Cardiac Rehabilitation

PT intervention for Patient w/ CAD
GOALS
1. Aerobic capacity is increased

2. Ability to perform physical tasks related to selfcare, home management, community and work
integration or reintegration, and leisure
activities is increased.
3. Physiological response to increased oxygen
demand is improved.
4. Strength, power and endurance are increased.
5. Symptoms associated with increased oxygen
demand are decreased.

GENERAL GOALS
6. Ability to recognize the recurrence is

increased, and intervention is sought in a
timely manner.
7. Risk of recurrence is reduced.
8. Behaviors that foster healthy habit,
wellness, and prevention are acquired.
9. Decision making is enhanced regarding
health of patient and use of home care
resources by px, family, significant others
& caregiver.

Traditional Acute Cardiac rehab. follows
px while recovering.
Provide hemodynamic monitoring of
progressive activity.
Discharge guidelines
Education
And information regading outpatient referral
Px w/ cardiac Hx may have PT need.

Adjust care accordingly

Px w/ CAD may not have symptoms of
ischemia
Size of injury
Medication
Increased systemic O2 consumption =

increased myocardial O2 consumption.
Whats past has past move on?
American Association of Cardiovascular & Pulmonary

Rehabilitation
American College of Rehabilitation
High Risk
Severely depressed LV function (EF<30%)
Resting complex ventricular arrythmias
PVCs appearing or increasing w/ exercise
Exertional hypotension (>15mmHg in SBP
during exercise.
Recent MI (<6 months) complicated by serious
vent arrythmias CHF, cardiogenic shock.
Exercise-induced ST-segment depression >2mm
Survivor of cardiac arrest
Exercise Prescription
Exercise Tolerance Test (ETT)
Graded Exercise Test (GXT)
Purpose:
To determine physiological responses during
a measured exercise stress ( increasing
workloads).
Allows the determination of functional
exercise capacity of an individual.
Purpose:
Serves as a basis for exercise prescription.
Symptoms-limited ETT is typically administered
prior to start of Phase II outpatient cardiac
rehabilitation program and following cardiac
rehab. As an outcome measure.
Used as a screening measure for CAD in
asymptomatic individuals.
ETT with radionuclide perfusion: assist in Dx of
suspected or established cardiovascular dis.
Contraindication
to
Absolute Contraindication to
Exercise Tolerance Test (ETT) / (GXT)
A recent significant change in the resting ECG

suggesting infarction or other acute cardiac
event.
Recent complicated MI (unless px is stable &
pain free)
Unstable angina
Uncontrolled ventricular arrythmia
Uncontrolled atrial arrythmia that compromises
cardiac function.
Third degree AV block w/o pacemaker.
Acute CHF
Absolute Contraindication to
Severe aortic stenosis

Suspected or known dissecting aneurysm
Active or suspected myocarditis or pericarditis
Thrombophlebitis or intracardiac thrombi
Recent systemic or pulmonary embolus
Acute infections
Significant emotional distress (psychosis)
Relative Contraindication to
Resting DBP > 115 mmHg or resting SBP >200
mmHg
Moderate valvular heart disease
Known electrolyte abnormalities
Fixed-rate pacemaker
Frequent or complex ventricular ectopy
Ventricular aneurysm
Relative Contraindication to
Uncontrolled metabolic disease
Chronic infectious disease (hepa. AIDS)
Neuromuscular, musculoskeletal or rheumatoid
DO
Advanced or complicated pregnancy
How to do it?
Cycle ergometer
Treadmill
Treadmill
Bruce
Naughton
Balke-Ware and Ware
Treadmill
Bruce
Naughton
Begin at 1.7 mph, 10% grade;

increase speed & grade every 3
min.
Begin at 1.2 mph, 0% grade;
increase speed & grade 3%
every 2 min.
Balke-Ware and Begin at constant speed of 3.3

mph; increase grade 3.5%
Ware
every min.
Treadmill
When to stop?
Maximal ETT
Defined by target end-point Heart Rate
Submaximal ETT
Symptom limited
Used to evaluate early recovery of patients after
MI, coronary bypass, or coronary angioplasty
Maximal SOB
A fall in PaO2 of > 20mmHg or a PaO2 <55
mmHg
A rise in PaCO2 of >10 mmHg or >65 mmHg
Cardiac ischemia or arrythmias
Symptom of fatigue
in DBP of 20 mmHg, Systolic hypertension
>250mmHg, in BP w/ increasing work loads
Leg pain
Total fatigue
Signs of insuficient CO
Reaching a ventilatory maximum
You have a positive ETT !

