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Notes for occupational therapy undergraduate course curriculum in India by Punita V. Solanki

Notes for occupational therapy undergraduate course curriculum in India by Punita V. Solanki

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Notes on Cardiac Conditions_Punita V. Solanki

  1. 1. Disclaimer The occupational therapy undergraduate notes have been prepared by Ms. Punita V. Solanki (Ex- Assistant Professor, Occupational Therapy School and Centre, Seth G. S. Medical College and King Edward VII Memorial Hospital, during her teaching tenure) as per the Maharashtra University of Health Sciences University curriculum requirements, between the years 2001 and 2012 and the references of the textbooks have been listed at the beginning or the end of each topics. Occupational therapy students are directed to refer the latest editions of the listed references or additional references to upgrade the latest information for the concerned topics and keep up-to-date with the latest evidence-based practice literature. However, these notes will be useful guide for preparing updated notes as per the latest syllabus requirements set by the concerned university. For further information may contact Ms. Punita V. Solanki. MSc (OT); Fellow ACOT, ADCR (Mumbai) ֍ www.orthorehab.in
  2. 2. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 1 Third BOTH Notes on Occupational Therapy in Medical Conditions Syllabus Number 6: Cardiac Conditions 1. Understand the clinical presentations with respect to physical findings, pathophysiology and investigations. 2. Interpretation of signs and symptoms during work assessment. Interpret from exercise performance based on parametric evaluation – ECG and Haemodynamic responses. Understand application of exercise training effect for work and activity. 3. Administer exercise protocols using modalities like Treadmills, Ergometer, Step Apparatus, Walking, Brisk Walking & Spot Jogging. Cardiac conditioning using Treadmill, Ergometer and Step Apparatus. 4. Categorization of cardiac patients on the basis of risk factors for exercise prescription. 5. Indications and Contraindications for work prescription and activity. 6. Effects of drugs on exercise performance. 7. Modification of work and activity programmes with respect to residual cardiac functions. Assessment on work simulation. 8. Define METS and state its classification in brief. References 1. Willard and Spackman’s Occupational Therapy – Helen L. Hopkins & Helen D. Smith. 8th Edition 1993. Chapter 18: Functional Restoration. Section 2: Cardiac Conditions: Page 650-652. 2. Willard and Spackman’s Occupational Therapy – Elizabeth Blesedell Crepeau, Ellen S. Cohn and Barbara A. Boyt Schell. 10th Edition 2003. Chapter 34: Cardiopulmonary Dysfunction in Children. Page 721-724. Chapter 41: Cardiopulmonary Dysfunction in Adults. Page 807-819.
  3. 3. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 2 3. Occupational Therapy for Physical Dysfunction – Catherine A. Trombly. 4th Edition 1997. Chapter 43: Cardiopulmonary Diseases. Page 875-892. 4. Occupational Therapy for Physical Dysfunction - Catherine A. Trombly, Mary Vining Radomski. 5th Edition 2002. Chapter 47: Cardiac & Pulmonary Diseases. Page: 1071-1089. 5. Occupational Therapy: Practice Skills for Physical Dysfunction – Lorraine Williams Pedretti. 4th Edition 1997. Chapter 36: Cardiac Dysfunctions. Page 693- 714. 6. Occupational Therapy: Practice Skills for Physical Dysfunction – Lorraine Williams Pedretti, Mary Beth Early. 5th Edition 2001. Chapter 49: Cardiac & Pulmonary Diseases. Page 966-980. 7. Occupational Therapy and Physical Dysfunction – Principles, Skills and Practice – Ann Turner, Margaret Foster, Sybil E. Johnson. 4th Edition 1996. Section 3: Cardiac Rehabilitation. Page 767-815. 8. Occupational Therapy and Physical Dysfunction – Principles, Skills and Practice – Annie Turner, Margaret Foster, Sybil E. Johnson. 5th Edition 2002. 9. Textbook of Work Physiology: Physiological bases of exercise – Per - Olof Astrand, Kaare Rodahl. 3rd Edition 1986. Chapter 8 & 10 10. Rehabilitation Medicine – Joseph Goodgold. 1st Edition 1988. Chapter 15 to 20 Page 217-284. 11. Rehabilitation Medicine: Principles and Practice – Joel A. DeLisa, Bruce M. Gans. 3rd Edition 1998. Chapter 54: Rehabilitation of the Cardiac Patient. Page 1337-1357. 12. Downey and Darling’s Physiological basis of rehabilitation medicine – Erwin G. Gonzalez, Stanley J. Myers, Joan E. Edelstein, James S. Lieberman & John A. Downey. 3rd Edition 2001. Chapter 9: Cardiopulmonary Physiology. Page 169-189.
  4. 4. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 3 13. Krusen’s Handbook of Physical Medicine and Rehabilitation – Frederick Kottke. 4th Edition 1990. Chapter 41: Rehabilitation of the Patient with Heart Disease. Page 874-903. 14. Therapeutic Exercise – John V. Basmajian. 5th Edition 1990. Chapter 20: Exercise and Coronary Artery Disease. Page 387-404. 15. Stress Testing: Principles and Practice – Myrvin H. Ellestad. 4th Edition 1996. 16. Clinical Cardiac Rehabilitation: A Cardiologist’s Guide – Fredric J. Pashkow, William A. Dafoe. 2nd Edition 1999. 17. Exercise standards for testing and training: A statement for healthcare professionals from the American Heart Association. Gerald F. Fletcher et al. Circulation 2001; 104; 1694-1740.
  5. 5. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 4 3. Administer exercise protocols using modalities like Treadmills, Ergometer, Step Apparatus, Walking, Brisk Walking & Spot Jogging Requirements for Exercise Stress Testing Protocols 1. Continuous ECG monitoring. 2. ECG recording when desired, preferably several simultaneous leads before, during and after exercise. A minimal recording of muscle potential is essential to an artifact free recording. 3. A type of activity that can be performed by the sedentary, poorly developed and under conditioned subjects as well as by the trained athlete. 4. A workload that can be varied according to the capacity of the individual but is standardized enough to deliver reproducible results and allow comparison with other patients tested. 5. Repeated frequent blood pressure measurements before, during and after exercise. 6. A way of estimating the aerobic requirements of individuals tested. 7. Maximum safety and minimum discomfort for each individual tested. 8. The highest possible specificity and sensitivity in the discrimination between health and disease. 9. A sufficient body of information available as to the response of normal and cardiac patients. 10. A first stage long enough for a warm up to occur. 11. A procedure short enough to be practical. Clinical Indications for Exercise Stress Testing 1. Evaluation of symptoms. 2. Progression and severity of disease: a. To know the pre-event - extent of disease. b. Post-event – risk stratification for MI, sudden death or need for revascularization. 3. Selection and evaluation of most effective therapy.
