cardiac rehabilitation : pahases and education

1. CENTER FOR PHYSIOTHERAPY AND
REHABILITATION SCIENCE
JAMIA MILLIA ISLAMIA
SUBMITTED TO: DR. JAMAL ALI MOIZ
SUBMITTED BY: FARZANA KHATOON
MPT 3RD SEM

2. CARDIAC REHABILITATION: PHASES AND
EDUCATION

3. • Cardiac rehabilitation is the process of restoring
psychological, physical and social function in the people with
manifestations of coronary artery disease( CAD). In the past
40 years there has been a profound shift from a conservative
approach that discouraged physical activities by patients with
angina pectoris and those who had a myocardial infarction
(MI) to one of encouraging as much activity as a patient
symptoms and medical status permit. Six week of bed rest
after MI used to be the standard treatment.

4. • Cardiac rehabilitation includes exercise training and a
wide spectrum of medical, physical and psychological
behavior changes. The multiple intervention approach
to risk factor modification (smoking cessation, proper
diet, stress management and exercise) in cardiac
rehabilitation favors decreased morbidity and
mortality .
• Strict bed rest has a significant detrimental effect on
physiological function. After just a few weeks or days,
the patient has a significantly decreased
cardiorespiratory fitness, blood volume, red blood cell
count , strength and flexibility and increased problems
of orthostatic hypotension and thromboembolism.

5. • Other potential benefits of cardiac rehabilitation includes a
decrease in the incidence and severity of depression and
anxiety, improved self-esteem, and a reduction in unusual
behavioral characteristic such as hostility and anger.

6. • Risk Stratification – Participants in cardiac rehabilitation
programs have traditionally been patients who were
considered at low risk for additional cardiovascular
complications.
• Current cardiac rehabilitation programs, therefore, include
the traditional MI and CABG patients as well as patients with
severe left ventricular dysfunction ( LVD), congestive heart
failure (CHF), heart transplantation, exercise-include
ischemia, peripheral vascular disease (PVD), dysrhythmias,
pacemaker, coronary angioplasty, valvular repairs, non-
ischemic CAD, pulmonary disease, diabetes mellitus, and
many elderly heart patients (24).

7. • An important addition to the rehabilitation process is the
stratification of patients into risk categories based on their
medical history and prognosis for future major cardiovascular
events and rate of survival during the first year following MI
or CABG.

8. • Several guidelines and algorithms in the design of a
patient programs in regard to the appropriateness of
exercise training (27-29).
• One such algorithm was proposed by DeBusk et al.
(27) and suggests stratifying patients into three main
risk categories (low, intermediate and high) based on
the extent of myocardial ischemia, LVD, the patients
hospital course and the results of a symptom- limited
graded exercise test (SL-GXT).
• This stratification usually take place 3 to 6 weeks
following hospital- discharge and identifies those
patient in need of a more formal and monitored
cardiac rehabilitation program.

9. -
The ACP define low, intermediate and high-risk patient as
follows (28).
• Low-risk patients
• Uncompleted clinical course in hospital.
• No evidence of myocardial ischemia.
• Functional capacity greater than 7 METs (metabolic
equivalents).
• Normal left ventricular function(LVF) (left ventricular ejection
fraction (FVEF>50%)
• Absence of significant ventricular ectopy.

10. • Intermediate risk patients
• St-segment depression greater than or equal to 2mm flat or
down sloping
• Reversible thallium defects
• moderate to good LVF (LVEF 35% to 49%)
• New development of angina pectoris

11. • High risk patients
• Prior MI or infarct involving 35% or more of the left
ventricle.
• LVEF less than 35% at rest.
• Fall in exercise systolic blood pressure BP or failure of
systolic BP to rise more than 10mmHg on exercise
Tolerance test.
• Persistent or recurrent ischemic pain 24 h or more after
hospital admission.
• Functional capacity less than 5 METS with hypotensive
BP response or St segment depression of 1mm or more.

12. •Although every patient entering a cardiac rehabilitation
program needs some basic training usually a minimum of 6 to 12
sessions as recommended by the AHA, those at low risk
(approximately 50%) can be replaced in a home exercise
program or once the recovery phase is completed may be treated
like most participants entering an adult fitness program.
•The intermediate and high risk patients however usually require
a longer more formal program with extensive monitoring while
engaged in physical activity until they have become medically
stable.

13. • The cardiac Rehabilitation plan- For the majority of
cardiac patients involved in cardiac rehabilitation the optimal
period of a comprehensive rehabilitation plan is variable
many recommended up to one year (24 25 30).
• The cardiac rehabilitation plan should be individually tailored
and based on the patient's medical history, prognosis,
functional capacity and specific needs. The program should
be aimed to maximize safety, efficiency and adherence.

14. The program plan may be portioned into four distant
phases recently defined by the ACSM as follows
• Phase 1 inpatient phase- phase 1 involved immediate
inpatient exercise rehabilitation that emphasizes patient
education For example informal discussion with nurses
and physicians and counseling. Exercise therapy should
include musculoskeletal ROM activities and activities of
daily living (sitting standing and walking)
• Purpose- The main purpose of phase 1 is to counter the
deconditioning effects of prolonged bed rest and to
prepare the patient for a return to normal daily life
activities.

15. Patients education in phase 1-
Based upon the level of readiness to learn and each
patient's expressed interests, patients in the Phase I
Cardiac Rehab program are given education regarding
their specific heart problem, activity/exercise, nutrition,
medication, risk factor and lifestyle changes, emergency
planning and community resources available for
assistance in rehabilitation. Educational videos are offered
via the "on demand" hospital video system

16. • Phase 2 early outpatient clinic or home-based phase :
Ideally phase 2 should commence within three weeks of
hospital discharge.
• Purpose: The main purpose of this phase is to
progressively improve patient's functional capacity,
lower cardiovascular risk factor and prepare the patient
for return of his or her vocation. This phase should
include exercise training and generally should last up to
three months.

17. • Exercise training should include progressive light to moderate
aerobic and strength training activities. In addition, Patient
should continue to receive risks factor education as well as
psychological support and vocational guidance
• Patients education-
Phase II also includes family and patients education about the
cardiovascular risk factors.

18. • Phase 3 late outpatient, community based or home-based
phase : the main purpose of phase 3 is to allow a patient to
continue to improve his or her physical status there should be
continued emphasizes on patient education and risk factor
modification.
• Patients are moved into this phase when medically stable
and desired outcome from exercise therapy has been
achieved(usually 6 to 12 weeks)

19. • Phase 4- community-based maintenance phase-
phase 4th is generally used to provide patients aim
means two monitor and maintain the results achieved
during the earlier phase of rehabilitation.

21. THANK YOU