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Cardiac Rehabilitation


Cardiac Rehabilitation DPT 732 S. Scherer Spring 2009 * * * * * * * * * * * * * * * * * * * * * * * * Cardiac Rehabilitation Case DPT 732 2009 Elizabeth is a 52 year ... – PowerPoint PPT presentation

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Title: Cardiac Rehabilitation

Cardiac Rehabilitation
  • DPT 732
  • S. Scherer
  • Spring 2009

  • Identify common impairments functional
    limitations in patients following CAB surgery
  • Select outcome measures for patients following
    CAB surgery or MI
  • Discuss aspects of plan of care for these
  • Describe components of comprehensive cardiac

  • CV disease
  • 1 cause of death
  • 1 death every 33 seconds
  • Coronary Artery Bypass CAB Surgery
  • gt ½ million surgeries per year
  • Clinical practice is changing

Changes in Surgical Management
  • Anesthesia procedures
  • Minimally invasive procedures
  • Smaller incision
  • Off pump
  • Shorter hospital length of stay

Clinical Course
  • Traditional
  • Acute Care (phase 1)
  • Outpatient (phase 2)
  • Wellness (phase 3)
  • Contemporary
  • Acute Care (phase 1)
  • Inpatient
  • Medical rehabilitation
  • Skilled nursing
  • Home health PT
  • Outpatient PT
  • Outpatient CR (phase 2)
  • Maintenance (phase 3)
  • Additional PT for comorbidities

Post CAB Complications
  • Myocardial injury
  • Blood loss
  • Incision infections
  • Atrial fibrillation
  • Pneumonia
  • Cognitive impairments
  • Bypass machine impairments
  • Microemboli
  • Cerebral hypoperfusion

PT considerations
  • Prevention of pulmonary complications
  • Upright positioning early mobilization
  • Deep breathing
  • Airway clearance techniques prn
  • Incisional precautions for 2 wks
  • No submersion in water running water OK
  • No cream or lotion directly in incision

PT considerations-- Sternal Precautions
  • Do not lift more than 8 pounds. (A gallon of milk
    weighs 8 pounds.)
  • Do not push or pull with your arms when moving in
    bed and getting out of bed.
  • Do not flex or extend your shoulders over 90.
  • Avoid reaching too far across your body.
  • Avoid twisting or deep bending.
  • Do not hold your breath during activity.
  • Brace your chest when coughing or sneezing.  This
    is vital during the first 2 weeks at home.
  • No driving. 
  • Avoid long periods of over the shoulder activity.
  • If you feel any pulling or stretching in your
    chest, stop what you are doing.  Do not repeat
    the motion that caused this feeling.
  • Report any clicking or popping noise around your
    chest bone to your surgeon right away. 

Outcome Measures
  • Medical
  • Morbidity
  • Mortality
  • Complication rates
  • Hospital LOS
  • Ejection fraction
  • Quality of life
  • Rehabilitation
  • Quality of life
  • ADL performance
  • Symptom impact
  • Habitual physical
  • activity level
  • Balance

Impairments Functional Limitations following CAB
  • Incisional (sternotomy and donor graft leg) pain
    and drainage
  • Continuous pain from the shoulders and neck
  • Thoracic pain
  • Respiratory problems
  • Feelings of weakness
  • Sleeping difficulties including chest wall pain
    with side lying, waking frequently and early,
    more nightmares than usual
  • Problems with wound healing
  • Dissatisfaction with postoperative supportive
  • Problems with eating
  • Ineffective coping
  • Depression

Functional Outcomes After CAB
  • Comparison groups
  • CAB --- Surgical
  • AMI, PTCA, Angina --- Nonsurgical
  • Functional outcome measurements
  • 6 Minute Walk Test --- Endurance
  • Duke Activity Status Index --- ADL/Endurance
  • RAND 36 Health Survey --- Health-related QoL
    (Self-report) (Lapier, 2003)

Surgical Non surgical Outcomes
Lapier, Journal of Cardiopulmonary
Rehabilitation 200323203-207.
ConclusionsFunctional Status
  • Functional limitations immediately after CAB are
  • CAB surgery limitations gt less invasive
  • Inability to perform ADLs is closely related to
    self reported QOL
  • After 1 year, 36 report self care as
    unsatisfactory (Lapier, 2003, Dimateo,

Goals of Cardiac Rehabilitation
  • Limit the adverse physiologic effects of cardiac
  • Limit the adverse psychological effects of
    cardiac illness
  • Reduce the risk of sudden death or reinfarction
  • Control cardiac symptoms
  • Stabilize or reduce atherosclerosis
  • Improve functional capacity
  • Enhance psycho-social and vocational status