  6. 6. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 5 4. Progression of disease. 5. Screening for latent coronary artery disease. 6. Evaluation of dysrhythmias. 7. Evaluation of functional capacity for exercise prescription and for knowing the disability status. 8. Evaluation of pacemaker or internal defibrillator function. Contraindications to Exercise Stress Testing Absolute Contraindications: 1. Acute myocardial infarction or recent change on resting ECG. 2. Active unstable angina. 3. Serious cardiac arrhythmias. 4. Acute pericarditis or endocarditis. 5. Severe or symptomatic aortic stenosis. 6. Severe left ventricular dysfunction. 7. Acute pulmonary edema, embolus or pulmonary infarction. 8. Acute or serious non-cardiac disorder. 9. Severe physical handicap or disability. 10. Dissecting aneurysm. Relative Contraindications: 1. Less serious non-cardiac disorder. 2. Significant arterial or pulmonary hypertension (>200 mm Hg systolic or >110 mm Hg diastolic) 3. Tachyarrhythmias or bradyarrhythmias. 4. Moderate valvular or myocardial heart disease. 5. Drug effect or electrolyte abnormalities. 6. Left main coronary obstruction or its equivalent.
  7. 7. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 6 7. Hypertrophic cardiomyopathy with rest gradient. 8. Mental or physical impairment resulting in inability to exercise. 9. Advanced or complicated pregnancy. 10. Uncontrolled metabolic disease. 11. Disorders that are exacerbated by exercise. 12. High degree Atrio-Ventricular block Preparations for exercise testing include the following 1. The subject should be instructed not to eat or smoke for 3 hours before the test. Water may be taken as needed at any time. Subjects should dress appropriately for exercise, especially with regard to footwear. No unusual physical efforts should be performed for at least 12 hours before testing. 2. When exercise testing is performed for diagnostic purposes, withdrawal of medications may be considered because some drugs (especially ß-blockers) attenuate the exercise responses and limit the test interpretation. There are no formal guidelines for tapering medications, but rebound phenomena may occur with abrupt discontinuation of ß-blockers in patients with a recent acute coronary syndrome. However, most subjects are tested while taking their usual medications. Specific questioning is important to determine which drugs have been taken so that the physician can be aware of possible electrolyte abnormalities and hemodynamic effects of cardioactive drugs. 3. A brief history and physical examination should be performed to rule out contraindications to testing or to detect important clinical signs such as a cardiac murmur, gallop sounds, pulmonary "wheezing," or rales. Subjects with a history of worsening unstable angina or decompensated heart failure should not undergo exercise testing until their condition stabilizes. A cardiac physical examination should indicate which subjects have valvular or congenital heart disease. Because hemodynamic responses to exercise may be abnormal in such subjects, such subjects
  8. 8. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 7 always warrant careful monitoring and, at times, may require early termination of testing. Special considerations should be made for those with elevated blood pressure and aortic stenosis. 4. If the indication for the testing is not clear, the subject should be questioned and the referring physician contacted. 5. A resting standard 12-lead electrocardiogram (ECG) should be obtained because it may differ from the resting pre-exercise ECG. The "torso" ECG distorts the standard ECG by shifting the axis to the right, increasing voltage in the inferior lead group. This may cause a disappearance of Q waves in a patient with a documented previous Q-wave inferior myocardial infarction (MI). 6. Standing ECG and blood pressure should be recorded (in the sitting position with cycle ergometry) to determine vasoregulatory abnormalities and positional changes, especially ST-segment depression. 7. A detailed explanation of the testing procedure should be given that outlines risks and possible complications. The subject should be instructed on how to perform the test, and these instructions should include a demonstration. If musculoskeletal or certain orthopedic limitations are a concern, the testing protocol should be modified. Criteria to Stop Exercise Test (Abnormal response to exercise test) or Indications for Test Termination: Absolute 1. Drop in Systolic Blood Pressure > 10 mm Hg from resting value despite increase in workload with evidence of ischemia. 2. Moderately Severe Angina (3+ to 4+) 3. Central Nervous System symptoms i.e. dizziness, unsteadiness/ataxia, near syncope, clumsiness, nausea or vomiting. 4. Signs of Poor perfusion (peripheral circulatory insufficiency) i.e. pallor, clammy skin, cyanosis.
  9. 9. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 8 5. Serious arrhythmias (sustained ventricular tachycardia). 6. Marked ECG changes i.e. ST segment deviation (elevation) > 1.0 mm in leads without diagnostic Q waves (other than V1 and AVR). 7. Patient’s request to stop the exercise. 8. Technical problems with monitoring ECG or Blood Pressure. Relative 1. Drop in Systolic Blood Pressure >10 mm Hg from resting value despite increasing workload without other evidence of ischemia. 2. Horizontal or downsloping ST segment depression > 2.0 mm. 3. Less serious arrhythmias. 4. Marked axis shift. 5. Increasing chest pain (angina). 6. Fatigue, shortness of breath, wheezing, leg cramps or intermittent claudication. 7. Exaggerated blood pressure response (> 250 mm Hg systolic; >115 mm Hg diastolic). 8. Development of bundle branch block that cannot be distinguished from Ventricular tachycardia. 9. Second or third degree Atrio-ventricular block. Exercise Stress Tests can be performed using various equipments and protocols such as Treadmills, Ergometers (Cycle or Arm), Step Apparatus etc. Exercise Test Protocols 1. Maximal test: Starting from rest, the workload is increased in a stepwise manner until the patient is exhausted. This is known as a “Maximal test” and its completion is confirmed by the fact that despite a further increase in the workload the heart rate and oxygen uptake do not show a concomitant rise.
  10. 10. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 9 If any untoward symptoms or signs appear before this physiological maximum is reached then the test is terminated and is referred to as a “Symptom Limited Maximal test” 2. Submaximal test: is a one carried out to a predetermined target heart rate usually 85 % of maximum. Maximum Age Adjusted Heart Rate is 220 - age. Protocols may be intermittent or continuous; single stage (single/fixed load) or multi stage with varying load (speed and grade). Treadmill: Exercise Stress test is usually performed on a treadmill using a standardized protocol that increases speed and grade in stepwise fashion. The treadmill is expensive and relatively immobile and electric power supply is a must. Recording of ECG and other measurements may be more complicated during walking and running than during cycle Ergometer however the treadmill is very useful and a must in a laboratory for basic research in exercise physiology. The treadmill employs more natural walking action and possibly for this reason has become the principle choice of test in clinical settings. Treadmill applies a more physiological workload than Ergometer. Subjects are much more likely to reach their aerobic capacity or their peak predicted heart rate on the Treadmill than on Ergometer. Apart from providing very slight and occasional support to the very apprehensive subject, the grab rails should not be touched during the test and this exclusion may make cycle Ergometer the choice for older and more disabled subjects. The many different protocols for clinical use include an initial low load (warm up), progressive exercise with adequate duration at each level and a recovery period (cool down). The most commonly used protocols are progressive, uninterrupted and the workload is increased in stages. Various Protocols available for treadmill tests are: 1. Balke. 2. Naughton.
