Cardiopulmonary Physical Therapy

Haneul Lee, DSc, PT

Guidelines for exercise prescription

Type (modality)

▪ Cardiorespiratory endurance activities

▪ Dynamic arm exercise (arm ergometer)

▪ Other aerobic activities

▪ Warm-up and cool-down activities

▪ Resistive exercise

Cardiorespiratory endurance activities Walking, jogging or cycling recommended to improve exercise

tolerance; can be maintained at a constant velocity;

Dynamic arm exercise Uses a smaller muscle mass, results in lower VO2 max (60-70%) than

leg ergometer At a given workload, HR and BP will be higher and stroke volume

will be lower

Other aerobic activities Swimming, skiing; less frequently used due to high inter-individual

variability, energy expenditure related to skill level Dancing, basketball, competitive activities should not be used with

high-risk and low-fit individuals – not recommended

Warm-up and cool-down activities Gradually increase or decrease the intensity of exercise, promote

circulatory and muscular adjustment to exercise Type : low intensity cardiorespiratory endurance activities, ROM,

functional mobility activities Duration : 5-10 minutes Abrupt beginning or cessation of exercise is not safe or recommended

Resistive exercise To improve strength and endurance in clinically stable patients Usually prescribed in later rehab, after a period of aerobic

conditioning Moderate intensity Precautions : carefully monitor BP, avoid breath-holding, Valsalva’s

response increase BP

Guidelines for exercise prescription Intensity

▪ prescribed as percentage of functional capacity revealed on ETT

▪ Typical training intensity is 60-7-% of functional capacity

▪ Lower training intensities may necessitate an increase in training duration

▪ Heart rate

▪ RPE (Rating of perceived exertion)

▪ METs (Meta

Heart rate Percentage of maximum heart rate achieved on ETT; without an ETT,

age-target HR is used

70-85% HR max closely corresponds to 60-80% of functional capacity

Beta blocker or calcium channel blocker medication : affects ability of HR to rise in response to an exercise

stress

Pacemaker affects ability of HR to

rise in response to an exercise stress

Environmental extremes, heavy arm

work, and Valsalva may affect HR

and BP responses

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Rating of perceived exertion (RPE) RPE values of 12-13 -> 60% of HR / 16 -> 85% of HR

Useful when patient is taking beta blockers or other HR suppressers

Problems with use of RPE alone to prescribe exercise intensity

▪ Individuals with psychological problems

▪ Unfamiliarity with RPE scale – may affect selection of ratings

METs (estimated energy expenditure) 40-85% of functional capacity achieved on ETT

Problems with use of METs alone to prescribe exercise intensity▪ Environmental stress may – may affect the known metabolic cost of an activity

▪ Varying skill level or stress of competition may affect the known metabolic cost of an activity

Guidelines for exercise prescription

Duration (modality)▪ Conditioning phase may vary from 15-60 minuets; depending on

intensity

▪ Average conditioning time is 20-30mins for moderate intensity exercise

▪ Severely compromised individuals may benefit from multiple, short exercise sessions spaced throughout the day

▪ Warm-up and cool-down periods are kept constant for 5-10 minutes

Frequency▪ Frequency of activity is depend on intensity and duration; the

lower the intensity, the shorter the duration, the greater the frequency

▪ Average 3-5 sessions / week for exercise at moderate intensities and duration

▪ Daily or multiple daily sessions for low intensity exercise

Progression▪ Modify exercise prescription if :

▪ HR is lower than target HR for given exercise intensity▪ RPE is lower for given exercise▪ Symptoms of ischemia do not appear at a given exercise intensity

▪ Rate of progression depends on age, health status, functional capacity, personal goals, preferences