Core Components Cardiac Rehabilitation
  • All cardiac rehabilitation/secondary
    prevention programs should contain specific core
    components that aim to optimize cardiovascular
    risk reduction, foster healthy behaviors and
    compliance with these behaviors, reduce
    disability, and promote an active lifestyle for
    patients with cardiovascular disease.
  • Balady GJ, Williams MA, Ades PA, et al. Core
    components of cardiac rehabilitation/secondary
    prevention programs 2007 update A scientific
    statement from the American Heart Association
    exercise, cardiac rehabilitation, and prevention
    committee, the Council on Clinical Cardiology
    the Councils on Cardiovascular Nursing,
    epidemiology and prevention, and nutrition,
    physical activity, and metabolism and the
    American Association of Cardiovascular and
    Pulmonary rehabilitation. Circulation. May 22

Cardiac Rehab Components
  • Comprehensive long-term services
  • Medical evaluation
  • Prescribed exercise
  • Cardiac risk factor modification
  • Counseling
  • Behavioral interventions

Phases of Cardiac Rehabilitation
  • Phase I Inpatient
  • Phase II Outpatient EKG monitored
  • Phase III Outpatient with decreasing monitoring
  • Phase IV Community based, independent exercise

Inpatient Cardiac Rehabilitation Principles
  • Goals
  • normal cardiovascular response to changes in
    position and ADLs
  • reach 3-4 MET activity level by discharge
  • Activity--Slow progression of activity intensity
    (increase by 1 MET/day)

Initiating Inpatient Cardiac Rehab
  • Post-MI, Post-surgery, Post-stent (no MI), CHF,
    heart transplant
  • Patient may begin if
  • MD approval/order
  • No chest discomfort (8 hours)
  • No new signs of decompensated heart failure
  • No abnormal EKG changes (8 hours)

Surgical vs. Medical Patients limitations to
  • Post-MI HR lt 120 beats/min or 20 beats above
    resting allowed with activity
  • Post-surgery 30 beats above resting is allowed
  • Surgical patients may have sternal precautions

Activity Progression in Cardiac Rehabilitation
  • HR
  • BP
  • SaO2
  • EKG
  • Symptoms
  • At each change in position

Cardiac Rehabilitation Programs Outpatient
  • Exercise Training performed by
  • Exercise Physiologist
  • MD supervised
  • Physiotherapist
  • Nurse
  • Risk Factor Modification provided by
  • Nurse/educator
  • Dietician
  • Behavioral support

  • Selection of appropriate patients
  • Proper monitoring
  • All professional exercise personnel must be able
    to do basic life support, including
  • Emergency procedures must be specified
  • Warm up and cool down are required

Exercise Risk
  • Risk of sudden death is low in cardiac patients,
    but still higher than healthy individuals
  • Cardiac arrest 1 111,966 person-hours
  • Risk of death 1 783,972 person-hours
  • Vigorous uncontrolled exercise risk of death
  • Cardiac 1 60,000 person-hours (1 event for 384
    people _at_ 3 hrs/ week)
  • 1 565,000 person-hours for healthy (1 3122
  • Principle role of cardiac rehab is to define
    exercise mode intensity that are SAFE
  • VanCamp (1986), Fletcher (1990)

Exercise Prescription
  • Patients should be tested on dosage of medication
    they will be taking during exercise
  • Beta-blockade blunts HR response, but VO2
    reserve and RPE may be used
  • Below threshold of angina ( use exercise test)

Cardiac Rehab Phase II
  • Supervised outpatient program 6-8 wks
  • Exercise test performed prior to rehab
  • EKG monitoring every session
  • Goals - increase exercise capacity to 5 METS
  • Patient education on HR, exercise, symptoms

  • Exercise Testing Prior to starting program

Components of Phase II
50 HRR, 3x/week, 60 minute sessions including
warm-up and cool-down
Physical Activity Core Components
  • Evaluation
  • Assess current PA level
  • Assess readiness to change behaviors
  • Interventions
  • Advice, support, counseling, follow-up
  • Advise activities
  • Expected Outcomes
  • Increased participation in physical activity
  • Increased aerobic fitness, well-being

Exercise Training Core Components
  • Evaluation
  • Symptom limited exercise test
  • HR, rhythm, ST segment changes, hemodynamics,
    signs, symptoms, perceived exertion, exercise
  • Risk stratify for level of supervision
  • Interventions
  • Individual exercise program (aerobic
  • F-I-T-T and progress
  • Expected Outcomes
  • Increased aerobic capacity, strength, flexibility
  • Reduced symptoms, improved risk factor profile,
    improved QOL