  11. 11. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 10 3. Bruce, Modified Bruce. 4. Ellestad. 5. Astrand & Rudahl, Modified Astrand. 6. Cornell. 7. Ramp. The Balke and Naughton protocols are probably best suited to the early post MI patients. The Bruce protocol is probably the most popular in use today and the Ellestad protocol is slightly more demanding but is less time consuming. Balke’s Treadmill Exercise Test Protocol Stage Speed 3.3 miles per hour Grade % Duration in minutes METS Level 1 Constant 2 2 2 Constant 6 4 3 Constant 10 6 4 Constant 14 8 5 Constant 18 10 6 Constant 22 12 Naughton’s Treadmill Exercise Test Protocol Stage Grade % for 2.0 mph speed Grade % for 3.0 mph speed Grade % for 3.4 mph speed Duration in minutes METS Level 1 2 2 0.0 2 3 3.5 0.0 2 4 7.0 2.5 2.0 2 5 10.5 5.0 4.0 2
  12. 12. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 11 6 14.0 7.5 6.0 2 7 17.5 10.0 8.0 2 8 12.5 10.0 2 9 15.0 12.0 2 10 17.5 14.0 2 11 20.0 16.0 2 12 22.5 18.0 2 13 25.0 20.0 2 14 27.5 22.0 2 15 30.0 24.0 2 16 32.5 26.0 2 Bruce’s Treadmill Exercise Test Protocol Stage Speed miles per hour Grade % Duration in minutes METS Level 1 1.7 10 3 2 2.5 12 3 3 3.4 14 3 4 4.2 16 3 5 5.0 18 3 6 5.5 20 3 7 6.0 22 3 Ellestad’s Treadmill Exercise Test Protocol Stage Speed miles per hour Grade % Duration in minutes METS Level 1 1.7 10 3 2 3.0 10 2 3 4.0 10 2
  13. 13. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 12 4 5.0 10 3 5 5.0 15 2 6 6.0 15 3 Cycle Ergometer: The use of the cycle in testing has several advantages over treadmill test. The patient’s thorax and arms are relatively stable allowing ECGs to be recorded with less muscle artifact and making it easier to record blood pressure accurately. Within limits the mechanical efficiency is independent of body weight i.e. patient’s body weight does not influence exercise capacity appreciably. Sitting on a cycle often produces less anxiety than walking on a mechanically/electrically driven treadmill. The cycle requires less space in the laboratory and is usually less expensive than a treadmill. The cycle may be mechanically or electrically braked and the workload is easily calibrated in watts or kilogram meters and tends to be less dependent on patient’s weight and physical efficiency. Cycle Ergometer tests can be divided into two types: 1. Progressive multistage and 2. Steady state. The protocols can be intermittent or continuous. In the progressive multistage protocol the power output is increased by a constant value usually 100 kilopond meters per minute (KPM) or 16.7 watts, every minute (16 watts) until maximal or target heart rate is reached. Measurements are made in the final 15 seconds of each minute. This test is particularly valuable when the ventilatory anaerobic threshold is being calculated from analysis of expired air. In the steady state protocol 3 power outputs are employed, each of 3-5 minutes duration, the intensity being usually 25%, 50% and 75% of estimated maximal effort. Measurements are made during the last minute of each stage, when the variables are judged to have reached a constant steady state. The maximum power
  14. 14. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 13 output for healthy adults (on the cycle Ergometer) can be estimated from the following equations: Male: Maximum Power Output (KPM) = [4200 – (age in yrs x 32.0)] + 3.5 x body wt (Kg) 2 Female: Maximum Power Output (KPM) = [2600 – (age in yrs x 14.0)] + 3.5 x body wt (Kg) 2 Cardiac patients may have a reduced work capacity and this has to be taken into account. In practice the healthy sedentary individual’s initial steady state test is usually 300 KPM (50 watts), 600 KPM (100 watts) and 750 KPM (125 watts). A fitter subject might be given at third power output of 900 KPM (150 watts). At initial assessment cardiac patients are usually given power outputs of 150 KPM (25 watts), 300 KPM (50 watts) and 450 KPM (75 watts). In patients unable to exercise with their legs because of orthopaedic problems or vascular insufficiency arm crank ergometry provides an excellent substitute. Step Test: In field studies a step test may be the only realistic test alternative. It is more difficult to standardize and offers limited possibilities for varying the demand on the oxygen transporting system. There is equipment variable. At the maximal effort the stepping pace must be high and there is always the risk that the subject may stumble when approaching a maximal rate of work. Besides in the unaccustomed subject the aftermath is sore muscles. It is even more difficult to perform recordings such as ECG on exercising subjects during a step test than is the case during the treadmill test. Master’s Test: The protocol for the Master’s test the best known single load test was constructed originally as an exercise tolerance test rather than a screening test for
  15. 15. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 14 coronary artery disease. The subject walked up and over a device two steps high with three steps, two of which were 9 inches above the floor and a top step 18 inches high. Even though Master used three steps in each ascent, two up and one down, it was called a two step test. After going up and over the patient then turned and walked over the steps again for a prescribed number of ascents. Blood pressure and pulse were then recorded; by knowing the patient’s weight and the time required to complete the test, the work per minute could be derived. It was suggested that the prescribed number of ascents be completed in 1½ minutes. Many years later, Master added the ECG and suggested that it be recorded before and after the step test. This test was accepted as the standard until the 1970s and for years was the most widely used in spite of its clinical limitations. Now it is rarely used in clinical practice. Jogging in place protocol: Jog in place protocol may be used in patients with appropriate monitoring, as a substitute for a Cycle Ergometer or Treadmill. Higher VO2 and double products are achieved by jogging in place when compared with the Bruce Treadmill protocol. Cardiac conditioning using Treadmill, Ergometer and Step Apparatus: Principles of Cardiovascular Conditioning: 1. Principle of Overloading: An exercise to be effective in augmenting conditioning must be at a work level greater than that at which the individual usually performs. This can be accomplished by manipulating the intensity, duration and frequency of the exercise with intensity as the most important component. 2. Principle of Specificity: Each type of exercise brings about a specific metabolic and physiologic adaptation resulting in a specific training effect. Power training using isometrics results in an increase in strength but may not increase endurance. Aerobic training is the type of exercise that leads to improvement in endurance,
