Week 7 - Cardiac Rehab Flashcards
Phase 1 of cardiac rehab
Inpatient covered by DRG
Phase II
Outpatient with monitoring —> EKG at all times
Covered by good plans 1 up to 8-12 weeks
Phase III
Outpatient with less individual monitoring
Not covered by most places
Phase IV
Independent maintenance program (never covered by insurance)
Goals of Inpatient CR one stabilized medically
Mobilize ASAP to prevent effects of bed rest
Educate - risk factors, s/s of CAD, ex tolerance, ex benefits
Progressive activity - 4 MET level
Normal hemodynamic response
Patient psychologically prepared to return home
Independent in HEP & self-monitoring of response to exercise
Responsibilities of the PT
Assess physiologic responses
Supervising exercise program
Accurately char and record pt program and response to treatment
Assist in pt and fam education
Prepare the pt for discharge and HEP
Adjusting protocol to optimize it for pt
When is exercise not initiated when it comes to resting HR for phase I?
> 120 bpm if medical tx (MI)
130 if surgical tx
Exercise intensity decreased if HR increases …
20 bpm if medical tx
30 bpm if surgical tx
When is exercise ceased in phase I of inpatient cardiac rehab
If HR fails to increase with an increase in activity level
** HR may be increased in anticipation of exercise**
Why would you use RPE?
For anyone whose HR response isn’t a reliable indicator
Pt post-cardiac transplant
Those w most types of pacemakers
Those using beta blockers
Equivalent of 20/30 rule for RPE in phase I inpatient cardiac rehab
12 to 13 or increase of 2 or 3 on 7-20 borg scale
When is exercise not initiated w/o specific approval by physician when it comes to BP?
Resting SBP exceeds 200 mmHg
Resting DBP exceeds 110 mmHg
General rules of progression
Pt response to exercise guides progression
Activity increased from: AAROM, AROM, AROM w/ trunk
Position progressed from reclined to sitting to standing
Bedrest to 10-25’ w assistance at bed, to 50-100’ in hall to 900’ or more w PT supervision
Pt performs shorter distances w/in unit w visual and telemetry monitoring w/o PT
Expected Outcomes by the time of discharge from phase I CR
Ascend and descend two fights of stairs w/o adverse symptoms
Ambulate > 1000’ w/o adverse symptoms
Independently perform exercise program
Demonstrate understanding of limits, precautions and be able to self-monitor responses to exercise
Entry points for Outpatient CR (Phase II)
Shortly following hospitalization for MI, CABG or PCI
May be 1-2 wks or several weeks post-DC from acute care
Outpatients being managed medially
May also be used as a supervised exercise program w/o MI or CAD w/o MI
Outpatient Cardiac Rehab
Close supervision w medical personnel and equipment on site
3 visits per week for 12 weeks
Some programs more flexible
Pts monitored visually and by telemetry
Phase III Cardiac rehab
Outpatient
Functional capacity at least 5 METS
No direct medical supervision
Less structured
More individualized
Self-monitoring of response to exercise
Components must be rolled into end of Phase II
Phase IV Cardiac Rehab
Outpatient
Maintenance or improvement from phase II and III
Not distinguishable from non cardiac population
Not supervised by PT
Program can be set up by the PT for the client to follow
Must also roll this component into end of “phase II”
Exercise Prescription for all Outpt Phases
Select activities the patient enjoys
Incorporate aerobic, flexibility and strengthening
Progress as tolerance improves within limitations of condition
Education and communication continues to be essential
Resistance exercise
Pt must first show normal response to aerobic exercise
Large muscle group
Weights that can be lifted for at least 20 reps
Weight increased when they reach 30 reps
Education sessions
Exercise independently
Choose foods wisely
Take and monitor the effects of meds
Modes of exercise for outpatient cardiac rehab
Three groupings based upon reliability of cardiac demand of activity both over time and across patients
Treadmill is most reliable within and among patients
Games are least reliable both within and among patient
Group 1 exercise for outpatient cardiac rehab
Constant intensity
Low variation from person to person
Treadmill and cycle, rowing and other ergometers
Potential for boredom
Group 2 for exercise for outpatient cardiac rehab
Intensity can vary based on skill level and over time
Swimming
Running or cycling
Cross-country skiing
Group 3 for exercise for outpatient cardiac rehab
Intensity varies over time and w skill level
Provides variety
Suitable for low-risk patient/clients only
Sports and games
More useful for phase III or IV than II
Risk of MSK or CV injury
Intensity of prescribed tolerated exercise
Mortality related to max intensity
Large increase in mortality between 7 and 6 METS
Progress patient to high levels when deemed safe (using GXT)
Prudently aggressive
High enough to increase exercise tolerance, VO2 max (>70%) but low enough to be safe (40%)
Prescribing intensity is easy for low risk or high risk and difficult for moderate risk
Prescribing activity by METs
Prescribe home exercise for low risk individuals to add variety/alleviate boredom
Restrict activities to safe MET level for moderate and high risk
Some lighter home activities can be prescribed immediately for moderate and high risk patients
HIIT
Intersperse intervals of exercise >85% of peak HR or workload w periods of low intensity exercise intervals (or rest)
Can mimic real life
HIIT qualities vs MICE
Mod to high intensity continuous exercise can reduce all-cause mortality
Appears safe and better tolerated by patients compared to MICE
Gives rise to many short and long term central and peripheral adaptations
Elicits greater changes in VO2peak
Increases risk factor control in diabetes, dyslipidemia, overweight and HTN
What is a strong independent predictor of morbidity/mortality in pts w/CAD and HF
VO2 peak
Benefits of HIIT vs MICE
HTN and CAD: greater improvement in VO2peak
MI: no different between low volume and high volume
Cardiac rehab: HIIT group did not experience any cardiac arrhythmias or excessive HR responses - safe intervention
When to start HIIT
For coronary pts w non altered ejection fraction and exercise tolerance >5 METS, introduce HIIT using 2 sessions at 60% of peak power output
If tolerated, workload increased to 80%
In case of altered ejection fraction and/or low exercise tolerance, usually start w minimum of 2 wks or 8-10 sessions in continuous mode before starting HIIT