▪ Duration is increased first, then intensity

Consider reduction in exercise intensity with▪ Acute illness : fever, flu

▪ Acute injury, orthopedic complications

▪ Progression of cardiac disease : edema, weight gain, unstable angina

▪ Overindulgence : food, caffeine, alcohol

▪ Environmental stressors : extremes of heat, cold, humidity, air pollution

Exercise prescription post-CABG

▪ Limit upper extremity exercise while sternal incision is haeling

▪ Avoid lifting , pushing, pulling for 4-6 weeks post surgery

1. Cardiac rehab phase I : Inpatient (Acute)

2. Cardiac rehab phase II : Outpatient (Sub acute)

3. Cardiac rehab phase III : Community exercise

(post discharge from phase 2)

4. Resistance Exercise Program

Length of hospital stay : 3-5 days for uncomplicated MI Exercise goals and outcomes

▪ Initiate early return to independence (home based setting) in ADL▪ Counteract deleterious effects of bed rest▪ Help resolve anxiety and depression▪ Provide patient and family education▪ Promote risk factor modification

Exercise guidelines▪ ADLs, selected arm and leg exercise, early supervised ambulation▪ Initial activities : low intensity (2-3 METs) -> 3-5METs by discharge▪ Short exercise sessions, 2-3 times a day, gradually duration is lengthened

and frequency is decreased ▪ Postsurgical patients

▪ Typically are progressed more rapidly than post-MI▪ Greater emphasis is placed on upper extremity ROM

▪ ETT may be used to determine functional capacity prior to discharge▪ Greater than 5 METs – safe!!

Patient and family education goals

▪ Improve understanding of cardiac disease and risk factor modification

▪ Teach self-monitoring procedure

▪ Teach general activity guidelines, activity pacing, energy conservation techniques, and home exercise

▪ Provide emotional support

Adverse responses to inpatient exercise leading to exercise discontinuation

▪ DBP > 110mmHg

▪ Decrease in SBP > 10 mmHg

▪ Second or third degree heart block

▪ Sings of exercise intolerance

▪ Angina, marked dyspnea, and ECG changes suggestive of ischemia

Outpatient cardiac rehabilitation (sub acute) Exercise goals and outcomes

▪ Improve functional capacity

▪ Progress toward full resumption of ADL, habitual and occupational activities ( Returning to Work)

▪ Promote risk factor modification, counseling as to lifestyle changes

▪ Encourage activity pacing, energy conservation; stress importance of taking proper rest periods

Exercise guidelines▪ Outpatient program : 36 visits (3 times a week for 12 weeks )

▪ ECG, HR, BP monitoring are required

▪ Duration : 30-60 minutes with 5-10 minutes of warm-up and cool-down

▪ Single mode or multiple modes

▪ Suggested exit point : 9 MET ( 5MET is needed for safe resumption of most ADL)

Exercise guidelines (Continued)

▪ When patients do not get ETT

▪ Initiate with 2-3 METS

▪ Increase continuously 0.5-1 METs

▪ Target HR : Resting HR + 20

Strength tainting in phase II programs

▪ Guidelines ▪ After 3 weeks cardiac rehab; 5 weeks post-MI or 8 weeks post-CABG

▪ Begin with use of elastic bands and light weight (1-3lbs)

▪ Progress to moderate loads ; 12-15 comfortable repetitions

Patient and family education

▪ Goals : progression of phase 1 goals

Community Exercise Programs (Post-Acute, Post-Discharge from Phase II Program)

Exercise goals and outcomes▪ Improve and/or maintain functional capacity

▪ Promote self-regulation of exercise programs

▪ Promote life-long commitment to risk factor modification

Exercise guidelines▪ Location : community centers, YMCA, or clinical facilities

▪ Entry level criteria : functional capacity of 5METs, clinically stable angina, medically controlled arrhythmias during exercise

▪ 3-4 times a week, 45 minutes or more session

▪ Regular medical check ups and periodic ETT generally required

▪ Discharge typically in 6-12 months

Aerobic exercise – typical and traditional for CR

Why “Resistance Exercise” is needed for cardiac rehabilitation? Proper resistance exercise – prevent muscle mass decreases, muscle strength increases