  16. 16. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 15 which includes exercise of large muscle masses; it can improve cardiovascular functional capacity. All these types of training are important in rehabilitation to improve BADL and Job related performances. 3. Principle of Individual variation: Training should be individualized according to person’s capacities and needs. Although some cardiac patients can run marathons for example, the functional capacities of most cardiac patients will not permit this to be accomplished regardless of the amount of training that the cardiac patient is willing to perform. 4. Principle of Reversibility: The beneficial effects of training are not permanent. The improvements attained begin to disappear only 2 weeks after cessation of exercise and half of the gains may be lost in only 5 weeks. When a patient on an exercise program goes on vacation, that patient should continue to exercise in a format similar to the exercise program or should plan other similar activities to be continued during the vacation. Drug Prescription Versus Exercise Prescription S. No Drug Prescription Exercise Prescription 1. Name of the Drug Type of Exercise 2. Strength of the Drug Exercise Intensity 3. Dosage Duration for each session 4. Frequency Frequency Exercise Prescription 1. Type of exercise: Exercise for cardiovascular conditioning should be isotonic, rhythmic and aerobic in nature, should use large muscle groups and should not involve a large isometric component. The most popular exercises are spot march, walking, climbing and descending stairs, cycle ergometer or stationary cycle, road cycling, treadmill walk or run, running, spot jogging, jogging, swimming, skipping
  17. 17. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 16 and hopping, marathon run, gymnastics, skating, skiing etc. as per the patients age, gender and general condition. In the recent years strength training and circuit weight training are being added to ongoing aerobic training and have been found to be a low risk for patients with good left ventricular function. However patients with impaired left ventricular functions may decompensate on resistive exercises. So these exercises are not prescribed for them or for those with uncontrolled arrhythmias or unstable angina. 2. Intensity of exercise: Exercise intensity may be prescribed in accordance with one of the five methods: a. American Heart Association method: A target heart rate of 70% to 85% of the maximum attainable heart rate determined on a stress test or derived for normal young adults by subtracting the exerciser’s age from 220. b. Karvonen method: Heart rate range is calculated as peak heart rate attained on a stress test, minus resting heart rate. Then 40% to 60% of the heart rate range is added to the resting heart rate to give a target heart rate zone for exercise. c. Oxygen consumption method: 67% to 80% of maximal oxygen consumption is an appropriate intensity and can be expressed in terms of heart rate using the stress test as a template if expired gases were measured. d. Work load method: і) Training sessions should be at two thirds of the maximal MET level attained on the stress test, or іі) 150 KPM (25 watts) lower than the maximal level attained on the cycle ergometer stress test, or ііі) Use the highest speed reached at 10% grade on the treadmill test as the speed for walking on flat terrain. e. Perceived exertion method: і) Borg RPE scale (Ratings of 11 - 15) or Modified Borg RPE scale (Ratings of 2 – 5) usually corresponds to an appropriate training intensity.
  18. 18. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 17 іі) Conversational exercise level: Patients should be able to talk while exercising (talk test) but probably would be too breathless to sing while exercising. 3. Duration of exercise: Improvements can be achieved while exercising for varying lengths of time per session, the duration depending on the level of fitness of the individual and the intensity of the exercise. The usual duration when exercise is at 70% of maximum heart rate is 20 – 30 minutes at conditioning level. The duration may be increased upto 60 minutes per session depending upon the intensity of exercise. In the poorly conditioned individual daily exercises for 3 – 5 minutes can bring about improvement. For the conditioned individual who prefers to exercise at higher intensities, duration of exercise may be reduced to 10 – 15 minutes. 4. Frequency of exercise: Training frequencies for aerobic exercise protocols may vary from 2 – 5 days per week. But the most consistent benefits appear to occur with frequencies of 3 times per week for 12 weeks or more. There is no contraindication to exercising every day but as the number of sessions increases the likelihood of musculoskeletal injury increases. 5. Format of an exercise session: There should be a warm up phase before and a cool down phase after the period of training i.e. stimulus phase where the exercise is performed at the prescribed intensity and duration that induce a training effect. The warm up period is usually at the lower intensity levels of exercise to be performed; gradually increasing to the prescribed intensity or it may be in the form of limbering up exercise. The purpose is to increase joint readiness, theoretically to open up existing collateral circulation and prevent sudden changes in peripheral resistance before the maximum contraction of the skeletal muscles required by the exercise. At the cool down period there is a gradual reduction in exercise intensity to
  19. 19. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 18 allow the gradual redistribution of blood from the extremities to other tissues and to prevent the sudden reduction in venous return, thereby reducing the possibility of post exercise hypotension or even syncope. Cool down also reduces the development of stiffness or soreness of joints and muscles. Maintenance Programs: After completion of formal exercise training in a cardiac rehabilitation program, which is approximately 12 weeks with performance safely up to 7 to 8 METS verifiable by stress test, exercisers should continue their physical conditioning in order to maintain the level of fitness that was attained. Patients can continue the same exercise at the same work level as their last exercise prescription using target pulse rate, conversational exercise level or Borg RPE as a guideline to avoid overexertion. To encourage the patient’s continued physical training exercise should become part of the individual’s recreational life style. Sports activities can be incorporated into the cardiovascular conditioning program and may be used as the exercise for maintenance but should not exceed the safe heart rate and symptomatic guidelines previously established. Sports such as bowling, golf, group volleyball etc can safely be involved in the daily or weekend routines. 8. Define METS and state its classification in brief. One MET (Basal Metabolic Equivalent) is equal to the energy consumed when a patient is at rest in a semi-Fowler position (semireclined with extremities supported), which is equal to 3.5 ml of Oxygen (O2) per minute per kilogram of body weight. As soon as the patient sits up, walks or performs activities the metabolic demands and oxygen consumption increases. Work physiologists have established guidelines, metabolic equivalent tables (METS), for determining levels of work based on oxygen consumption and calorie equivalents which indicate the ratio between basal metabolism and metabolism related to specific activity performance. Energy is measured by the amount of