Phase III Outcomes
  • Functional capacity goals gt 8 METS or 2x energy
    requirements of work
  • Training effects expected
  • No cardiac symptoms
  • EKG monitoring happens occasionally, or when
    increasing activity parameters
  • Patients learn self-monitoring of HR and symptoms

Cardiac Rehab Phase IV
  • Unsupervised program
  • Community Based

Expected Outcomes
  • Improved exercise tolerance
  • Return to work
  • Improved Quality of life
  • Decreased risk factors (secondary prevention)
  • Weight loss
  • Low cholesterol with dietary changes
  • Smoking cessation

AHCPR Cardiac Rehabilitation Recommendations
  • Exercise Training (A evidence)
  • Strength Training (B evidence)
  • Exercise habits (B evidence)

Aerobic Capacity and Endurance Goals
  • Improved with appropriately prescribed and
    supervised exercise training program
  • Peak VO2 Increased 11-66 after 3 months
  • Increased submaximal exercise endurance (longer
    at given rate with lower HR BP)
  • Decreased exercise induced ischemia at same
    cardiac work (Rate-pressure product)
  • Increased participation in exercise (does not
    continue after end of rehab program)

Additional effects of Exercise Training
  • 27 decrease in all cause mortality
  • 31 decrease cardiac mortality
  • No effect on MI recurrence
  • Taylor, R.S., A. Brown, S. Ebrahim, et al.,
    Exercise-based rehabilitation for patients with
    coronary heart disease systematic review and
    meta-analysis of randomized controlled trials.
    American Journal of Medicine, 2004. 116(10) p.

Effects of Exercise Training
  • Does not limit atherosclerosis process
  • No effect on development of collateral
  • Decreases myocardial ischemia
  • Little effect on ejection fraction
  • Elderly patients have exercise trainability
    similar to that of younger patients
  • Minimal adverse events

Other Effects of Exercise Training
  • BP reductions
  • HDL 5-15, no effect of LDL total cholesterol
  • Inconsistent effect on controlling body weight
    (nutrition intervention better)
  • No effect on smoking cessation
  • Improves psychological well being (effect occurs
    with and without other counseling services)

Resistance Training in Cardiac Rehabilitation
  • AACVPR states patients may begin
  • Minimum of 5 weeks post MI, including 3 weeks of
    participation in cardiac rehab
  • Minimum 8 weeks post CABG, including 3 weeks of
    participation in cardiac rehab
  • Resistance training defined at gt 50 of 1RM
  • Theraband, light weights (1-3) may be initiated
    sooner if indicated

Secondary Prevention
  • Education is important in the management of
  • Education, counseling and behavioral modification
    do not improve exercise capacity
  • Alternative approaches (home telemetry
    monitoring) useful for clinically stable patients

Return to Work
  • Work rates 49-93 after MI
  • 20 do not return to work after revascularization
  • Factors that influence return to work
  • Demographic socioeconomic factors only 50
  • Physical/emotional functioning 29
  • Medical factors 20
  • Patients perception of own activity status very
    predictive of return to work
  • Mark, DB (1992)

Utilization of Cardiac Rehab
  • 15 of qualified patients who have had MI or CABG
  • Lack of physician referral
  • Poor patient motivation
  • Logistics
  • Financial
  • DeBusk, (1993)

Adherence to Cardiac Rehab (Exercise Programs)
  • Factors contributing to decreased adherence
  • Lack of attention to individual needs- limited
  • Inconvenient location or schedule
  • Inadequate leadership
  • Sedentary occupation or leisure time

Long-Term Effects of Two Psychological
Interventions on Physical Exercise.
  • Sniehotta, 2005
  • Treatment 1 Detailed action plans Strategy
    aimed at barriers
  • Treatment 2 Detailed planning AND Weekly diary
  • Both interventions enhance physical activity

General physical activity for 3 groups and 3
times. Sniehotta,
Billing Issues
  • Centers for Medicare Medicaid Services (CMS)
    cardiac rehab coverage (link)
  • Conditions
  • Post MI, stent, CHF, valve replacement
  • 18 weeks 36 sessions
  • Incident to Physician service
  • Cardiac rehab billing codes

Peripheral Arterial Disease Rehabilitation
  • Peripheral Arterial Disease (PAD)
  • Atherosclerosis in the peripheral vessels,
    usually the femoral/iliac which causes decreased
    blood flow to the legs

PAD with IC
  • Intermittent Claudication
  • Aching or cramping pain that occurs in the legs
    with walking, forcing the person to stop walking,
    and decreases with rest. Re-occurs consistently
    with the same level of activity

Diagnosis of PAD
  • Ankle-Brachial Index (ABI)
  • Highest ankle systolic blood pressure divided by
    highest arm blood pressure
  • Normal 0.91-1.3