Indicates that there is a point at w/c the myocardial
O2 supply is inadequate to meet the myocardial O2
demand.
Positive for ischemia
You have a negative ETT !

Indicates that at every tested physiological
workload there is a balance between O2 supply and
demand.
The Patient have an ankle fracture of 3

weeks duration!
The Patient have an ankle fracture of 3

weeks duration!
Use Pharmacological Stress test..
Persantine thallium test
Causes Vasodilation
Limitation in the amount of vasodilation
s/sx below which an upper limit
For exercise should be set. (ACSM)
Onset of angina or other symptoms of
cardiovascular insufficiency
Plateau or decreased in SBP, SBP >240 mm Hg, or
DBP >110 mmHg
>1mm ST-segment displacement, horizontal or
downsloping.
Radionuclide evidence of LV dysfunction or onset
of moderate to severe wall motion abnormalities
during exertion.
s/sx below which an upper limit
For exercise should be set. (ACSM)
Increased frequency of ventricular arrythmias.
Other significant ECG disturbances, 20 or 30 AV
block, atrial fibrillation, SVT, complex ventricular
ectopy, ect..
Other s/sx of intolerance to exercise
Peak exercise HR should be approximately 10 pbm
below the HR associated with any of the above
criteria.
Excluded from exercise Training: In/out px (ACSM)

Unstable angina
Symptomatic heart failure
Uncontrolled arrythmias
Moderate to severe aortic stenosis
Uncontrolled DM
Acute systemic illness or fever
Uncontrolled tachycardia (HR>100 bpm) (>120)
Resting SBP => 200 mmHg; DBP =>110 mmHg
Excluded from exercise Training:

Thrombophlebitis
Uncontrolled atrial or ventricular dysrhythmias
Unconpensated CHF
3rd degree A-V block (w/o pacemaker)
Active pericarditis or myocarditis
Recent embolism
Excluded from exercise Training:

Resting ST segment displacement >2mm
Uncontrolled diabetes (resting glucose > 400
mg/dL)
Severe orthoperic problems that would prohibit
exercise
Other metabolic problems, such as acute
thyroiditis, hyperkalemia, hypovolemia, ect..
be
FITT
Frequency
Dependent upon intensity & duration
The lower the intensity, the shorter the
duration = the greater the frequency.
Average: 3-5 sessions/week for exercise
at moderate intensities and duration, >5
METs
Daily or multiple sessions for low intensity,
<5METs
Frequency
Most consistent benefit w/ exercise

training : at least 3x per week for 12 or
more weeks.
Intensity
Heart Rate
Borgs Rate of Perceived
exertion
Intensity
Heart Rate
Percentage of max. HR achieved on ETT

w/o ETT: 220 age
UE: 220 age 11
w/ CAD: supervised ETT should be done
70 85 % of HR
Deconditioned: 50 60% of HR
Intensity
Heart Rate
Karvonens formula
Heart Rate Reserve
THRR=[(HRmax - HRrest) x 0.4 and 0.8] +
HRrest
Intensity
Heart Rate
Beta blocker or calcium channel blocker
Affects ability of HR to rise in response to exercise
Pacemaker:
Affects ability of HR to rise in response to exercise
Environmental extremes, heavy arm work,

isometric exercise, and valsalva may affect HR
and BP response.
Intensity
Rate of Perceived Exertion
Intensity
Rate of Perceived Exertion
RPE of 12-13 60% of HR range

RPE of 16 85% of HR range
Useful if beta-blocker or other HR
suppresser are used
Limitations:
Individual w/ psychological problems
Unfamiliarity w/ RPE scale
Intensity
METs
40-85% of functional capacity (max. METs)
achieved in ETT.
Limitations:
w/ high intensity exercise (jogging), need to adopt a
discontinuous work pattern: walk 5 min, jog 3 min. to
achieve the desired intensity.
Varying skill level or stress of competition may affect
the know metabolic cost of an activity.
Environmental stresses: heat, cold, high humidity,
altitude, wind, changes in terrain. May affect known
METs
Time
GOAL: 30 to 40 minutes of aerobic exercise with an
additional 5 to minutes of warm-up and an adequate
cool-down.
Deconditioned: Interval work, rests every 5 minutes.
The higher the intensity = the shorter the duration
Average: 20 30 minutes for moderate intensity
exercise.
Severely compromised: multiple, short exercises
Type
Good News?
Patient has the opportunity to try and
experience a wide variety of equipment.
Best equipment?
The one they enjoy and will use
Progression
Modify exercise if:
HR is lower than target HR for a given exercise
intensity
RPE is lower (exercise is perceived as easier) for a
given exercise.
Symptoms of ischemia do not appear at a given
exercise intensity.
Rate of progression depends on age, health,

