Cardiac Rehabilitation Phase PDF

CARDIAC REHABILITATION  CARDIAC REHABILITATION Definition It is a teamwork process of restoring, physical ,psychological and, mental function to the optimal level for patient with cardiac problem through improved health behaviors to slow or reverse progression of the disease.” Cardiovascular “r...

CARDIAC REHABILITATION  CARDIAC REHABILITATION Definition It is a teamwork process of restoring, physical ,psychological and, mental function to the optimal level for patient with cardiac problem through improved health behaviors to slow or reverse progression of the disease.” Cardiovascular “rehabilitation should add life to years.”  Cardiac Rehabilitation program Cardiac rehabilitation[CR] consists of three phases and should be offered to all cardiac patients who would benefit. CR is mainly prescribed to patients with ischemic heart disease, with myocardial infarction, after coronary angioplasty, after coronary by-pass graft surgery and to patients with chronic heart failure. CR begins as soon as possible in intensive care units, only if the patient is in stable medical condition.  Cardiac rehabilitation team A comprehensive cardiac rehabilitation programs include a wide range of skilled health professional staff.The family and /or close friends are an important part of any rehabilitation team, communication between staff, patient and support persons to clarify problems, goals, treatment and outcomes.  Cardiac rehabilitation team Cardiac rehabilitation team members: - Cardiologist. - Nurse. - Physical therapy. - Occupational therapy. - Nutritionist. - Psychologist. - Vocational counselor. - Social worker. Contraindications for entry into inpatient and outpatient exercise program (1) Unstable angina. (2) Hypertension, (B.P more than 200/100 at rest). (3) Moderate to severe aortic stenosis. (4) Orthostatic blood pressure drops of more than 20 mmHg. (5) Uncontrolled ventricular or atrial arrhythmia. (6) Uncontrolled sinus tachycardia (> 120 b/min.) (7) Uncontrolled diabetes. (8) Severe orthopedic problems. (9) S-T segment displacement more than 3 mm. (10) 3rd degree of A - V block. (11) Acute systemic illness. (12) Acute pericarditis, myocarditis or endocarditis. (13) Thrombophlebitis. (14) Recent embolism  Cardiac rehabilitation Phase I (Inpatient phase) - It is supervised inpatient phase of low level exercise with 24 hours ECG monitor - It begins with a written referral from the attending physician for MI patient and after CABG. It should be started as soon as the patient's condition is stabilized(24-48h)  Patient candidate to phase I: A) Patient with myocardial infarction B) CABG C) Valve surgery &cardiac transplantation Duration: Usually 4-6 days Goals of phase I: 1) To initiate early physical therapy activities to : a) Return to the activities of ADL. b) To offset the prolonged bed rest effects. c) To decrease anxiety and depression. d) To determine the effects of prescribed medications during activities. 2) To initiate patient and Family education : a) To outline the course of cardiac rehabilitation and plan for resumption of life at home. b) To modify risk factors of atherosclerosis as dietary changes, stop smoking and stress- management. The deconditioning effects of prolonged bed rest: (1) Decrease in the physical work capacity. (2) Decrease in the contractile strength of body musculature. (3) Decrease in Lung Volumes and capacities. (4) Orthostatic hypotension. (5) Decreased in the circulating blood volume. (6) Decrease in the concentration of serum protein. (7) Negative nitrogen and calcium balance.  Patient assessment 1)Chart review: a)Medical problems from past history, physical examination. b) Medications. c) Laboratory studies. d) Diagnostic tests. e) Any report from other cardiac rehabilitation team, reviewing the chart daily to detect any change in the patient’s condition. 2)Patient interview: Assessment of the patient's over all cognition (orientation),memory, comprehension and Learning needs). The patient's response towards illness and health, his support system and personal goals. Knowledge about heart disease and risk factors. Knowledge about the previous life style, exercise and recreational activities. Knowledge about the patient's work (the type of work, number of hours per day, his attitude towards work, and work – related pressure). Questions about his pain.  