How big a problem is PAD?
  • 12-14 of USA population
  • Up until age 65, more prevalent in men
  • Associated with CHD and CVA
  • Disabling you dont know how lucky you are to
    be able to walk
  • Walking limited to under one block

Typical outcome measures
  • Maximal walking time Absolute Claudication
    Distance (ACD)
  • Pain-free walking time Initial Claudication
    Distance (ICD)
  • Self-reported walking limitations
  • Peak VO2
  • Quality of Life

Graded protocols for Quantifying Claudication
Labs EH, et al. Vasc Med 1999. Hiatt et al, J
Cardiopulmonary Rehabil 1988.
Characteristics of Individuals with Symptomatic
  • Adult mean age 65
  • Peak VO2 50 of age-predicted normal
  • ICD 110 meters
  • Sedentary

Effective interventions
  • Medication to control risk factors
  • Medication to improve claudication
  • Surgery (angioplasty or bypass)
  • Exercise Training
  • Home
  • Supervised
  • Dynamic

Supervised Treadmill Exercise vs Control
Supervised vs Home exercise
Pre-Post Supervised Programs
  • Increases of ICD and ACD 44-200
  • Hiatt et al
  • ACD 123
  • Peak VO2 30
  • ICD 165

Drug Therapy
  • Cilostazol (Pletal)
  • Vasodilation, inhibit platelet aggregation
  • Pentoxifylline
  • Methylxanthine derivative lowers plasma
  • L-carnitine

Drug therapy vs Placebo
Exercise vs. surgery
  • Angioplasty has initial increase in ACD, but same
    as exercise group after 12 months
  • Exercise has no adverse effects
  • Creasy 1990

Components of Effective Exercise Programs
  • 3x/week
  • At least 30 minutes
  • Walk until onset or moderate pain
  • Rest until pain subsides
  • Repeat
  • Increase grade when can do 10 minutes
  • weeks

Exercise Program Example
  • Warm up (5 min), 50 min intermittent exercise,
  • Week 1 2 mph 0 grade 3 min x 8 intervals
  • Week 2 2 mph 0 grade 6 min x 8 intervals
  • Week 3 2 mph 0 grade 10 min x 3 intervals
  • Week 6 3 mph 5 grade 10 min x 3 intervals

  • Supervised Exercise programs are beneficial in
    improving exercise tolerance in patients with
    cardiac or vascular disease
  • Other components of cardiac rehabilitation also
    produce beneficial effects on depression, risk
    profile and quality of life.

  • Describe the key components of cardiac
    rehabilitation for patients post CAB surgery
    using concept map
  • Determine ability to charge for cardiac
    rehabilitation for case example
  • Advocate for cardiac rehabilitation care for
    patient example

Cardiac Rehabilitation
Cardiac Rehabilitation Case DPT 732 2009
  • Elizabeth is a 52 year old woman who comes to
    your clinic 8 weeks after a double bypass surgery
    for coronary artery disease. She has been
    religiously observing her sternal precautions.
    Elizabeth now has lost shoulder ROM and complains
    of shoulder stiffness than limits her dressing,
    reaching, bathing. Elizabeth also complains of
    pain in her knees when walking.
  • Elizabeth has been referred to cardiac rehab
    phase II to start as soon as possible and has
    been referred to your clinic for PT to increase
    shoulder ROM and function. She received her
    stress test for cardiac rehab and is scheduled to
    start cardiac rehab at a hospital in town next
    week. She asks you if you can do the cardiac
    rehab here as well as the PT for her shoulders so
    she wont have to drive to 2 separate facilities.
    Even though she cant work because of her
    shoulders, she has a 10 year old at home. You
    have been considering whether to start a cardiac
    rehabilitation program at your clinic, so this is
    a push to start thinking about it.
  • Patient was prescribed these medications
    Inderal, Aspirin, Plavix, Zestril , Zocor
  • She reports she is only taking the aspirin

Question 1
  • Which impairments do you hypothesize are related
    to the sternal precautions and are not a common
    limitation following CAB surgery?
  • Decreased Shoulder ROM
  • Knee pain with walking

Question 2
  • What should the PT do about Elizabeths
  • Tell her to take them all as the doctor ordered
  • Ask why she is not taking all her medications as
  • Educate her on the purpose of the medications
  • Talk with her pharmacist about her not using the

Question 3
  • What is the best way to get Elizabeth to have PT
    and cardiac rehabilitation services?
  • PT can see Elizabeth for PT and cardiac rehab and
    charge for each service
  • PT can see Elizabeth for PT and refer to cardiac
  • PT to see Elizabeth for PT and cardiac rehab and
    charge as PT services