  20. 20. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 19 oxygen consumed to maintain metabolic processes such as respiration, circulation, peristalsis, temperature, glandular functions etc and to carry out activities. It is expressed as a MET level. Activities are graded in six levels from minimal (less than 1.5 METS) to excessively severe (7 or more METS). The following are some examples of MET levels and activities: 1. Minimal (Less than 1.5 METS): rest, sitting on bedside, standing at bedside (1- 1.2), listening to the radio (1.45). 2. Light (1.5-2.5 METS): eating (1.5), sewing (1.6), getting in or out of bed (1.65), writing (1.8), driving or propelling a wheelchair (2.5). 3. Moderate (2.5-3.5 METS): playing piano (2.5-2.7), dressing (2.5-3.5), preparing meals (3), walking (3.2), taking a warm shower (3.5). 4. Heavy (3.5-5 METS): having a bowel movement (3.6-4.7), making the bed (3.9), golfing (4), walking down the stairs (4.5), gardening (4.5). 5. Severe (5-7 METS): walking with brace or crutches (6.5), playing tennis (6), scrubbing a floor (5.3), riding a bicycle 8 to 10 miles per hour (7). 6. Excessively Severe (more than 7): skiing (8), mowing lawn (7.7), climbing stairs rapidly (9), having sexual intercourse (6-9). Performance speed, air temperature, emotional tension, use of assistive devices and locomotor problems during activity can upgrade the MET level and thus further challenge cardiac output and energy requirements. This knowledge of MET levels classification is used advantageously by occupational therapists in the field of cardiopulmonary rehabilitation. MET level assessment is a commonly used measure to indicate endurance and activity tolerance. Exercise Prescription according to METS Level: Exercise for the cardiac patient is prescribed in a manner similar to and with as much care as a drug prescription. The prescription of exercise should specify the type of exercise, intensity, duration and frequency. With respect to Work load method the intensity of exercise in a training
  21. 21. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 20 session should be at two thirds of the maximal METS level attained on the stress test during the outpatient phase rehabilitation. The inpatient phase lasts approximately 5 to 14 days and begins early while the patient is still in the coronary care unit. As per the guidelines for Inpatient reconditioning programs the functional activity prescription is initiated from 1.5 METS level. In this phase activities in the range between 1 to 5 METs levels are indicated as tolerated by the patient in the form of upper extremity calisthenics, stair climbing, bicycling and walking. Return to Employment as per METS Level: Individuals who can perform 7 METS or higher without any limitations or abnormal responses should be able to return to most jobs except those of a heavy industrial nature. Bench Marks of Exercise Capacity METS Level Exercise Capacity < 5 Associated with a poor prognosis in patient < 65 years old 5 Equated with limit for ADLs, the usual exercise limit in the immediate post MI period 10 Considered a normal level of fitness. In patient with angina, there is no improved survival with bypass surgery vs. medical management 13 Indicates good prognosis despite any abnormal exercise response 18 Aerobic master athlete 22 Well trained competitive athlete
  22. 22. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 21 1. Understand the clinical presentations with respect to physical findings, pathophysiology and investigations. 2. Interpretation of signs and symptoms during work assessment. Interpret from exercise performance based on parametric evaluation – ECG and Haemodynamic responses. Understand application of exercise training effect for work and activity. Physical Findings: Signs and Symptoms of Cardiac Distress 1. Angina: Chest pain. Site: Retrosternal. Character: Usually described as squeezing, tightness, aching, burning, choking, strangling, vice like, lump in the chest, heaviness, pressure etc Radiation: across the chest, both arms, shoulders more commonly left side, interscapular region, neck, jaw, fingers, epigastric region. Duration: exertional angina lasts for 1-5 minutes, emotion induced angina lasts for 5-15 minutes, any pain which lasts only for a few seconds is not ischemic in origin. Precipitating factors: exertion, uphill climbing, emotional stress, sudden exposure to cold. More intense or longer lasting pain forewarns of greater ischemia. 2. Dyspnoea: Shortness of breath at rest or with usual or unaccustomed activity. Note the duration of Dyspnoea. It is due to increased work of breathing, decreased vital capacity, bronchial spasm, hypoxemia or reflex hyperventilation. Paroxysmal nocturnal Dyspnoea occurs due to left sided cardiac failure. 3. Diaphoresis: Cold clammy sweat that comes on suddenly. 4. Orthopnoea: Dyspnoea brought on by lying supine. Count the number pillows the patient sleeps on to breathe comfortably. Due to congestive heart failure because of increased venous return in the supine position which exacerbates preexisting pulmonary venous hypertension. 5. Fatigue: Generalized feeling of exhaustion. The Borg or Modified Borg Rate of Perceived Exertion scale is used to grade fatigue level.
  23. 23. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 22 6. Nausea/Emesis: Vomiting or signs that the patient feels sick. 7. Cerebral signs: Ataxia, dizziness, confusion, fainting (syncope) are all signs that the brain is not getting enough oxygen due to cardiac dysfunction 8. Orthostatic hypotension: Drop in Systolic blood pressure of greater than 10 mm of Hg with change of position from supine to sitting or sitting to standing. 9. Persistent dry hacking cough: In pulmonary infarction, pulmonary venous hypertension and tracheobronchial compression due to underlying cardiac disease. The cough is irritating, non productive and more marked at night. 10. Palpitation: an unpleasant subjective awareness of the heart beat. Seen in left ventricular volume overload as in aortic and mitral regurgitation, left to right shunts such as VSD, PDA, cardiac arrhythmias etc. 11. Oedema: accumulation of fluid in the interstitial tissues due to cardiac disease with congestive heart failure. This leads to unusual weight gain within few days of onset of illness/ episode. 12. Cyanosis: Blue tinge of the skin and mucous membrane to dark bluish hue. Can be peripheral due to cutaneous vasoconstriction or central due to impaired pulmonary gas exchange due to cardiac or pulmonary disease, right to left shunts. 13. Clubbing: Obliteration of the normal angle between the nail and the dorsum of the finger with or without longitudinal curving of the nail. Graded as mild, moderate, severe and gross. Interpretation based on following clinical parameters 1. Blood Pressure: To be considered normal blood pressure must be less than 140/90 mm of Hg at rest. Patients with blood pressure more than 140/90 mm of Hg at rest without underlying systemic disorder are diagnosed as cases of essential hypertension.