Exercise prescription for Phase 1 Exercise prescription depends on the patient's individual status and level of recovery. Mode of exercise: 1. Active free exercise 2. Breathing exercise 3. Walking 4. Ascending and descending stairs Intensity: (1) The exercises in phase I should be Low intensity, gradually increasing the metabolic cost, safe and of dynamic nature. (2) Activities are described in METs or metabolic equivalents. METs: measures energy requirement for basal homeostasis, when the subject is in the resting position (awake or sitting position) METs = 3.5:4 ml of O2 /Kg/minute. (3) Most inpatient programs begin with activities 2-3 METs and progress to 5 - METs before discharge. Duration: 15 min Frequency: Twice daily with 5-10 repetitions for each joint * For the post-surgical patients: Ambulation begins from the first day for post- surgical patients. Activity progression is faster and the patient works at slightly higher intensity. Emphasis is placed on the upper extremity R.O.M to counteract shoulder and chest pain and reduced motion but avoid lateral stretching of chest that pulls on the incision. Program in steps for Phase 1: Step METs Activity description for surgical Activity description for ischemic patient number patient Step l 1-1.5 ARM for all extremities from supine Up in chair two times, assistant walk in the room Step 2 1-1.5 Repeat Repeat assistant walk in the room & corridor Step 3 1-2 Repeat with mild resistance Repeat with increase distance Step 4 1.5-2 ARM for all extremities from sitting & Repeat breathing ex. Step 5 1.5-2 Repeat with mild resistance& walking ARM for all extremities from standing up to 50 feet with 1-2 pound wt& lateral binding and trunk twist Step 6 1.5-2 ARM for all extremities from standing Repeat 5 with 1-2 pound wt& walking more than 100 feet Step 7 1.5-2.5 Repeat 6 & walking more than 200 Repeat 6& walking down one flight feet Step 8 2-2.5 Repeat 7 & walking more than 300 Repeat 7 & walking down two flight feet Step 9 2.5-3 Repeat 8 & slight knee bind& walking Up one flight & walking down one flight down one flight Step 3-3.5 Repeat 9 & walking down two flights Repeat 9 10 Step 3.5 Repeat 10 & walking down one Repeat 10 11 flight& up one flight -Limb exercise like PROM, AAROM/ARROM are performed to patients It helps to improve joint ROM, function, muscle strength, soft tissue length It decreases the risk of thromboembolism -TENS can be given for relief of pain[ incisional pain] Post surgical patient walking in the hospital corridor accompanied by physical therapist. Level (1): 1.0-1.5 METS, Position: Supine Ankle Rotations: Circle each foot clockwise and then counterclockwise. Hip & Knee Flexion & Extension: Bring each knee, alternating, to chest. Wrist Rotation: circle wrist clockwise, then counterclockwise Foot Flexion & Extension: Point toes toward your trunk, then away. Hand Flexion & Extension: Raise hands up, then down. Shoulder Flexion: Slide arm away from body 90 degrees, then back toward body. Level (1): Position: supine Level (2): 2.5-3.5 METS, Position: SITTING Foot Flexion & Extension: Raise both feet up, then point towards the floor. Shoulder Flexion – 90 Degrees: Raise arm from shoulder to 90 degrees, then relax down. Level (2):Position: Sitting Level (3): 3.5-4.5 METS , Position: STANDING Hip & Knee Flexion and Extension: Alternately lift one leg, then the other. March in place. Shoulder Flexion: Bring arms to level of shoulder and relax down other side. Trunk Bends: Slowly bend from waist to one side, stand up straight, then bend to the other side. Trunk Rotations: Place hands on hips & slowly rotate from side to side. Elbow Circles: Bring hands to shoulders and circle arms in one direction. Level (3): Position: Standing Exercise program before discharge: - From standing: a)Trunk twist: hands on hip and rotate the shoulders to both sides. b) Side bending. c) Elbow circles. d)raise and partial squat: Hands on the back chair or on a wall rise up on toes until tension is felt in calves, return to starting position and bend knee slightly. e) Arm lift. f) Walking in place: Hands on the back of chair (Raise foot 8-12 inches). - Front sitting: 1-Toe raise and heel rises until tension. 2-Ankle circles. 3-Arm lifts. 4-Alternate leg lift (tighten thigh muscles). 5-Alternate Knee lift (lift Knee 4 - 8 inches). Criteria for termination of inpatient exercise programs: So these patients will need further diagnostic evaluation and change in the exercise prescription. 1-Excessive fatigue. 2-Failure of the monitoring equipment. 3-Peripheral circulatory insufficiency as pallor, cyanosis, significant exertional dyspnea, ataxia, confusion, nausea and headedness. 4-Inappropriate bradycardia (drop of the heart rate more than 10b/m with increase or no change in the exercise intensity). 5-Hypertensive response to exercise. -S.B.P raises about 50 mmHg from resting, more than that is hypertensive response, also less than that indicates shock. -The D.B.P raises very little about 15 mmHg from resting, more than that up to 20 mmHg is considered critical. 6-Exercises induced hypotension (drop of S.B.P more than 20 mmHg). 7-Exercise induced angina. 8-Exercise induced left bundle branch block. 9-Exercise - induced 2nd or 3rd degree of A-V block. 10-S-T segment displacement about 3 mm horizontal or downsloping from rest. 11-Ventricular tachycardia: -Three or more consecutive premature ventricular contractions. -Multifocal premature ventricular contractions.