This document provides guidelines for exercise prescription during Phase I cardiac rehabilitation for myocardial infarction patients. Phase I involves inpatient rehabilitation with a focus on patient education, counseling, and low-intensity exercises like range of motion, ankle exercises, and walking. Exercises are progressed over time in terms of intensity, duration, and type to prepare patients for discharge and continued rehabilitation in an outpatient setting. Factors like heart rate, blood pressure, symptoms, and perceived exertion are monitored during sessions to ensure safety.

1. CENTER FOR PHYSIOTHERAPY AND REHABILITATION
SCIENCE
JAMIA MILLIA ISLAMIA
Submitted to: Dr. Jamal Moiz
Submitted by:Qurat ul aein

2. Qurat ul aein
MPT 3rd sem
19mpc005

3. CARDIAC REHABILITATION
• Cardiac rehabilitation are comprehensive long term program
involving-
a)medical evaluation,
b)exercise prescription,
c)cardiac risk factor modification,
d)education and
e)counselling.

4. Phases Of Cardiac Rehabilitation
Phase I
Or
Inpatient phase
Phase II
Or
Early outpatient,
Clinic or
Home based
Phase III
Or
Late outpatient,
Community based
or
Home based
Phase IV
Or
Community based
maintenance
phase

5. Cardiac rehabilitation in myocardial infarction
Cardiac physiology in post myocardial infarction patients: the effect of cardiac
rehabilitation programs—a systematic review and update meta-analysis
Irene Kirolos1
, Danny Yakoub2
, Fiorella Pendola3
, Omar Picado4
, Aghapy Kirolos1
, Yehoshua C. Levine1
, Sunil Jha1
,
Rajesh Kabra1
, Brandon Cave1
, Rami N. Khouzam1
CRP objectively improves various aspects of functional cardiac capacity in post MI patients, this is mediated through higher EF and peak
VO2
, lower resting HR, LVEDV and WMSI. This effect may explain the reported improvement of functionality and mortality among those
patients. Cardiac physiology in post myocardial infarction patients: the effect of cardiac rehabilitation programs—a systematic review and
update meta-analysis

6. PHASE I CARDIAC REHABILITATION
• Involves immediate inpatient exercise rehabilitation that emphasizes:
a) Patient education (informal discussions with nurses and physicians) and
b) Counselling.
• Exercise therapy-
a) Musculoskeletal ROM activities.
b) ADLs (sitting, standing, and walking).
• Purpose:
a) Counter the deconditioning effects of prolonged bed rest,
b) Prepare patient for a return to normal daily activities.

7. Exercise
1. Design and implementation should be based on physiological principles that can be used by a variety of health
professionals within either an inpatient or a transitional setting, and should be integrated into a cooperative clinical
pathway.
2. Flexibility in the PA plan is critical to individualization; alternatively, an individualized plan may be devel- oped for
patients who do not fit the clinical pathway.
3. Specific criteria for beginning and advancing inpatient activities are required.

8. • Each cardiac patient is faced with unique set of physiological, medical, and
psychological characteristics that affect his or her readiness to safely begin the
exercise portion of the rehabilitation program.
• Thorough medical, nursing, and physical therapy assessment, including review of
medical records (admission, operative, and progress notes and reports from
diagnostic studies, including cardiac catheterization, electrophysiology,
echocardiography, and nuclear tests), form the basis of an appropriate exercise
prescription.

9. Education
1. A standardized collection of cardiac teaching plans that outline the content area topics should be available.
2. Appropriate and readable teaching aids are required to reinforce patient education content.
3. Patients must be involved in identifying their own high-priority learning needs.
4. Patient readiness to learn should be assessed before every potential teaching encounter.

10. Discharge planning
1. At a minimum, one predischarge visit for every CR patient must • address survival skills and postdischarge “dos and don’ts,”
• evaluate and estimate predischarge functional ability, and
• provide information about outpatient programming.