  24. 24. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 23 Normal/Appropriate Response to Exercise/Work: Systemic blood pressure should rise with exercise/activity. The diastolic blood pressure while exercising should stay the same or drop slightly. The diastolic blood pressure while exercising should not be more than 10 mm Hg greater than resting pressure. A patient who has a history of high blood pressure (hypertension) is likely to have an exaggerated blood pressure response with exercise. Inappropriate Response to Exercise/Work: Systolic blood pressure ≥ 220 mm of Hg, Diastolic blood pressure ≥ 110 mm of Hg, Postural hypotension (≥ 10 - 20 mm of Hg drop in systolic pressure), decrease in Systolic pressure with activity. Spontaneous normalization of previously elevated blood pressure after myocardial infarction is a sign of incipient heart failure and indicates poor prognosis. Effect of Training: Training causes the blood pressure to be lower slightly at rest and during any submaximal or maximal workload. It is now known that the marked drop in resistance to blood flow is a major factor. This effect is mainly due to a dramatic increase in blood flow to the skin and muscles. 2. Heart Rate: A normal heart rate range at rest is 60 to 100 bpm. For someone who is fit such as a runner may have a heart rate in the 40s or 50s bpm. After open heart surgery it is common for a patient to have a heart rate in the low 100s. If the patients heart rate is uncontrolled and is running 120 bpm or higher at rest, exercise is contraindicated. Normal/Appropriate Response to Exercise/Work: Heart rate increases with activity and should not be more than 20 bpm above resting heart rate in proportion to the intensity and duration of exercise. In the first 2 weeks of convalescence, during exercise the heart rate should not increase more than 20 bpm above resting for a patient with an MI and about 30 bpm for a patient after surgery.
  25. 25. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 24 Inappropriate Response to Exercise/Work: Heart rate more than 20 bpm above resting heart rate with activity, resting heart rate ≥ 120 bpm, pulse drops or fails to rise with activity. Effect of Training: Training causes the heart rate to be lower at rest and during any submaximal workload, but the maximal heart rate does not change. This bradycardia of training is the most noticeable and clinically important change that occurs with aerobic conditioning and it is primarily because of an increase in vagal tone combined with a decrease in sympathetic tone and lower levels of circulating catecholamines. 3. Ventilation & Respiration: Ventilation is defined as the work performed by the musculoskeletal pump to generate gas flow through the conducting tubules of anatomic dead space and into the functional unit of the lung. Respiration is the exchange of gas across the large surface area of the lung’s blood-gas interface. Both functions are essential for oxygen uptake and subsequent delivery to the tissues. Respiratory Rate normally ranges from 12 to 20 breaths per minute (bpm). Normal/Appropriate Response to Exercise/Work: The minute ventilation increases in a linear fashion with the increasing work intensity up to a point and then the response becomes much steeper. During most of this increase there is no measurable change in PCO2, PO2 or pH. With greater loads there is a decrease in the pH that is not proportional to the ventilatory response and with very high loads PO2 may decrease. The rate and volume/depth of respiration increases with exercise. Inappropriate Response to Exercise/Work: Hyperpnoea, Dyspnoea (shortness of breath) Tachypnoea (rapid shallow breathing) not proportional to the intensity and duration of exercise/work. Effect of Training: Training has less of an effect on the ventilatory response to exercise than the cardiac response. In general, the rate of respiration is somewhat
  26. 26. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 25 slower and the depth greater at any given submaximal load, but the minute ventilation remains essentially unchanged. 4. Blood Volume: (Cardiac Output): The amount of blood ejected per minute. Normal/Appropriate Response to Exercise/Work: The immediate effect of exercise is to reduce blood volume. Effect of Training: Long term exercise and conditioning produces a significant increase in blood volume. The size and number of blood vessels are also increased significantly. 5. Stress Electrocardiogram: Normal/Appropriate Response to Exercise/Work: Normal Sinus Rhythm, Absence of arrhythmias and segment changes. Inappropriate Response to Exercise/Work: Any rapid serious arrhythmias or increase in ectopic activity, development of 2-3 degree heart blocks (Atrio-Ventricular block). Horizontal or downsloping ST segment depression (>1.0 mm) from baseline, ST segment elevation > 1.0 mm from baseline in leads without Q waves, Decrease in heart rate as exercise increases, Estimated functional capacity of < 3 METs.
  27. 27. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 26 Possible mechanisms of benefit from exercise therapy: Fox and Haskell presented a comprehensive listing of the possible mechanisms whereby physical activity might improve the prognoses of patients prone to MI: I) Light Activity: A) Life style advice: general improvement in life style B). Psychosocial effects: Camaraderie, Joie de vivre, relaxation and eu-stress. II) Moderate Activity: A) Reduced cardiac work rate: Due to lower heart rate, lower blood pressure, increased myocardial efficiency and muscle force. B) Improved O2 Transport: Due to increased blood volume, better flow distribution, increased capillarity, increased tissue enzymes, increased hemoglobin?, increased arterial O2 content? C) Hormonal changes: Decreased catecholamines, increased growth hormone and thyroid hormone. D) Blood coagulability: increased fibrinolysis, decreased platelet stickiness. III) Intense Activity: A) Habituation B) Enlargement of coronary arteries and may be collaterals. IV) Increased energy usage: A) Decreased body mass: lower work rate and easier heat loss. B) Muscles strengthened and therefore less after load C) Blood profile: increased HDL cholesterol, decreased triglycerides, improved glucose tolerance.
  28. 28. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 27 4. Categorization of cardiac patients on the basis of risk factors for exercise prescription. The Framingham study correlates the presence of several risk factors to the progression of the arteriosclerotic process. The American Heart Association (AHA) divides patients with cardiac disorders into 3 categories based on risk factors: 1. Patients with risk factors that are not controllable or that cannot be changed: a) Age. b) Gender and c) Heredity/Family history. 2. Patients with major risk factors that can be changed: a) Cigarette smoking. b) High blood pressure (Hypertension). c) Blood cholesterol levels (Hyperlipidemia). d) Physical inactivity (Sedentary lifestyle). 3. Patients with contributing factors: a) Diabetes. b) Obesity. c) Psychological stress. Age: Risk of heart disease increases with age. Gender: Men are likely to develop heart disease an average of 10 years earlier than women but as women approach menopause they lose the protective effect of estrogen and their risk of heart disease increases. The risk of heart disease in women continues to rise after menopause until the 70s. Then their incidence of heart disease surpasses that of men. Heredity/Family History: A first degree relative such as father, mother or sibling developing heart disease before age 50 increases one’s risk. The highest risk of developing heart disease for both men and women occurs when another sibling with heart disease increases one’s risk by 3-4 times that of a person without a sibling history of the disease.
