[OT 1022] Cardiac Rehabilitation

• Cardiac rehabilitation

  Interdisciplinary team approach to patients with functional limitations secondary to heart disease

  
• 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 heart disease
• Primary prevention


  Involves screening clients, to identify and treat risk factors before illnesses develop
• Secondary prevention


  Initiated to improve the risk factor or heart disease risk factors and limit further morbidity and mortality
• Multidisciplinary team members

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

  • Techniques that overlap with other professionals, Communication is important, 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 (Stress management relaxation technique) education, 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 cardiac rehabilitation program, CR program modification, Coordination of medical care, Patient education
• Modifiable risk factors for coronary artery disease

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

  • Increasing age
  • Gender: male > female
  • Prior history: cardiac, peripheral vascular, or cerebrovascular disease
  • Family history: genetics
  • Cultural or socioeconomic
• Lifestyle modification without medication

  Recommended in stage 1 hypertension
• Medications

  Recommended for stage 2 hypertension, or when lifestyle modification does not normalize blood pressure
• Signs and symptoms of cardiac distress

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

  
• Borg Rate of Perceived Exertion Scale


  Used to assess the client's exertion level during activity
• Specific Activity Scale classes

  • 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
• 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 III


  Clients with cardiac diseases resulting in marked limitations in physical activities. Client cannot do more than 50% of the activities he or she does.
• CLASS IV


  This category includes patients with cardiac disease resulting in inability to carry out physical activities w/o discomfort.
• CLASS I


  Ordinary physical activity, such as walking and climbing stairs, does not cause angina. It occurs prolong exertion or extraneous exertion during work and other recreational activities.
• CLASS II


  Ordinary activity is somewhat limited. This includes walking or climbing stairs rapidly; walking uphill; and walking or climbing stairs after meals, in cold, when under emotional stress.
• CLASS III


  Ordinary physical activity is significantly limited. This includes walking one to two blocks on level surface and climbing more than one flight in normal conditions.
• CLASS IV


  Patients are unable to carry out any physical activity without discomfort. Angina syndrome may be present at rest.
• PHASE I : INPATIENT CARDIAC REHABILITATION


  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.
• PHASE II : OUTPATIENT CARDIAC REHABILITATION


  Exercise can be advanced patient is closely monitored on an outpatient basis. Return to work. Stress management and relaxation techniques.
• PHASE III : COMMUNITY-BASED EXERCISE PROGRAMS


  Some individuals require treatment in their place of residence because they are not strong enough to tolerate outpatient therapy. 'maintenance phase'.
• HEART RATE (HR)


  Number of beats per minute; can be monitored by feeling the patient's pulse at the radial, brachial, or carotid sites.
• BLOOD PRESSURE (BP)


  Pressure that the blood exerts against the walls of any vessel as the heart beats.

  
• RATE-PRESSURE PRODUCT (RPP)


  Product of HR and SBP (RPP= HR x SBP). During any activity, the RPP should rise at peak and return to baseline in recovery (after 5 to 10 minutes of rest).
• PSYCHOSOCIAL CONSIDERATIONS

  Fear and anxiety develop initially as patients confront their mortality. Denial is common in patients with cardiac disease. Depression is common 3 to 6 days after MI and may last many months.
• BENEFITS OF PHYSICAL ACTIVITY ON RISK FACTORS FOR CAD

  Low-density lipoprotein (LDL) and triglycerides reduced 3-5%. High-density lipoproteins (HDL) increased by 4.6%. SBP and DBP reduced up to 3.4mmHg (greater reduction seen in hypertensive patients). Weight loss and subsequent weight maintenance enhanced. Rates of smoking cessation and maintenance of abstinence improved.
• LIFESTYLE MODIFICATION


  Key component in improving cardiovascular health. Support groups, counseling, and medical management → key roles in successful cessation of smoking, alcohol consumption, drug abuse.
• PATIENT AND FAMILY EDUCATION

  The team must instruct: Cardiac or pulmonary anatomy, Disease process, Management of symptoms, Risk factors, Diet and exercise, Energy conservation techniques. Inclusion of family members in an educational program provides support indirectly to the client through the family unit.
• ENERGY CONSERVATION TECHNIQUES (ECT)

  Intentional, planned management of personal energy resources to prevent their depletion. Objective: balance rest and activity during times of fatigue so that valued activities and goal can be maintained.
• FIVE KEY AREAS IN ECT

  • Planning
  • Prioritizing
  • Pacing
  • Position
  • Technology and Adaptive Equipment
• STRATEGIES (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 one.
• 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.
• STRATEGIES (PACE)

  Avoid rushing by allowing enough time for each task. Work and move at a moderate pace. Fast walking takes 15x as much energy as slow walking. Climbing stairs takes 7x as much energy as walking. 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.