status, functional capacity, personal goals,
preference.
NOTE: Duration is increased FIRST, then
intensity
Cardiac Rehab. - MI
Phase I : Inpatient component
Phase II : Out patient
Exercise Training period
Phase III
:Maintenance
Cardiac Rehab. - MI
When to start aerobic & strength
training?
After the ETT result
When can ETT be given after MI ?
After MI, wound healing begin.
Wound is stable within 4 to 6 weeks.
ETT is within 4 to 6 weeks
Cardiac Rehab. - MI
Hospital stay is 3 to 5 days

Role of PT:
Monitor activity tolerance
Prepare for D/C
Educate the patient to recognize adverse
symptoms with activity
Support risk factor modification techniques
Provide emotional support
And collaborate with other team member
GOAL: 20 to 30 minutes of ambulation 1-2

min/day at 4 6 weeks post MI.
Cardiac Rehab. - MI
VS monitoring : before, after, if possible during

activity.
Intensity:
Low intensity
Borgs Fairly light range
HR increase of 10 20 bpm (depending on Med)
2 3 METs (D/C at 3-5 METs)
1 to 2 METs = HR by 10 to 20 bpm if w/t

(uncommon)
beta blocker
USE RPE
Cardiac Rehab. - MI
What if the px. is on Beta-blocker
and the HR increased by 20 bpm
during low level in-patient activity
?
Inadequate medication
Or, activity is higher than appropriate
Cardiac Rehab. - MI
What if HR or BP has decreased ?
w/ or w/o med evaluate for Arrythmia

Inpatient Cardiac Rehab. Program
1
1-1.5 CCU- Essentially bedrest
1.5-2 Sitting-Limited room ambulation
2-2.5 Room-Limited hall ambulation
2.5-3 Progressive Hall ambulation
3-4
Progressive Hall ambulation
4-5
Stair climbing
Cardiac Rehab. - MI
Home Exercise Program (HEP)
Two more important concept prior to D/C
1. Symptom Recognition
2. Appropriate activity guidelines
Consider environmental condition
Cardiac Rehab. - MI
Can I buy a an equipment I saw on
TV so I can continue my exercise
at home?
Px should be monitored on similar

equipment for safety before doing the
exercise at home.
This is NOT the time to for a patient to try a
new type of exercise modality.
Walking: exercise of choice ease and
familiarity
Cardiac Rehab. - MI
Phase II : Out patient
Exercise /Activity goals & outcome
1. Improve functional capacity

2. Progress toward full resumption of ADL,
habitual & occupational activities.
3. Promote risk factor modification, counseling
as to lifestyle changes.
4. Encourage activity pacing, energy
conservation; stress importance of taking
proper rest period
Cardiac Rehab. - MI
Phase II: Out patient
Patient commonly undergo a symptom-limited

maximal stress test (ETT) at 4 6 weeks post
MI.
(-) ETT ?
Use 70 80% or 65 80% of HRmax
(+) ETT ?
MVO2 below the patient ischemic

threshold
Clinical measure of MVO2 is RPP
Do NOT exceed 90% of patients RPP
Cardiac Rehab. - MI
Phase II
: Out patient
Outpatient Program : ave. 36 visit (3/wk x

12wk)
Frequency: 3 4 sessions/week
Intensity : 5METs (needed for most ADL) to 9
METs
Time : 30 60 min w/ 5-10 min of warm-up &
cool down
Type: single mode or multiple modes, circuit
training
Cardiac Rehab. - MI
Phase II
: Out patient
Can we give strengthening /

resistance exercise ?
Resistance ex. Has been shown to be safe

and effective method of improving strength
and cardiovascular endurance, modify resk
factors and enhancing self efficacy in lowrisk cardiac patients
Cardiac Rehab. - MI
Phase II
: Out patient
Can we give strengthening / resistance

exercise ?
Begin w/ use of elastic bands, & light hand

weights ( 1-3lbs) progress to load of 12 to
15 rep comfortably.
MUST before Strengthening:
In cardiac rehab for at least 3 weeks