Rapidly return to occupational activity and leisure

Improve QOL and psychological pride

Goals and outcomes Improve muscle strength and endurance

Enhance functional independence

Decrease cardiac demands during daily activities

Exercise guidelines

10 minutes of warm-up and cool down exercise

Keep normal breath while muscle contracture

Slowly exercise up to full ROM when lifting

Large muscle –> small muscle

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Patient criteria for resistance training Post-MI or cardiac surgery : minimum of 5 weeks after insult or surgery and

4 weeks of participation in a supervised CR endurance training program No evidence of the following conditions

▪ Congestive heart failure, uncontrolled dysrhythmias, sever vascular disease, uncontrolled hypertension, and unstable symptoms

Start with low resistance One set of 10-15 repetitions and progress slowly

Mode – Resistance includes ; Weights, 50% or more of maximum weight used to

complete one repetition Elastic bands Light (1-5lbs) cuff and hand weights Wall pulleys

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Perceived exertion (RPE)

11-13 range ( “light” to “somewhat hard”)

Rate-pressure product should not exceed that prescribed during endurance exercise

Resistance exercise is no longer dangerous but safe and effective (EBP)

20-25% increase of muscle strength

10-12% increase of functional capacity when combined with aerobic exercise

Usually prescribed in later rehabilitation phase

1. Decreased HR at rest and during exercise; improved HR recovery after exercise

2. Increase stroke volume3. Increase myocardial oxygen supply and myocardial

contractility4. Improved respiratory capacity during exercise5. Improved functional capacity of exercise6. Reduced body fat, increased lean body mass7. Decrease serum lipoproteins8. Improved glucose tolerance9. Improvement in measures of psychological status and

functioning :self-confidence and sense of well-being10. Increased participation in exercise

Encourage risk factor modification Cessation of smoking, weight control, glucose and lipid control

Avoid excessive strain, protection of extremities from injury and extremes of temperature

Exercise training for patients with PVD : Improved functional capacity / peripheral bold flow / muscle oxidative

capacity Consider interval training with frequent rests Walking program, moderate intensity and duration, 2-3 times a day,

3-7 days /week Non-weight bearing exercise (cycle or arm ergometer) necessary Well-fitting shoes essential

Lower extremity exercise

Modified Buerger-Allen exercises

▪ Postural exercises + active plantar and dorsiflexion of ankle

▪ Active exercises improve blood flow during and after exercise

▪ Effects less pronounced in patient with PVD

Resistive calf exercise : most effective method of increasing blood flow

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Deep vein thrombosis (DVT)

Early stage – asymptomatic

Symptomatic patients – dull ache, pain, tenderness in calf, slight edema or fever

▪ Acute : bed rest till signs of inflammation have subsided with elevation of involved leg

▪ Anticoagulation medications

▪ Exercise therapy contraindicated during acute phase

: increases pain, potential to dislodge clot, progress to pulmonary embolism

▪ Elastic stocking

Chronic venous insufficiency

Management of edema▪ Positioning : extremity elevation, elevate leg as much as possible▪ Compression therapy

▪ Bandages (elastic)▪ Paste bandages (Unna boot) – applied for 4-7 days▪ Compression pump therapy, used for 1-2 hours session

twice daily▪ Red Flag : do not apply compression therapy to a limb with an

ABI <0.8 or with evidence of active cellulitis or infection▪ Exercise

▪ Active ankle exercise : muscle pump exercises ( dorsiflexion/plantarflexion, foot circles)

▪ Cycle ergometer in sitting ▪ Early ambulation as soon as patient is able to get out of bed, 3-4 times a day

Patient education : meticulous skin care

Sever conditions with dermal ulceration may require surgery

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Elsevier3. Cardiovascular and pulmonary Physical Therapy Evidence to Practice, 5th

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W.Darlence Reid, Frank Chung, Kylie Hill, SLACK Inc.5. PTEXAM the complete study guide, Scott M Giles, Scorebuilders