11. CONTRAINDICATIONS
• Unstable angina
• Resting systolic BP > 200mmHg or resting diastolic BP > 100 mmHg
• Orthostatic BP drop 20mmHg or more
• Moderate to severe aortic stenosis
• Acute systemic illness or fever
• Uncontrolled atrial or ventricular dysrhythmias
• Uncontrolled sinus tachycardia (>120bpm)

12. • Uncontrolled CHF
• 3rd degree atrioventricular block
• Active pericarditis or myocarditis
• Recent embolism
• Thrombophlebitis
• Resting ST displacement (> 3mm)
• Uncontrolled diabetes
• Orthopaedic problems that would prohibit exercise.

13. Cardiac rehabilitation/
Physical therapy
Ward activity Patient education
STEP 1: 1.5 METs
• Passive ROM to major joints,
• Active ankle exercises,
• 5 repetitions;
• Deep breathing (supine) twice daily.
• Bed rest
• May feed self
• Orient to CCU
• Orient to e
STEP 2: 1.5 METs
• Active assisted ROM to major muscle groups,
• Active ankle exercises,
• 5 repetitions;
• Deep breathing (supine/sitting) twice daily.
• Feed self
• Partial morning care (washing
hands & face, brushing teeth in
bed)
• Beside commode.
• Answer patient & family
questions regarding progress,
procedures, reason for activity
limitation
• Explain RPE scale
STEP 3: 1.5 METs
• Active ROM to major muscle groups,
• Active ankle exercises,
• 5 repetitions;
• Deep breathing (sitting) twice daily
• Begin sitting in chair for short
periods as tolerated 2 times daily
• Bathe self
• Bedside commode.
Guidelines For Myocardial Infaraction Patients

14. STEP 4: 1.5 METs
• Active exercises: Shoulder flxn & abd; elbow
flxn; hip flxn; knee etxn; toe raises; ankle
exercises,
• 5 repetitions;
• Deep breathing (standing) twice daily.
• Bathroom privileges
• Sit in chair 3 times daily
• Up in chair for meals
• Bathe self, dress, comb hair
(sitting).
STEP 5: 1.5-2 METs
• Active exercises: shoulder flxn, abd, &
circumduction; elbow flxn; trunk lateral flxn;
hip flxn & abd; knee extn; toe raises; ankle
exercises,
• 5 repetitions each (standing) twice daily.
• Monitored ambulation: 100-200ft, twice
daily, with physician approval.
• Bathroom privileges
• Up as tolerated in room
• Stand at sink to shave & comb hair
• Bathe self & dress
• Up in chair as tolerated.
• Answer patient & family
questions
• Patient discharge booklet &
other printed material (AHA)
• Encourage patient & family to
attend group classes or do 1:1
sessions.
STEP 6: 1.5-2 METs
• Standing: exercises outlined in step 5,
• 5-10 repetitions;
• Once daily
• Monitored ambulation: 5mins (440 ft.
• Increase ambulation up to 1 lap
(440 ft) with assistance if
appropriate, twice daily.
• Explain value of exercise
• Begin discharge instructions
with patient & family when
appropriate
• Encourage group or 1:1
session

15. STEP 7: 1.5-2 METs
• Standing: exercises from step 5 with 1 lb weight each
extremity,
• 5-10 repetitions, once daily
• Monitored ambulation: 5-10 mins (440-1000 ft).
• Sit up in chair most of
the day
• Increase ambulation up
to 3 laps ( 1100 ft).
STEP 8:1.5-2.5 METs
• Standing: exercises from step 5 with 1 lb weight each
extremity,
• 10 repetitions, once daily
• Monitored ambulation: 10 mins (1,980 ft) if appropriate.
• Increase ambulation up
to 5 laps (1.980 ft).
• Give instructions in home
exercise program
• Initiate referral to phase II if
appropriate.
STEP 9: 1.5-2.5 METs
• Standing: exercises from step 5 with 2 lb weight each
extremity,
• 10 repetitions, once daily
• Monitored ambulation if appropriate.
• Increase ambulation to
6 laps (2,640 ft daily).
STEP 10: 1.5-3 METs
• Exercises from step 5 with 2 lb weight each extremity,
• 10 repetitions, once daily.
• Monitored ambulation if appropriate.
• Increase ambulation up
to 8 laps (3,330 ft)
daily.