At least 5 wks post-MI or 8 wks post-CABG
Cardiac Rehab. - MI
Phase III
:Maintenance
Exercise/activity goals & outcomes

1. Improve &/or maintain functional outcome
2. Promote self-regulation of exercise programs.
3. Promote life long commitment to risk-factor
modification
D/C in 6 12 months
Cardiac Rehab. - MI
Phase III
:Maintenance
Location: community center, YMCA, or clinical

facilities.
Entry level criteria:
5 METS,
clinically stable angina
Medically controlled arrythmias during
exercise
Progression
Supervised self-regulation
Cardiac Rehab. - MI
Phase III
:Maintenance
Location: community center, YMCA, or clinical

facilities.
Entry level criteria:
5 METS,
clinically stable angina
Medically controlled arrythmias during
exercise
Progression
Supervised self-regulation
Exercises
Post PTCA
Ex. Post PTCA
NO strict guidelines as to when to resume

aerobic activities.
Common: Wait to exercise approximately 2
weeks post-PTCA to allow inflammatory
process to subside.
Use post-PTCA ETT to prescribe exercise.
Ambulate at low intensity & comfortable pace
during the 1st 1 to 2 weeks post-PTCA.
Avoid moderate to higher intensities associated
w/ aerobic training.
Exercises
Post CABG
Ex. Post CABG
Ex. Post CABG
Ex. Post CABG
Ex. Post CABG
Ex. Post CABG

Recovery slower than PTCA
Care for the donor site.
PNF, ROM ex.. Low repetition 1 to 2x/day
?
NO UE flexibility ex. untill 4-6 weeks.
Avoid lifting, pushing, pulling for 4 to 6

weeks post-surgery.
GOAL: 30 minutes ambulation 1 to 2x/day
at 4 to 6 weeks post surgery
Exercises:
Congestive
Heart Failure
Ex. For CHF

GOALs .. ?
1.
2.
3.
4.
5.
6.
7.
8.
Physiological response to increase O2 demand is

improved.
Self-management of syptoms is improve.
Ability to perform physical task is increased
Behavior that foster healthy habits, wellness, and
prevention are aquired.
Disability associated w/ acute or chronic illness is
reduced
Risk of secondary impairment is reduced
Awareness and use of community resources is improved
Performance of and independence in ADL is increased
Function
al
Class I
Class II
Class III
Class IV
Permissible work Loads
Max.
Patients with cardiac disease but without resulting

limitation of physical activity. Ordinary physical
activity does not cause undue fatigue, palpitation,
dyspnea, or anginal pain.
6.5 METs
Patients with cardiac disease resulting in slight

limitation of physical activity. They are comfortable
at rest. Ordinary physical activity results in fatigue,
palpitation, dyspnea, or anginal pain
4.5 METs
Patients with cardiac disease resulting in marked

limitation of physical activity. They are comfortable
at rest. Less than ordinary activity causes fatigue,
palpitation, dyspnea, or anginal pain.
3.0 METs
Patients with cardiac disease resulting in inability to

carry on any physical activity without discomfort.
Symptoms of heart failure or the anginal syndrome
may be present even at rest. If any physical activity
is undertaken, discomfort is increased.
1.5 METs
Ex. For CHF

When to give Exercise .. ?
1. Medically stable
2. Exercise capacity > 3 METs
3. Exercise enduced ischemia & arrythmias are
poor indicators
Ex. For CHF

Exercise Parameters .. ?
Low intensity: 40-60% VO2, gradually
increasing, interval training.
Monitor w/ RPE (rating of 12-14), ECG, BP,
signs of exertional intolerance;
HR response may be impaired (digoxin)
HR limited to HRr + 10-20 bpm
Exercise HR >115 bpm generally
contraindicated
Negative treppe effect
Ex. For CHF

Exercise Parameters .. ?
Check for delayed response
Edema of LE, weight gain
NOT candidate for resistance exercise

(<6METs)
Monitor SaO2
Emphasize: energy conservation, selfmonitoring techniques
Exercises:
Cardiac
Transplant
Ex. For CHF

Presents with:
1.
2.
3.
4.
5.
6.
Calf cramps (15% of px) due to

immunosuppresive drug cyclosporine.
Decreased LE strength
Obesity : Long term corticosteroid
Increased risk of Fx : osteoporosis
Increased changes of atherosclerosis in the
coronary arteries of the donor heart.
Exercise intolerance due to extended inactivity
& convalescence.
Ex. For CHF

