Cardiac Rehabilitation

• Cardiac Rehabilitation (CR)


  'interdisciplinary team approach to patients with functional limitations secondary to heart disease (HD)'

  
• Focus of Cardiac Rehabilitation

  Restoring patients to their optimal medical, physical, mental, psychologic, social, emotional, sexual, vocational, and economic status compatible with the severity of their HD
• Primary prevention vs Secondary prevention

  Primary prevention aims to prevent the initial occurrence of a disorder, secondary prevention aims to reduce the impact of a disorder
• Multidisciplinary team and roles

  • Physical Therapist
  • Occupational Therapist
  • Psychologist
  • Nutritionist
  • Rehabilitation nurse
  • Physiatrist
• Physical Therapist


  • FIM scoring, Treatment of physical comorbidities, Balance, gait, and stair training, Supervision of aerobic training sessions, Chest physical therapy, Home equipment recommendations
• Occupational Therapist


  • FIM scoring, Treatment of physical comorbidities, Cognitive and safety evaluation, ECT and pacing education, Use of assistive devices, SMRT, Home equipment recommendations
• Psychologist


  • Cognitive and psychosocial evaluation and therapy, Behavioral modification and smoking cessation
• Nutritionist


  • Dietary evaluation, education, and counseling
• Rehabilitation nurse


  • Wound and skin care, Pain management, Safety education, Medication education, Risk factor education
• Physiatrist


  • Prescription of CR program, CR program modification, Coordination of medical care, Patient education
• Modifiable risk factors for coronary artery disease (CAD)

  • Physical inactivity
  • Hypertension
  • Smoking
  • Dyslipidemia
  • Overweight or obesity
  • Diabetes
• Non-modifiable risk factors for coronary artery disease (CAD)

  • Increasing age
  • Gender: male > female
  • Prior history: cardiac, peripheral vascular, or cerebrovascular disease
  • Family history: genetics
  • Cultural or socioeconomic
• Classification of hypertension (HTN)

  Lifestyle modification without medication recommended in stage 1 HTN, Medications recommended for stage 2 HTN or when lifestyle modification do not normalize BP

  
• Classification of hypertension (HTN)

  • Normal: SBP<120, DBP<80
  • Prehypertension: SBP 120-139, DBP 80-89
  • Stage 1 hypertension: SBP 140-159, DBP 90-99
  • Stage 2 hypertension: SBP>160, DBP>100
• Signs and Symptoms of Cardiac Distress

  • Angina
  • Dyspnea
  • Orthopnea
  • Diaphoresis
  • Fatigue
  • Orthostatic hypotension
  • Nausea/emesis

  
• Borg Rate of Perceived Exertion Scale

  Assesses the level of exertion during physical activity

  
• Assessing Cardiovascular Disability - Specific Activity Scale

  • Class I: Can perform activities requiring < 7 METs
  • Class II: Can perform activities requiring < 5 METs but not > 7 METs
  • Class III: Can perform activities requiring < 2 METs but not > 5 METs
  • Class IV: Cannot perform activities requiring > 2 METs
• Basal Metabolic Equivalent Table of Self-Care and Homemaking Tasks

  • 1-2 METs: Eating, seated; transfers, bed to chair; washing face and hand; brushing hair, walking 1mph
  • 2-3 METs: Seated sponge bath, standing sponge bath, dressing and undressing, seated warm shower, walking 2-3 mph, W/C propulsion 1.2mph
  • 3-4 METs: Standing shower, warm; bowel movement on toilet; climbing stairs at 24 ft/min
  • 4-5 METs: Hot shower, sexual intercourse
  • 5-6 METs: Sexual intercourse, walking up stairs at 30 feet/min
  • 6-7 METs: Walking with braces and crutches
• Canadian Cardiovascular Society Functional Classification

  • Class I: Ordinary physical activity does not cause angina
  • Class II: Ordinary activity is somewhat limited
  • Class III: Ordinary physical activity is significantly limited
  • Class IV: Unable to carry out any physical activity without discomfort
• Phases of Cardiac Rehabilitation

  • Inpatient cardiac rehabilitation - Phase 1
  • Outpatient cardiac rehabilitation - Phase 2
  • Community-based exercise programs - Phase 3
• Inpatient cardiac rehabilitation - Phase 1

  Monitored low level physical activity, including ADL, Reinforcement of cardiac and postsurgical precautions, Instruction in energy conservation and graded activity, Establishment of guidelines for appropriate activity levels at discharge
• Outpatient cardiac rehabilitation - Phase 2


  Exercise can be advanced patient is closely monitored on an outpatient basis, Return to work, Stress management and relaxation techniques
• Community-based exercise programs - Phase 3


  Some individuals require treatment in their place of residence because they are not strong enough to tolerate outpatient therapy, 'maintenance phase'
• Monitoring Response to Activity