  29. 29. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 28 Smoking: is a major modifiable risk factor in heart disease. People who smoke increase their risk of dying of heart disease by a factor of two to three. Smoking damages the endothelial lining of the coronary arteries increasing their susceptibility to plaque formation. Nicotine causes vasoconstriction of the arteries and increases heart rate. Smoking makes the heart more susceptible to lethal ventricular arrhythmias and predisposes it to coronary artery spasm. Carbon monoxide in cigarette smoke binds with hemoglobin faster than oxygen resulting in less oxygen being distributed to the tissues. Nicotine also alters the metabolism of fats increasing the levels of athrogenic low density lipoprotein (LDL) cholesterol and decreasing the levels of the heart protective high density lipoprotein (HDL) cholesterol. Smoking causes the blood to coagulate more quickly and promotes thrombus formation. Guidelines for smoking interventions: The entire treatment and rehabilitation team should provide a clear and consistent message that the patient should stop smoking. An occupational therapist should be assigned to work with the patient to develop problem solving skills to replace the smoking behavior with a more appropriate activity. 1. At each visit advice the patient that you would like him or her to quit smoking. 2. Ask the patients what they are willing to do about their smoking. 3. Reinforce positive attempts to quit smoking. 4. Reinforce the patient who has quit smoking. 5. Expect that the patient may relapse. 6. Do not give up; most ex smokers have tried to quit several times before finally succeeding. Hypertension: Patients with hypertension have a progressive increase in both nonfatal and fatal cardiovascular disease because of high systolic and diastolic blood pressure. The AHA classifies blood pressure greater than 140/90 at rest as
  30. 30. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 29 hypertension. Hypertension damages the arterial walls and causes increased myocardial oxygen consumption because of the heart’s need to do more work against high pressures. High blood pressure may be diagnosed after several elevated blood pressure readings. It is controlled by medications, weight loss, moderation in alcohol and sodium intake and physical activity. Hyperlipidemia: It has been demonstrated that a total cholesterol level above 200 mg/dL, and LDL cholesterol above 130 mg/dL and HDL cholesterol of less than 35 mg/dL significantly increases the risk of heart disease. Cholesterol levels may be lowered through a low fat diet, regular aerobic exercise and weight loss program. If these efforts are unsuccessful the physician will probably prescribe a lipid lowering drug. This is more useful in individuals who inherit an inability to metabolize lipids normally. Sedentary lifestyle: People who are physically inactive have twice the rate of heart disease as those who exercise regularly. Regular exercise reduces blood pressure, lowers levels of atherogenic LDL cholesterol in the blood, raises the level of heart protective HDL cholesterol and increases insulin sensitivity and glucose tolerance. The Center for Disease Control’s Behavioural Risk Factor Surveillance Study defined adequate aerobic exercise as sustained physical activity 3 to 4 times per week for at least 30 minutes. Because of the effect of exercise on the heart, circulatory system and other risk factors aerobic exercise is an effective weapon against heart disease.
  31. 31. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 30 Diabetes: Women who have diabetes lose the protective effect of their hormones against heart disease and their risk of coronary artery disease increases to seven times that of the general population. It has been demonstrated that keeping blood sugar levels in tight control reduces macrovascular and microvascular disease in patients with type I diabetes, which reduces their risk of heart disease. Recent studies suggest that patients with type II diabetes also receive this benefit with tight blood sugar control. Obesity: The precise role of obesity in coronary artery disease is difficult to determine as it is closely associated with other risk factors such as hypertension, diabetes, hyperlipidemia and physical inactivity. Loss of even 5 to 10% of weight can improve these risk factors. With every pound lost the cholesterol level drops by 1 mg/dL. Blood pressure is also reduced with weight loss. Central or abdominal obesity is linked to increased risk of coronary artery disease. Psychological Stress: Stress increases the heart rate, blood pressure, blood lipid levels and blood clotting. Managing chronic stressors with relaxation techniques or through behavioural change in response to stress helps to minimize or eliminate the effect of stress on the body. As part of secondary prevention the therapist must direct considerable energy towards teaching the patient the significance of these risk factors and methods of ameliorating them. Classification for Exercise Risk: After the medical evaluation is complete subjects can be classified by risk on the basis of their characteristics. This classification is used to determine the need for subsequent supervision and the level of monitoring required.
  32. 32. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 31 Risk Classification for Exercise Training: Class A: Apparently healthy individuals. Class B: Presence of known, stable cardiovascular disease with low risk for complications with vigorous exercise but slightly greater than for apparently healthy individuals. Class C: Those at moderate to high risk for cardiac complications during exercise and/or unable to self regulate activity or to understand recommended activity level. Class D: Unstable disease with activity restriction. Activity Guidelines: Class A: No restrictions other than basic guidelines. No supervision required. Class B: Activity should be individualized with exercise prescription provided by qualified individuals and approved by primary healthcare provider. Medical supervision during initial prescription session is beneficial. Class C: Same as Class B but supervision during all exercise sessions until safety is established. Class D: No activity is recommended for conditioning purposes. Daily activities must be prescribed on the basis of individual assessment.
  33. 33. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 32 6. Effects of drugs on exercise performance: β-Blockers: (Propranolol, Metropolol, Atenolol, Pindolol) Subjects with angina who receive β-Blockers may achieve a higher exercise capacity with less ST segment depression and less angina if the drugs prevent them from reaching their ischemic rate-pressure product. Maximum heart rate and systolic blood pressure product may be reduced. The time of ingestion and the dosage of these medications before exercise testing should be recorded. Vasodilators: (Hydralazine, prazosin and minoxidil) These agents can increase exercise capacity in subjects with angina pectoris. There has been no scientific validation that long-acting nitrates increase exercise capacity in subjects with angina when they are tested after long term administration. Digitalis: ST segment depression can be induced or accentuated during exercise in individuals who are taking digitalis, including both normal subjects and subjects with CAD. A normal QT interval is associated with digitalis induced ST changes whereas prolonged QT intervals occur with ischemia, other type I anti-arrhythmic drugs, electrolyte imbalance and other medical problems. Exercise induced ST segment depression may persist for 2 weeks after digitalis is discontinued. Diuretics: (Chlorthalidone) Most diuretics have little influence on heart rate and cardiac performance but do decrease plasma volume, peripheral resistance and blood pressure. Diuretics can cause hypokalemia which results in muscle fatigue, ventricular ectopy and rarely ST segment depression.
