Cardiac Rehabilitation
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Transcript of Cardiac Rehabilitation
CARDIAC REHABILITATION
Prepared By: Floriza P. de Leon
GOALS OF CARDIAC REHABILITATION Increasing functional capacity of the
patient Changing natural history of the disease
to reduce morbidity and mortality
EPIDEMIOLOGY Leading cause of morbidity and
mortality in the adult population in the US
CAD is the number one cause of mortality in men age 45 yrs old and in women aged 75 and older
RISK FACTORS FOR CADIRREVERSIBLE RISKS REVERSIBLE RISKS
Male gender Cigarrete Smoking
Past history of CAD Hypertension
Family History ofPremature CAD (before age 55 year in a parent orSibling
Low HDL Cholesterol (<0.9 mmmol/L (200 mg/dL))
Past history of occlusive PVD High Lipoprotein A
Past history of CVD Abdominal Obesity
Hypertriglyceridemia (>2.8 mmol/L (250 mg/dL))
Hyperinsulinemia
Diabetes Mellitus
Sedentary Lifestyle
EXERCISE PHYSIOLOGYPT needs to understand the cardiac
response to exercise and the effects of aerobic training in order to design a safe and effective rehabilitation program for any given patient
EXERCISE PHYSIOLOGYAerobic Capacity Physiological term used to measure the
work capacity of an individual Represented by the maximum oxygen
consumption (VO2 Max)
Table shows relationship between O2 and intensity of work being performed
EXERCISE PHYSIOLOGYCardiac Output Increases with increasing work In early exercise, CO increases due to
augmented stroke volume via the Frank-starling mechanism
Relationship between CO and oxygen consumption
EXERCISE PHYSIOLOGYHeart Rate Increases in a linear manner when
plotted against the VOS or other measures of physical work
Limited by the person’s age Even with regular exercise there is a
linear decrease in the maximum HR with age
MHR = 220 - age
EXERCISE PHYSIOLOGYStroke Volume Represents the quantity of blood
pumped with each heartbeat Major determinant of SV is the diastoling
filling volume, which is inversely related to the HR
EXERCISE PHYSIOLOGYMyocardial Oxygen Consumption Actual oxygen consumption of the heart as opposed
to the VO2, which represents the oxygen consumption of the whole body (mainly due to skeletal mm)
Angina threshold: point where the myocardial oxygen demand exceeds the ability of coronary circulation to meet the demand
Activities performed with the LE as opposed to LE generate a higher MVO2
Activities performed supine as opposed to upright generate a higher MVO2 at low intensities and a lower MVO2 at higher intensities
Activities that have an isometric component generate a higher MVO2, than a similar activity at the same VO2, without an isometric component
EXERCISE PHYSIOLOGYMyocardial Oxygen Consumption
UE
AEROBIC TRAININGRefers to an exercise program that involves
dynamic exercise with large mm groups and of a sufficient intensity, duration, and frequency to alter the cardiopulmonary response to exercise
Major contributors to Physical Fitness:1. Strength2. Endurance3. Coordination4. Flexibility5. Speed 6. Power
PRINCIPLES OF AEROBIC TRAINING For cardiopulmonary patient, cardiorespiratory
endurance is emphasized for maintenance of health and rehabilitation of individuals
Aerobic activity- Rhythmical- Sustained for prolonged periods of time- Uses large mm group High impact activities (running and jumping) are not
generally recommended for promoting cardiorespiratory endurance because of the increased risk of injury
Low impact/non weight bearing activities have a lower incidence of injury and are generally recommended for cardiopulmonary px
As in all types of training, to be most effective, it must be specific
DETERMINANTS OF AN AEROBIC EXERCISE PROGRAM INTENSITY DURATION FREQUENCY MODE
INTENSITY Overload principle Specificity principle Quantifying intensity
Heart Rate VO2 Max Rating of Perceived Exertion
Overload- Stress on an organism is greater than the one
regularly encountered during daily life- Exercise must be above the training stimulus
threshold for adaptation to occur- Stimulus threshold stimulus that elicits a training or
conditioning response
Specificity - Adaptations in metabolic and physiologic systems depending on the imposed d
INTENSITYHeart Rate Maximum Heart Rate
220-age Karvonens Formula
THR= RHR + (MHR - RHR) (60-80%)Deconditioned – 40-50%Cardiopulmonary disease – 40 – 60%Healthy individuals – 60 – 80%
For UE workMHR = 220 – age - 11
INTENSITYRating of Perceived Exertion Useful for patients with heart rate
suppressors e.g. Beta blockers
Original Revised
INTENSITYRating of Perceived Exertion Original version ( 6-20 )
Remember only the ODD numbers
12- 60% HR range
13- 65 – 70% HR range 16- 85% HR range
7 – VERY VERY9 - VERY11 - LIGHT13 – SOMEWHAT HARD 15 - HARD17 - VERY 19 – VERY VERY