16. Guidelines to modify or terminate phase I exercise session for
cardiac patients
• Fatigue
• Failure of monitoring equipment
• Light headedness, confusion. Ataxia, cyanosis, dyspnoea, nausea or any peripheral
circulatory insufficiency
• Onset of angina with exercise
• Symptomatic supraventricular tachycardia

17. • Onset of 2nd or 3rd degree atrioventricular block
• Frequent multifocal PVCs
• Exercise hypotension (> 20mmhg drop in systolic BP during exercise)
• Excessive BP rise ( systolic BP > 220mmHg, diastolic BP > 110 mmHg)
• Inappropriate bradycardia ( drop in HR > 10bpm) with an increase or no change in
workload.
• ST displacement (3mm)
• Ventricular tachycardia ( 3 or more consecutive opremature ventricular contractions)
• Exercise induced LBBB

18. EXERCISE PRESCRIPTION FOR PHASE I
1. ROM EXERCISES:
• Due to surgical trauma to muscle and bones of upper body, these area may become atrophied and are
vulnerable to development of adhesions.
• Upper extremity ROM exercises may enhance blood flow to the damaged areas and accelerate tissue repair. In
addition to increasing muscular strength and flexibility.
• ROM exercises include:
• Shoulder flexion, abduction and internal & external rotation
• Elbow flexion
• Hip flexion, abduction, internal and external rotation
• Ankle PF and DF

19. • Initially 5 repetitions of each should be perform once or twice daily with a gradual
progression to 10-15 repetitions twice daily.
• When patients can comfortably execute 10-15 repetitions, 1-3 lb wrist weights may
be added.

20. 2. AMBULATION:
• Ambulatory activities in phase 1 should be low in intensity (approx. 1.5-3 METS)
and initially include self care activities (eating, sitting), which are gradually
progressed to slow walking, ROM exercises and activities of daily living.
• Later stair climbing can also be introduced.

21. • The duration of ambulatory part of the exercise session may be progressively
extended to up to 20mins.
• When patients are physically stronger they can participate in formalized physical
activity program including stationary cycling and treadmill walking.

22. 3. EXERCISE INTENSITY:
• Exercise performed in phase 1 typically do not exceed 2-3 METS.
• There is no set rule in determining training (target) HR for the in patient, two methods
are generally used:
i. The use of fixed low level HR- may not be appropriate because of wide range of
resting heart rates among patients.
ii. A specified no. of beats above the patients standing resting HR.
• The use of Borg Rating of Perceived Exertion Scale is encouraged after first few days in
the hospital.
• Patient should aim to achieve levels of 10-12 (light) on the 15 point category RPE Scale.

23. 4. DISCHARGE PLAN:
• During the final days in hospital patient should be prepared for the continuation of
rehabilitation program after discharge.
• The pre discharge plan should include:
• Strategies for risk factor modification,
• Dietary counselling,
• Education on medications,
• An emergency plan,
• Exercise prescription for use at home (ROM exercise, information on walking and
stationary cycling and recommendations for stair climbing and other ADLs).

24. 5. HR, HAEMODYNAMIC AND RPE TO EXERCISE:
• HR responses for ROM exercise and ambulatory activities during first few days of
rehabilitation should not exceed 5-10 beats/min above resting level.
• SBP usually does not rise more than 5 mmHg during ROM activities and 10- 20 mmHg
during ambulation.
• RPE for both activities are between 10-12 (light) on the category RPE scale.

25. FITT PRINCIPLE FOR PHASE I
Frequency 2-3 times/day
Intensity MI: RHR + 20
CABG: RHR + 20
Duration MI: 5-20 min
CABG: 10-20 min
Activity ROM, treadmill, bike, one flight of stairs

27. THANK YOU