  • Heart rate (HR)
  • Blood pressure (BP)
  • Rate-pressure product (RPP)

  
• Appropriate cardiovascular response to activity

  Heart rate increases with activity to no more than 20 bpm above the resting heart rate, Systolic blood pressure rises with activity, Absence of adverse symptoms

  
• Inappropriate cardiovascular response to activity


  HR > 20 bpm above the resting heart rate, RHR > 120, HR drops or does not rise with activity, SBP > 220 mmHg, Postural hypotension, Decrease in SBP with activity, Excessive shortness of breath, Angina, nausea, and vomiting, Excessive sweating, Extreme fatigue (RPE > 15)

  
• Lifestyle Modification


  Key component in improving cardiovascular health, Support groups, counseling, and medical management play key roles in successful cessation of smoking, alcohol consumption, drug abuse
• Components of Lifestyle Modification

  • Exercise education
  • Graded program of increased activity and participation
  • Stretching, strengthening, and aerobic activity
  • Guidelines for monitoring HR, BP, and RPE
  • Cool down
  • Environmental factors and warning signs
  • Emergency guidelines
• Patient and Family Education


  The team must instruct on cardiac or pulmonary anatomy, disease process, management of symptoms, risk factors, diet and exercise, and energy conservation techniques. Inclusion of family members provides indirect support to the client.
• Energy Conservation Techniques (ECT)


  Intentional, planned management of personal energy resources to prevent their depletion, Objective is to balance rest and activity during times of fatigue so that valued activities and goals can be maintained
• Five Key Areas in ECT

  • Planning
  • Prioritizing
  • Pacing
  • Position
  • Technology and Adaptive Equipment
• Strategies for Planning and Prioritizing

  • Plan for adequate rest periods during the day
  • Identify activities that tire you more (heavy) and tire you less (light) and alternate these activities
  • Important tasks should be done first and when you have the most energy
  • Do the most important tasks, and eliminate unnecessary ones
  • Know that some tasks may require help from others
  • Delegate work to others
  • Keep things that you use most where they are easily accessible
  • Have necessary supplies and equipment together before starting an activity
  • Arrange work area for activity to be done
  • Divide jobs into smaller ones
• Energy Conservation Daily Diary

  Can be used to track and record daily activity, activity tolerance, and levels of tiredness or fatigue, Patients document the level of energy perceived at beginning of task and then at completion of task (0 no energy to 10 high energy)
• Strategies for Pacing


  • Avoid rushing by allowing enough time for each task
  • Work and move at a moderate pace
  • Use slow flowing motions > fast jerky movements
  • Take frequent rest breaks
  • Reduce activities that cause sudden or prolonged strain
  • Listen to your body and know your limits
  • Rest before you feel tired, instead of taking a long rest period after you get tired
• Strategies for Position


  • Sit to do work rather than stand
  • Place and store items between the chest and pelvis level for easy reach
  • Use good posture and body mechanics during activities
  • Avoid overhead reaching and bending over
  • Modify your home to maximize efficient energy use
  • Avoid unnecessary multiple trips via stairs if living in a multistoried house
  • Organize tasks to reduce clutter and prevent extra movement
• Strategies for Technology and Equipment

  • Use electronic devices
  • Use wheels to transport objects rather than carrying them
  • Use online shopping
  • Install swing-out shelving, revolving shelves
  • Use smart devices to schedule, plan, or monitor activities and control home appliances remotely
• Application of ECT: Grocery Shopping

  PLAN: Schedule a day and time during the week to go grocery shopping, PRIORITIZE: Form a shopping list, PACE: Avoid rushing, POSITION: Place heavy items in the shopping cart near the handle for better leverage, TECHNOLOGY AND ENVIRONMENT: online grocery shopping, use a small wheeled cart
• Application of ECT: Housework and Cleaning

  PLAN AND PRIORITIZE: break up chores over the entire week by doing a little each day, PACE: clean at moderate pace, POSITION: If the home has two floors, get 2 sets of cleaning equipment, one for each floor; eliminate unnecessary clutter; avoid bending, use of long shower hose; proper body mechanics when cleaning, TECHNOLOGY AND ADAPTIVE EQUIPMENT: Use of basket or cart for transporting cleaning supplies and appliances
• Application of ECT: Bathing


  PLAN & PRIORITIZE: Set a regular time of the day for this activity, PACE: Avoid overexertion by taking rest breaks, POSITION: Place and organize soap, shampoo, and conditioner or dispensers at height that are reachable when sitting; most efficiently performed in a seated position; avoid bending over to reach distal parts; use good body mechanics when getting up from shower chair, TECHNOLOGY AND ADAPTIVE EQUIPMENT: handheld showers, long-handled bath sponges, accessories like grab bars and non-slip strips to minimize risk of falls and reduce anxiety