INTENSITYRating of Perceived Exertion Revised version ( 0-10 )0 – nothing at all0.5 – VERY VERY (just noticeable)1- VERY2 - WEAK3 – MODERATE4 - SOME - WHAT5 - STRONG (heavy)7 – VERY10 VERY VERY
INTENSITY Exercising at a high intensity elicits a
greater improvement of the VO2 max
The higher the intensity, the longer the exercise intervals, the faster the training effect
Exercising at high intensities increases the risk for CV complications and musculoskeletal injury
INTENSITYGoal Achievement of intensity 60-90% MHR
OR 50-85% VO2 Max Beginners: 50-60% VO2 Max Average: 60-70% VO2 Max Fit: 75-85% VO2 Max Maximum oxygen consumption (VO2
Max) BEST measure of exercise intensity
DURATIONDependent on Total work performed Intensity Frequency Fitness level
HIGH intensity SHORT duration
LOW intensity LONG duration
DURATION Poor functional capacity
5 - 10 minutes Beginners
10 - 20 minutes Average
15 - 45 minutes Fit
30 – 60 minutes
DURATIONModerate to Minimal intensity 20 – 30 minutesHigh intensity 10 – 15 minutes
Exercise longer than 45 minutes increases the risk for musculoskeletal complications
FREQUENCY Dependent on the health and age of the
individual
LOW intensity HIGH frequency
HIGH intensity LOW frequency
FREQUENCY POOR
Daily Beginner
Every other day Optimal frequency
3-4 times a week 2 times a week does not generally evoke CV
changes for well population Increase in frequency beyond optimal range,
increases risk for musculoskeletal complications
30-45 mins 3x a week protects against CV disorders
FREQUENCY3 – 5 sessions / week Greater than 5 METS
Daily or multiple daily sessions Less than 5 METS
MODE Large muscles Rhythmic Long duration Lower extremity versus Upper extremity
exercise
MODELower extremity Upper extremity
Larger muscle mass Higher VO2 max HR increases linearly
as a function of increased workload / VO2 max
HR plateaus just before maximal VO2 max
Systolic BP increases Diastolic BP remains
the same
Smaller muscle mass
Lower VO2 max than LE exercise
HR higher Stroke volume
lower Systolic AND
Diastolic BP higher
Warm-upAerobic exercise period
Cool-down
EXERCISE PROGRAM
WARM-UP Muscle temperature NCV Vasodilation Adaptation of respiratory centers Venous return
WARM-UP 2 components Graduated low intensity warm-up (5-10
minutes) of total body movementHR increase 20bpm
Flexibility exercises
WARM-UP Should NOT cause fatigue Decreases
Risk for ECG changes (arrythmias)Musculoskeletal disorder
AEROBIC EXERCISE Continuous Interval Circuit Circuit-interval
CONTINUOUS Submaximal and sustained Achievement of the steady state Duration; 20 – 60 minutes Intensity: 60 – 85% VO2 Max Most effective in increasing endurance
for healthy individuals
CONTINUOUSTwo types: Intermediate Slow Distance
20-60 minutes continuous exerciseMost commonly used for managing weight
Long Slow DistanceLonger than 60 minutes for athletic trainingProvided after 6months of successful ISD
INTERVAL Designed to improve strength and
power more than endurance Incorporates recovery after continual
exercise Useful for beginners Work – rest - work
INTERVAL Exercise period is followed by rest
intervalRest relief (Passive recovery)Work relief (Active recovery)
Work recovery ratio1:1 to 1:5
1 : 1.5 work interval allows the succeeding exercise interval to begin before recovery is complete
INTERVALAerobic Interval Training For patients with poor CV fitness 2-15 minutes at 50-80% functional
capacity
Anaerobic Interval Training For patients with high CV fitness 30 sec – 4 minutes at 85-100%
functional capacity Usually results in greater lactic acid
concentrations
CIRCUIT Series of exercise activities Several exercise modes Improves both strength and endurance
CIRCUIT INTERVAL Stresses both aerobic and anerobic
systems Delays the need for glycolysis and lactic
acid production
COOL-DOWN Prevents
Pooling of bloodPost-exercise syncope Ischemia, arrythmias, and other
complications Increases oxidation of metabolic waste Length of cool-down phase proportional
to intensity and length of the conditioning phase
Typical 30-40 aerobic exercise periodWarrants a 5-10 minute cool-down phase
CORONARY ARTERY DISEASE In-patient phase Out-patient phase Maintenance phase
PHASE I (IN-PATIENT PHASE/ICU/CCU PHASE) In px groups: uncomplicated myocardial
infarctions, post-operative CV, pulmonary, PVD and any others that may benefit from such services while in the hospital
Includes supervised ambulatory therapy Staff to px ratio – 1:1 ECG monitoring equipment must be available for
determining appropriate exercise response and an emergence team should be available on the premises
1-2 METS in CCU; 3-4 METS in ward Begins in the CCU once the px is medically stable 1-2 wks in duration
