Cardiovascular disease (CVD) is the leading cause of death and a major cause of disability worldwide. (WHO., 2003)
Cardiac rehabilitation is the process of restoring psychological, physical and social function in the people with manifestations of coronary artery disease( CAD).
2. • Cardiovascular disease (CVD) is the leading cause of death and a
major cause of disability worldwide. (WHO., 2003)
• In many countries, personalized rehabilitation programmes after
surgical or non-surgical myocardial reperfusion have become an
important part of a multifaceted approach aimed at treating coronary
artery disease and helping the patient to achieve complete social and
professional rehabilitation.
• Following a documented physician referral, patients hospitalized
after a cardiac event or a procedure associated with coronary artery
disease (CAD), cardiac valve replacement, or myocardial infarction
(MI) should be provided with a program consisting of early
assessment and mobilization, identification of and education
regarding CVD risk factors, assessment of the patient’s level of
readiness for physical activity, and comprehensive discharge
planning.
3. • Cardiac rehabilitation is the process of restoring psychological,
physical and social function in the people with manifestations of
coronary artery disease( CAD).
• 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.
4. • In patents who have undergone coronary artery bypass graft (
CABG) surgery, physical activity can decreased postsurgical
stiffness and prevent complication of postsurgical atelectasis.
• 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.
5. 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.
6. 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.
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.
7. • 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)
• Phase 4th 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.
8. Exercise prescription for the cardiac patient
• It needs an individual approach to exercise prescription is
recommended.
• To be most effective each exercise prescription should have specific
guidelines concerning the frequency, intensity, duration, mode and
progression of the exercise program.
10. • Before beginning formal physical activity in the inpatient setting, a
baseline assessment should be conducted by a healthcare provider
who possesses the skills and competencies necessary to assess and
document heart and lung sounds, peripheral pulses, and
musculoskeletal strength and flexibility.
11. • Exercise prescription for phase 1- some of the more important
aspects of phase 1 cardiac rehabilitation include the need to
maintain work capacity, strength and flexibility and to counter the
deconditioning effects of prolonged to bed rest.
In this section that type, intensity and duration of exercises for the
phase 1 cardiac patient will be discussed. In addition, some details
regarding discharge planning and the psychological responses to
exercise will be addressed.
• Range of motion exercises
• Ambulation
12. The goals for inpatient rehabilitation programs are as follows:
• Offset the deleterious physiologic and psychological effects of bed rest.
• Provide additional medical surveillance of patients.
• Identify patients with significant cardiovascular, physical, or cognitive
impairments that may influence prognosis.
• Enable patients to safely return to activities of daily living within limits
imposed by their CVD.
• Prepare the patient and support system at home or in a transitional setting
to optimize recovery following acute-care hospital discharge.
• Facilitate patient entry, including physician referral into an outpatient
cardiac rehabilitation program.
13.
14. • Phase 2 outpatient cardiac rehabilitation- Organized, supervised
outpatient cardiac rehabilitation has become an important part of the
rehabilitation process and should begin when the patient is
discharged from the hospital
• Exercise prescription for phase-2 - During phase 2, the purpose of
the exercise prescription for the cardiac patient should be the
development of functional capacity. This section addressed the
principles of exercise prescriptions intensity, frequency, duration,
mode of training and the rate of progression as applied to the cardiac
patient.
15. • As the patients progress, the duration of the exercise session can
gradually increase in 5 minutes session per week until a 45-minute
session is attained.
• Once a 45-minute duration of training has been attained frequency
of training can be reduced or maintain between 3 to 5 times per
week. for most patients this may take 4 to 6 weeks .
• The standard formal outpatient program usually consists of 3 visits
per week and includes both the exercise and educational components
of rehabilitation.
16.
17. Endurance activities
• The ACSM has classified endurance activities on the basis of the
rate of energy expenditure.
• Walking
• Jogging
• Stationary cycling-
• Arm- leg cycle ergometry - the use of arm leg cycle ergometer
such as air dyne is it proper mode of exercise in cardiac
rehabilitation programs
• Arm cycle Ergometry
• Swimming
• Stair climbing and stair stepping
21. • Resistance training - along with the ROM, flexibility exercise
previously described for phase-1 resistance like strength training
should be emphasized during phase -2 of a cardiac Rehab .
• Exercise prescription for resistance training (RT)- when the
patient is properly screened resistance training should be initiated
with careful consideration of the patient's medical status and
functional capacity.
• Guidelines for resistance training (RT) for cardio patients include a
minimum of 8 to 10 exercises involving the major muscle groups
performed a minimum of two times per week , each exercise should
consist of one set of 12 to 15 repetitions at an intensity that
corresponds to RPE of 15 to 16 .
22. Warm up and cool down
• Each exercise session should incorporate a warm up and cool down
period of 10 to 15 minutes each.
• The warm up should be designed to increase the metabolic rate
gradually from a resting level to a level of energy expenditure needed
for the conditioning phase of the session .
• Barnard et al., demonstrated serious ECG abnormalities, ST segment
depression, and dysrhythmias in middle aged adults when certain
exercise was undertaken without proper warm-up.
23. • The importance of the cool-down is equal to that the warm up
period. The major purpose of cooling down is to keep active the
primary muscle group that were involved in the exercise.
24. Phase 3 and 4: community based cardiac rehabilitation program
• The phase 3 program may be conducted in an organized and
supervised community based setting and phase 4 denotes a
long term maintainance program that can be unsupervised.
• The phase 3 and 4 program should provide cardiac patient
with an opportunity to continue their conditioning activities of
phase I and phase II. Participants in the phase 3 and 4 have
typically been out of the hospital for 6 to 12 weeks.
• In addition they should be clinically stable, knowledgeable
about cardiac symptoms and able to self regulate exercise
regimens. They should have a minimum functional capacity of
5 METS.
25.
26. • Table shows the guidelines for exercise prescription used in phase
III and IV At this stage of training the exercise prescriptions is
similar for both MI and CABG patients and become closer to that
recommended for the healthy adults.
• As patients continue to progress in the program, the intensity may
reach 85% of functional capacity
• The duration of training should be between 30 and 60 minutes
depending on available time and the intensity of the exercise
27. Summary
• This chapter has described in detail how exercises prescribed to
cardiac patient in an inpatient phase I ,outpatient phase II ,and
community-based phase III or maintenance phase IV program setting .
• Inpatient programs for the patient without complications usually
began 3 days after MI or 1-2 days after CABG. Programs are
conducted at a low intensity and emphasize on Rom exercise,
ambulation and normal activities of daily living such as climbing stairs
.
• Outpatient programs are recommended for at least 6 to 12 weeks
after hospital discharge followed by three to six months in a
community-based program and a long-term maintenance program.
28. • Stratification Based on the patient's prognosis for further
cardiovascular events and rate of survival during the first year forming
an MI or CABG is crucial.
• Patient stratification is a major determinant of the design of each
patient program in regard do the appropriateness of training: the type,
duration and intensity of the exercise prescribed and the level of
medical monitoring and supervision needed .
• Standards for exercise prescription for each phase of
rehabilitation have been recommended by the AHA , ACSM and
AACVPR because of the physical limitation in cardiac patients' ,
progression of exercises intensity tends to be lower, and the frequency
greater and duration longer than in programs recommended for a
healthy individuals.