Consideration:
Heart is denervated
Include BP and Perceived exertion in the
monitoring
Use longer period of warm-up and cool down :
slower physiological response to exercise and
recovery.
Exercises:
Pacemaker
Automatic
implantable
CARDIOVERTERDefibrilator
Ex. For CHF

Consideration:
Should know the setting of the Heart Rate.
ST segment changes may be common and are
NOT specific for ischemia.
Avoid UE aerobic or strengthening exercises
initially after implant. to avoid dislodging the
device.
Danger with electronic signals like anti-theft
device.
Angina During Exercise

What to do ?
Angina During Exercise What to do?

immediate goal decrease MVO2
Activity immediately STOP
Sit px or lie down on bed
Take HR and BP ASAP
In the Facility:
Seek help to initiate facility guidelines ASAP
May include:
Suplemental O2, a 12-lead EKG, NTG or other
anti-ischemic meds.
Angina During Exercise What to do?

Out patient:
Px have own NTG, help px take it
One NTG sublingually
NOTE: NTG should produce a tingling or burning
sensation
NONE? NTG is outdated

Wait 5 min. repeat dose if symptoms not
completely gone
3rd dose may be taken
Possible Effects of
Physical Training /
Cardiac
Rehabilitation
Decreased HR at rest & during exercise;

improved HR recovery after exercise.
Increased SV.
Increase Myocardial O2 supply &
myocardial contractility; myocardial
hypertrophy.
Improved respiratory capacity during
exercise.
Improved functional capacity of exercising
muscles.
Reduced body fat, increased lean body
mass, successful weight reduction
requires multifactorial intervention
Decreased serum lipoproteins

(cholesterol, triglycerides).
Improve glucose tolerance.
Improve blood fibrinolytic activity
and coagulability.
Improved in the measures of
psychological status and functioning:
self-confidence & sense of well-being.
No
More !!!

Cardiac Rehabilitation

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PT intervention for Patient w/ CAD

1. Aerobic capacity is increased

PT intervention for Patient w/ CAD

6. Ability to recognize the recurrence is

PT intervention for Patient w/ CAD

Px w/ cardiac Hx may have PT need.

PT intervention for Patient w/ CAD

Increased systemic O2 consumption =

American Association of Cardiovascular & Pulmonary

A recent significant change in the resting ECG

Severe aortic stenosis

Begin at 1.7 mph, 10% grade;

Balke-Ware and Begin at constant speed of 3.3

You have a positive ETT !

You have a negative ETT !

The Patient have an ankle fracture of 3

The Patient have an ankle fracture of 3

Excluded from exercise Training: In/out px (ACSM)

Excluded from exercise Training:

Excluded from exercise Training:

Most consistent benefit w/ exercise

Percentage of max. HR achieved on ETT

Environmental extremes, heavy arm work,

RPE of 12-13 60% of HR range

Rate of progression depends on age, health,

Hospital stay is 3 to 5 days

GOAL: 20 to 30 minutes of ambulation 1-2

VS monitoring : before, after, if possible during

1 to 2 METs = HR by 10 to 20 bpm if w/t

Phase I : Inpatient component

1-1.5 CCU- Essentially bedrest

1.5-2 Sitting-Limited room ambulation

2-2.5 Room-Limited hall ambulation

2.5-3 Progressive Hall ambulation

Progressive Hall ambulation

Consider environmental condition

Px should be monitored on similar

Exercise /Activity goals & outcome

1. Improve functional capacity

Patient commonly undergo a symptom-limited

MVO2 below the patient ischemic

Outpatient Program : ave. 36 visit (3/wk x

Can we give strengthening /

Resistance ex. Has been shown to be safe

Can we give strengthening / resistance

Begin w/ use of elastic bands, & light hand

In cardiac rehab for at least 3 weeks

Exercise/activity goals & outcomes

Location: community center, YMCA, or clinical

Location: community center, YMCA, or clinical

Ex. Post PTCA

NO strict guidelines as to when to resume

Ex. Post CABG

Ex. Post CABG

Ex. Post CABG

Ex. Post CABG

Ex. Post CABG

Avoid lifting, pushing, pulling for 4 to 6

Ex. For CHF

Physiological response to increase O2 demand is

Permissible work Loads

Patients with cardiac disease but without resulting

Patients with cardiac disease resulting in slight