PHASE I (IN-PATIENT PHASE/ICU/CCU PHASE) Goals: Provide additional medical surveillance To return px to activities of daily living To offset the deleterious physiological
and psychological effects of bed rest Prepare px and families for stages of
cardiac rehabilitation and life at home that will follow
PHASE I (IN-PATIENT PHASE/ICU/CCU PHASE) Role of PT: Evaluating the physiological response to
exercise Supervising the exercise and ambulation Accurately charting and recording
patients progress and responses preparing the patient for discharge and remaining phases of rehabilitation program
PHASE I (IN-PATIENT PHASE/ICU/CCU PHASE) In-Patient Exercise Prescription Methods1-3 Days post MI: low intensity activities (2-3 METS) Reduce the risk of thrombi Self care activities, selected arm and leg exercises Lying to sitting to standing Orthostatic stress Protective chair posture (high back rest and low seat) which reduces
cardiac output by 10% compared to supine Increased duration of sitting Use of bedside commode which loads the heart with only up to 3
METS unlike bed pan which increases load up to 4.7 METS PROM – 1.5 METS only AROM – 1.7 METS only for the UE and 2 METS only for the LE 3-5 days Post MI Walking, treadmill, cycle ergometer 5-10 mins of exercise session Most of the time exercise intensity is low and session so short that
warm up and cool down are not applicable Calisthenics, self-care, early ambulation around the bed
PHASE I (IN-PATIENT PHASE/ICU/CCU PHASE) Stress Test for Prognostic Stratification Should be submaximal Pxs with more than 40 years of age;
limit HR to 130 bpm and workload to 5 METS
Pxs with less than 40 years of age; limit HR to 140 bpm and workload to 7 METS
PHASE II (OUT-PATIENT) Should begin immediately after dismissal from the
hospital: 2nd or 3rd wk after MI or open heart surgery Important time for continued medical surveillance as well
as beginning intervention programs for lifestyle changes Outpatient versus home or community based facility 4-7 METS Highly supervised 0-3 mos in duration Goals: Improve functional or exercise capacity Enhance cardiac functions Promote early return to normal activity Promote positive lifestyle changes Decrease risk factors
PHASE II (OUT-PATIENT) Activities: Interval conditioning Circuit conditioning Circuit interval conditioning Continuous training Intensity: with functional capacity of greater than 5 METS>
prescriptive techniques using heart rate and RPE Frequency: 3-4 sessions per day Duration: 10-15 mins and progress to 30-60 mins Progression rate: 1 MET/2 wks Discharge planning: Aerobic capacity of at least 5 METS Px’s ability to self monitor his or her exercise program Stability of px(absence of contraindication to exercise) Psychologic and emotional status of the px
PHASE II (OUT-PATIENT) Stress Testing Should be maximal Treadmill or bicycle ergometer
Criteria for Terminating Stress Test Px is exhausted Px has dyspnea Px is experiencing cramps(leg fatigue) Px has pain over LE mm Excessive chess pain Circulatory insufficiency ECG changes
PHASE II (OUT-PATIENT) Contraindications for Stress Testing Acute MI Unstable angina pectoris Acute myocarditis/pericarditis Coronary artery lesion Stenosis HPN (225/110 mm Hg) Acute systemic illness Congestive heart failure
PHASEIII (COMMUNITY EX PROGRAM PHYSICAL CONDITIONING/MAINTENANCE) Participants: 6-12 wks post hospital discharge Clinically stable or decrease angina Medically controlled dysrhythmias Knowledge of symptoms Ability to self-regulate their exercise Minimum functional capacity of 5 METS During the 1st 3-6 mos Intensity is 50-85% of functional capacity Duration: 45 mins Frequency: 3-4 sessions/wk
PHASEIII (COMMUNITY EX PROGRAM PHYSICAL CONDITIONING/MAINTENANCE)
Goals: Maintenance of function Compliance of exercise program Risk factor education and modification Promote long term fitness Physical Training: includes recreational
activities
PHASEIII (COMMUNITY EX PROGRAM PHYSICAL CONDITIONING/MAINTENANCE Physiological Effects: Decreased HR Increased SV Decreased CO at each submaximal work level Increased ability to extract O2 from the blood Increased size and number of mitochondria Increased myoglobin Decreased O2 utilization by myocardial cells Improved contractility of heart mm
PHASEIII (COMMUNITY EX PROGRAM PHYSICAL CONDITIONING/MAINTENANCE
Clinical Effects: HR decreases at rest Workload performed at a maximal level
would be increased Heavier workload, increased endurance Criteria for discharge: same as Phase II,
with the functional capacity of individual, consistent with vocational and recreational requirements/goals of the individual
SEX Those who can tolerate 5 METS or more Orgasm expenditure = 5 METS Px who can climb 2 flights of stairs can
return to sexual activities