Cardiac Rehabilitation

Definition: It is a process of restoring an individual with a cardiac problem to maximum level of activity which is compatible with the functional capacity of his/her heart According to United States Public Health Services (USPHS), it is defined as a rehabilitation program that involves

          ·          Medical evaluation

          ·          Prescription of exercises

          ·          Education

          ·          Psychological counseling of a patient with cardiac diseases

Rehabilitation team

          ·          Cardiologist

          ·          Pulmonologist (physician)

          ·          Physiotherapist

          ·          Occupational therapist

          ·          Dietician

          ·          Medical social worker

          ·          Psychiatrist

Indications

          ·          MI

          ·          CABG

          ·          Valve repairs/replacements

          ·          Cardiac transplantation

          ·          Stable angina

          ·          Precutaneous angioplasty

Equipments

          ·          Radiotelemetry monitoring unit:

o   Oscilloscope

o   Strip chart recorder

o   Transmitters

          ·          Treadmill, rowing machines

          ·          Bicycle ergometer

          ·          Arm ergometer

          ·          Defibrillator, ECG

          ·          Mobile standing, mercury sphygmomanometer

          ·          Exercise bicycles

          ·          Stethoscope

          ·          Data board

          ·          File cabinet

          ·          Dumbbells and weight

          ·          Pulleys

Contraindications

          ·          Unstable postmyocardial infraction

          ·          Unstable angina

          ·          Resting systolic BP more than 200 mm of Hg and diastolic BP more than 110 mm of Hg

          ·          Orthostatic hypotension

          ·          Acute systemic illness or fever

          ·          Uncontrolled atrial or ventricular arrhythmias

          ·          Uncontrolled sinus tachycardia more than 120 beats/min

          ·          Recent embolism

          ·          Uncontrolled diabetes

          ·          Orthopedics problem

Aims

          ·          To reduce the frequency and severity of MI

          ·          To increase exercise tolerance

          ·          To improve CVS endurance

          ·          To provide psychological support

          ·          Identification and treatment of risk factors

          ·          To restore the patient confidence to lead a normal life

          ·          Early ambulation

Principles

          ·          Controlling effectively the symptoms of cardiac diseases

          ·          Modification of cardiac risk factors to prevent progression of IHD

          ·          To reduce risk factors of sudden cardiac disease

          ·          Identification and treatment of risk factors

          ·          Limitation of adverse effects of illness

Rehabilitation program

          ·          Acute phase (in patient program) 1-2 weeks

          ·          Convalescent phase (immediate post discharge period, 2-6 weeks)

          ·          Training phase (6-8 weeks)

          ·          Long terms maintenance

I. Acute phase

          ·          It is an in patient program from 1-2 weeks

          ·          Family education

          ·          To decrease psychological and emotional problems

          ·          Determining the effectiveness of medications in controlling abnormal ECG response to activity

Education

          ·          Case sheet reading

          ·          Blood pressure

          ·          Vital signs

          ·          Pulsation

          ·          ECG report

          ·          Any joint limitations

          ·          Check for clinical indication exercise program

This phase is divided into two levels

1. Low level exercises (in the bed)

          ·          It is from 3-6 days

          ·          The main aim is to prevent respiratory and circulatory complications, maintain ROM and muscle tone

          ·          Deep breathing exercise

          ·          Coughing techniques

          ·          Ankle toe movements

          ·          Hip and knee flexion, extension exercises

          ·          Upper limb shoulder, elbow and wrist movements

          ·          These exercises may be done passively, active assisted or actively depending on the patient condition

          ·          Initially, they are done for 5-10 mins/session for 2-4 times daily

2. Moderate level exercises

          ·          From 6-21 days

          ·          Continue with low level exercises

          ·          Sitting in chair

          ·          Walking in corridor

          ·          Encourage ADL (face washing, hand feeding, dressing)

          ·          Shoulder girdle exercise

          ·          Small distance walking around the bed

          ·          Gradually increasing the speed and distance of walking

          ·          Staircase climbing once a day

          ·          Low level treadmill walking

Interpretation

          ·          In most patient this level of activity will increase the heart beats up to 125-150 mm of Hg

          ·          Low level to moderate level exercise provides important information regarding the patient stability prognosis and medical therapy

          ·          If the patient is able to complete the exercises and self care activities without any significant CVS problem then the patient can be progress to monitor ambulation for e.g. initial distance walked is recorded (50-100 yards for the patient without complication)

II. Convalescent phase

          ·          The main goal is to maintain early mobilization and gradual increase in endurance for exercises at the same intensity

          ·          After the discharge from hospital (after 3 weeks – 6 weeks) the home management includes:

o   Advise to have rest for 8-10 hours during night and 1-2 hours during daytime

o   Avoid driving

o   Change of occupation may be necessary

o   Avoidance of risk factors and diet modification

o   Phase – I exercises are continued up to two weeks after discharge

o   After two weeks, outdoor activities can be started

o   Walking in the garden

o   Staircase climbing

o   Isotonic exercises

o   Upper and lower extremity free exercises

III. Training phase: (also write Bruce protocol in exercise testing)

          ·          This is the actual exercises training program

          ·          It begins with limited exercise tolerance testing to screen out clinical indication for exercises

          ·          It also helps to determine target heart rate.

          ·          Target heart rate (THR) as low as 60-70% of max heart rate results in effective training

          ·          Teach the patient use of Borg scale

o   6-7 – Very very light activities

o   8-9 – Very light

o   10-11 – Fairly light

o   12-13 – Somewhat hard

o   14-15 – Hard activities

o   16-17 – Very hard

o   18-19 – Very very hard

o   20 – Exhaustion

          ·          Each exercise program should have a warm up (10-15 min), training (20-60 mins) period and cool down period (5-15 mins)

          ·          Equipments such as treadmill, upper and lower ergometers, rowing machines, pulleys dumbbells, weight can be used

          ·          Aerobic exercise program is based on intensity, frequency, duration and mode of activity

          ·          The training program includes 3 sessions/weeks for 6-8 weeks

          ·          Dynamic, rhythmic and aerobic exercises are mainly done

          ·          Encourage sports and jogging

Objectives

          ·          Increase exercise capacity

          ·          Increase strength and endurance

          ·          Encourage physical activity

          ·          Teach the patient techniques of self monitored

          ·          Education on medications, blood pressure regulation, control of arrhythmias, atherosclerotic diseases

          ·          Relieve anxiety and depression

          ·          Teach personal health habits

Instructions before exercises

          ·          Do not eat heavy meal for 3 hours before exercise session

          ·          No smoking and alcoholism

          ·          To wear comfortable clothing

          ·          Any symptoms of pain, dyspnea, fatigue, sweating, soreness, calf muscle cramps should be informed before the exercises training begins

IV. Maintenance phase

          ·          It is the most important phase as the benefits of exercise training is last within a few weeks due to deconditioning

          ·          Exercise for at least twice a weeks for 30 min

          ·          ECG monitoring is not necessary

          ·          Emphasis is given on the muscles depending upon the lifestyle and occupation of the patient

          ·          These includes:

o   Walking

o   Bicycling

o   Jogging

o   Swimming

o   Sports activities

o   Resisted exercises using weights, dumbbells, pulleys