  34. 34. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 33 Calcium Channel Blockers: (Verapamil, Diltiazem) These agents reduce peripheral resistance and heart rate. If patients taking calcium blockers perform exercise tests, ischemia may come on at higher workloads and systolic blood pressure and heart rate may be decreased for a given level of exercise. If exercise is terminated by angina, work tolerance may also be increased by these drugs. Angiotensin Converting Enzyme (ACE) Inhibitors: (Captopril) Systolic blood pressure is lower during exercise in patients taking ACE inhibitors than in controls. Little change in heart rate occurs. Nitrates: (Long acting nitrates such as Pentanitrate, Isordil, Erythrol Tetranitrate) These drugs delay the onset of ST segment depression and reduce its magnitude in patients who take it before the exercise test. 7. Modification of work and activity programmes with respect to residual cardiac functions. Assessment on work simulation: As an ADL task or exercise program is graded the client’s physiological tolerance of these activities must be monitored and documented. At the beginning of each therapy session, the occupational therapist should take the client’s vital signs at rest. Pulse rate, blood pressure, respiratory rate and oxygen saturation should be measured and recorded using oximeter. If the client’s resting vital signs are not within the ranges considered medically safe for him/her the session should be discontinued. If the client’s resting vital signs are within a medically safe range then the intervention can continue. In general oxygen saturation should be maintained at ≥ 90 % during functional activity. Pulse rate should be limited to an increase no more than 20-30 beats per
  35. 35. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 34 minute above the resting rate. As a general rule the blood pressure should be limited to an increase or decrease of no more than 15-20 mm Hg. The intervention of modification of work and activity program in cardiac rehabilitation is based on 1. Compensatory Frame of Reference: in which adaptations are considered in activities of daily living (ADL) and change in life style is suggested. METs level classification and vital signs are taken into account while prescribing an activity for daily routine. Patients are grouped into Class A/B/C/D based on Risk classification for exercise training for exercise and activity prescription and for the need of supervision. 2. Learning Frame of Reference: This includes patient education about the symptoms of increased cardiac work before activity progression, tips on energy conservation techniques, work simplification techniques and time management. 3. Behavioural Frame of Reference: This includes adaptation of behaviours using Biofeedback equipments, Relaxation techniques, Anxiety and Stress management skills, Counseling etc. The basic needs of the individual can be summed up in the acronym SABRES, which stands for: S: Sleep. A: Arousal. B: Breathing. R: Rest. E: Effort. S: Self Esteem. This concept is used as the theoretical basis for intervention.
  36. 36. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 35 About 10 -12 weeks from the time of the infarction or surgery most people begin to return to work. Adapting to going back to work is most easily accomplished by returning to a three day week i.e. Mondays, Wednesdays and Fridays during the first month keeping Tuesdays, Thursdays and Saturdays for rest and exercise. The place of work, the performance required, the travelling entailed and the psychological factors involved must all be taken into account when the occupational therapist and the patient plan strategies and consider whether it is the work itself or personality clashes that require attention. Based on METs level individuals who can perform 7 METs or higher without any limitations or abnormal responses should be able to return to most jobs except those of a heavy industrial nature. Those who can exercise at 5 METs or greater but less than 7 METs can perform sedentary work and most household chores, whereas those who perform at 3 or 4 METs level may not be suited to return to employment. When The reason for the low peak work load attained is a low level of physical fitness; a cardiovascular conditioning program can help which also includes work simulation. Cardiac patients in the 5 METs or greater range can increase their capacity by 15 % to as much as 50 % after 2-3 months of reconditioning. Work Simulation Work simulation may be appropriate for patients with reduced exercise tolerance (less than 7 METs) or those with Left ventricular dysfunction who have jobs that require a significant isometric component. To be able to match the patient’s clinical status and cardiovascular functional capacity to the requirements of the job a thorough evaluation of the job should include a detailed pen and paper analysis of the energy cost of the walking, climbing, lifting, carrying, stacking or shoveling and the duration of these activities
  37. 37. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 36 during the 8 hour workday. Not only the routine tasks performed at work but also the peak activity and duration of this activity should be determined. In an exercise test for work evaluation one can simulate this peak level of activity by a spurt of increased exercise intensity during the exercise test. There should be continuous ECG and Blood Pressure monitoring before, during and after the work testing. The environmental conditions in the area, the mode of transportation to and from work and the household chores needed to be done after work are equally important considerations in the work evaluation. There are various work samples available for simulated job analysis. For example: The TOWER (Testing, Orientation and Work Evaluation in Rehabilitation) System and some of the work samples in Valpar Component Work Sample Series are actual job samples; Baltimore Therapeutic Equipment Work Simulator is a simulated job sample; The Work Evaluation Systems Technology (WEST) is a cluster trait sample. 5. Indications and Contraindications for work prescription and activity: General Guidelines for Exercise/Work/Activity Prescriptions: 1. Exercise/Work only when feeling physically well. Wait until the symptoms and signs have been absent for more than 2 days before resuming activity. 2. Do not exercise or work soon after eating (Heavy meals i.e. lunch or dinner). Wait at least 2 hours. Eating increases the blood flow requirements of the intestinal tract. During vigorous activity, the demands of the muscles for blood may exceed the ability of the circulation to supply both the bowel and the exercising muscles, thus depriving the organs of blood, resulting in cramps, nausea or faintness. 3. Drink adequate fluids. Water is generally the replacement fluid of choice for most individuals. Disease and medications may increase susceptibility to heat illness and
  38. 38. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 37 fluid loss. In general water should be taken before, during and soon after any moderate to vigorous intensity exercise lasting for more than 30 minutes in duration. 4. Adjust exercise/work to the weather (environmental conditions). If the air temperature is > 80° F, exercise in the early morning or late afternoon to avoid the heat. Activity is better tolerated if humidity is low and a breeze is present. Exercise in the heat causes excessive fluid loss; therefore adequate fluid intake is important before, during and after each session. 5. Wear proper clothing and shoes. Dress in loose fitting comfortable clothes made of porous material appropriate for the weather. Wear light coloured clothing and a cap in direct sunlight. Wear shoes designed for exercise. 6. Understand personal limitations. Everyone should have periodic medical evaluations. 7. Select appropriate exercise or activity with due considerations to residual capacity. Endurance/Aerobic exercise should be a major component of activities. 8. Be alert for cardiopulmonary symptoms. If symptoms occur during activity or exercise obtain medical consultation before continuing the activity. 9. Slow down for hills. A useful guide is to maintain the same rating of perceived exertion as in a usual workout or daily routine. 10. Do not work or exercise beyond fatigue levels. Watch out for signs of over exercising such as inability to finish, inability to converse during the activity, faintness, aches and pains, sleeplessness, chronic fatigue which persists even after stopping the activity. 11. Start slowly and progress gradually. Allow time to adapt. 12. Follow work simplification and energy conservation guidelines during work or daily living activity. Mechanical devices should be used when possible to reduce the amount of lifting required.
  39. 39. Ms. Punita V. Solanki. Lecturer (Occupational Therapy) March 2009 38 13. Avoid activities that involve sustained contraction of a single muscle group or resistance loads that induce a Valsalva maneuver; which involves holding of breaths. 14. Follow optimal postures during work or exercise based on biomechanical and ergonomic principles.

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