Lec3 - Physio post surgical intervention

• Priorities post op:

  • Prehab
  • Early mobility
  • Breathing exercises/sputum clearance
  • Mobility of shoulders/chest/spine
  • Activity restrictions
  • Education
  • Refer to cardiac rehab
• Cardiac Screening Protocol:

  • Extubated
  • Oxygen
  • PaO2 > 9 kPa
  • Able to independently expectorate
  • CVS stable
  • Weaning inotropes
  • No IABP in situ
  • No respiratory history
  • No pre-existing mobility issues
  • Those not meeting the above criteria will be assessed and treated as appropriate
• Cardiovascular Prevention & Rehabilitation

  1. identify and refer pts
  2. manage referral and recruit pt
  3. assess pt
  4. develop pt care plan
  5. deliver comprehensive cardiac rehabilitation programme
  6. conduct final cardiac rehabilitation assessment
  7. discharge and transition to long term management
  8. patient discharge
• • bones take 6 to 8 weeks to heal
  • How much can patients lift in the first 6 weeks post sternotomy?
  • Anything – it’s not what you do, it’s how you do it
• FITT principles:

  • Frequency: at least 3 times a week - 1 supervised, 2 home
  • Intensity:
  • moderate to vigorous
  • 40 to 70% HRR
  • 11 to 14 Borg RPE
  • Time: 20 to 30 minutes conditioning + 15 minutes warm up + 10 minutes cool down
  • Type: cardiovascular/aerobic or interval

  
• ESC (2011) Minimum recommendations of implementation of Resistance Training:

  • Step 1 - Pre-training
  • objective: learn and practice correct implementation, improve intermuscular coordination
  • intensity: 30% of 1 RM, RPE of 12
  • reps: 5 to 10
  • training volume: 2 to 3 times a week, 1 to 3 circuits
  • Step 2 - resistance/endurance
  • objective: local aerobic endurance intermuscular coordination
  • intensity: 30 to 40% of 1 RM, RPE of 12 to 15
  • reps: 12 to 25
  • training volume: 2 to 3 times a week, 1 circuit
  • Step 3 - strength
  • objective: increase muscle mass, muscle build up, intramuscular coordination
  • intensity: 40 to 60% of 1 RM, RPE of 8 to 15
  • reps: 5 to 10
  • training volume: 2 to 3 times a week, 1 circuit
• • HIIT training has improved fitness levels after 8 weeks -> 85%+ HRR
  • only to be completes later on into their rehab programme
  • dependent on patient
  • improvement of 1.06 ml/kg/min VO2 peak
• Is HIIT safe for cardiac populations?

  • The likelihood of a cardiac event in high risk individuals appears to be low when conducting either moderate, or high intensity exercise
• • 1mL increase in VO2 associated with an approximate 15% decrease in risk of death
  • Low CRF is associated with highest risk
  • Higher CRF is associated with lower risk
• post ICD

  • start with only lower limb exercises at first, as upper limb exercises can increase the risk of disrupting the leads and cause infections on the wound
• ICD - Does Exercise help?

  • Increased parasympathetic tone – lower risk of arrhythmia
  • Less cardiac strain – lower RPP
  • Overcome anxiety with exercise
  • The device can help cardiac function/lower risk but doesn’t alter the peripheral muscle dysfunction of heart failure
  • STRONG LEGS SPARE THE HEART
• ICD - Exercise Considerations:

  • shoulder ROM
  • Timescale post implantation
  • Why inserted – high risk if secondary prevention
  • Know settings to prevent inappropriate therapy
  • Dangerous alone activities
  • Avoid magnets!
  • Contact sports?
• Need to address peripheral muscle dysfunction

  
• How soon can a patient start cardiac rehab post ICD insertion?

  • as soon as they can
• Potential Exercise Circuit post ICD:

  • For CV Fitness: 20-30mins moderate intensity x 3 per week

  
• Left Ventricular Assist Device - Exercise Considerations

  • Consider the level of support from the VAD: fixed pump speed
  • What do you monitor?
  • Increased flow is preload dependent - warm up
  • Slow down after exercise to avoid large haemodynamic shift - cool down
  • Other devices; CRT +/or ICD
• LVAD - Considerations for exercise

  • These patients are anticoagulated – bruise/bleed easier
  • Consider drive line – avoid bouncing/twisting/bilat arms above head – shouldn’t lie of front
  • Different carrying options (bag, belt)
  • Peripherally muscles are deconditioned due to pre VAD HF
  • They may have an ICD/sternotomy incision – first 6 week restrictions can lead to ROM deficits
  • Spares MUST be present!
  • Trained family member may need to be present
  • What do you monitor? Flow rate & Watts
  • Increased flow is preload dependent
  • Slow down after exercise to avoid large haemodynamic shift
• LVAD circuit:

  • not allowed to jog, not allowed to use arms

  
• When can VLAD patients start Cardiac rehab:

  • Need first out-patient review
  • Some centres do regular CPEX’s and require patients to do an initial CPEX before referral
  • Most have a sternotomy
  • Some patients require a trained chaperone to be present so need to accommodate them in sessions
  • Talk to your local LVAD centre re training
• Types of transplant:

  • orthotic cardiac transplant
  • heterotopic cardiac transplant

  
• Heart transplant exercise considerations:

  • Prolonged warm-up/cool-down to allow the catecholamines to affect HR/BP – choose appropriate FC test
  • Difficult to use HRR due to the abnormal CVS response to exercise, use a THR 20 beats greater than RHR
  • Increased reliance on RPE and observation
  • Less subjective ischaemic symptoms
  • Advise patient on other symptoms of ischaemia eg sweating, palpitations, breathlessness
  • Consider LV function for risk stratification, may not be normal
  • Reduced overall exercise tolerance
• Heart transplant exercise considerations cont:

  • Consider length of illness pre transplant (disuse atrophy and defects of muscle metabolism associated with HF)
  • Include weight bearing & resistance work but avoid high impact work
  • After a rejection episode, tailor exercise to reduce impact/stress on the skeletal system
  • Frequent rejection exacerbates risk of osteoporosis and muscle atrophy
  • Rejection increases the risk of reduced CO and arrhythmia
  • Discontinue ex if infection is present (greater risk due to immunosuppression)