung Volumes
and capacities & atelectasis
 Circulatory complications: DVT, Decreased in the
circulating blood volume, Orthostatic hypotension
 Musculoskeletal complications: Decrease in the
contractile strength of body musculature, joint
dysfunction
 Decrease in the physical work capacity.
Objectives of Phase I
Cardiac Rehabilitation
offset the prolonged bed rest effects
Mobilize the patient
soon
Prevent muscle
atrophy
Prevent blood clot
formation
Prevent pneumonia
Prevent lethargy
Objectives of Phase I
Cardiac Rehabilitation
• 2. Patient & Family Education
• To outline the course of cardiac rehabilitation
and plan for resumption of life at home.
• To modify risk factors of atherosclerosis as
dietary changes, stop smoking
• For Behavior modification as stress
management at home &work, creation of
hobbies - time out, conflict resolution skills
Education
Objectives of Phase I
Cardiac Rehabilitation
3- Provide A Safe Discharge To Home
Provide enough physical stamina to go
home and perform ADL’s
Reduce fear
Criteria for termination of inpatient
exercise programs:
 Excessive fatigue.
 Failure of the monitoring equipment.
 Peripheral circulatory insufficiency as :pallor, cyanosis, significant exertional dyspnea, ataxia, confusion,
nausea and headedness.
 Inappropriate bradycardia (drop of the heart rate more than 10
b/m with increase or no change in the exercise intensity).
 Hypertensive response to exercise.
 S.B.P raises about 50 mmHg from resting, more than that  is
hypertensive response.
 The D.B.P raises very little about 15 mmHg from resting, more than
that up to 20 mmHg is considered critical.
 Exercises induced hypotension (drop of S.B.P more than 20
mmHg).
Cont.
 Exercise induced angina.
 Exercise induced left bundle branch block.
 Exercise - induced 2nd or 3rd degree of A-V block.
 S-T segment displacement about 3 mm or
downsloping from rest.
 Ventricular tachycardia:
Three or more consecutive premature ventricular
contractions.
Multifocal premature ventricular contractions.
http://www.youtube.com/watch?v=s7cJyoaM-Yg
Principles of Training
 The exercises in phase I should be Low intensity,
gradually increasing the metabolic cost, safe and
of dynamic nature.
 Activities are described in METs or metabolic
equivalents.
METs : measures energy requirement for basal
homeostasis, when the subject is in the resting
position (a wake or sitting position) METs = 3.5:4 ml of
O2/Kg/minute
 Most inpatient programs begin with activities 2-3
METs and progress to 5 - METs before discharge
Specific exercise progressions within
program
 Passive to active Resistive ex.
 Distal to intermediate to proximal joint exercises.
 From extremities to trunk.
 From supine to sitting then standing.
 Progressive increase in the ambulation distance then
stair climbing (down) and then progression to stair up.
 Initially, the patient does the ex for short duration and
high frequency (several times) per day until the
patient's condition improves and vice versa will occur.
For the post surgical patients
Graduated mobilization is initiated early in
acute units.
Activities in the first 24-48 are usually
included breathing ex., ARM of arm\leg, and
limited self care activities.
 Activity progression is faster and the patient
works at slightly higher intensity.
Emphasis is placed on the upper extremity
R.O.M to counteract shoulder and chest pain
Monitoring exercise responses:
In phase I:
 HR
 BP
 ECG
 Rating of Perceived
exertion
(R.P.E);(Handout I
)
 Signs and symptoms of
exertional intolerance:
1) Excessive fatigue.
2) Persistent dyspnea.
3) Severe leg claudication.
4) Ataxia.
5) Anginal pain.
6) Dizziness or confusion.
7) Pallor or cold sweating.
Exercise prescription
•
•
•
•
Frequency =2-3times/day
Intensity :
resting HR+20 bpm post MI
resting HR+30 bpm post
CAPG
• RPE<11 or to individual
tolerance
• Timing: 5-20 mins
• Type of ex.:
• Sitting/standing
functional activity ;
ROM ex; walking ;
circulatory ex. Breathing
ex. ……..act
Phase 1.5: post discharge phase
 This phase begins after the patient returns home from the hospital.
 Better understanding of how to keep the heart healthy and strong is
emphasized. Team members work with patients and family
members.
 Team members check the patient's medical status and continuing
recovery; they should offer reassurance as the patient regains
health and strength.
 This phase of recovery includes low-level exercise and physical
activity, as well as instruction regarding changes for the resumption
of an active and satisfying lifestyle.
 Risk reduction strategies are emphasized again.
 After 2-6 weeks of recovery at home depend on local protocols and
patient’s fitness , the patient is ready to start phase 2 of his/her
cardiac rehabilitation.
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