Phase I Cardiac RehabilitationPhase I Cardiac Rehabilitation

As a PT, what do I doAs a PT, what do I do

with these very sick people ?with these very sick people ?

Objectives of Phase I Objectives of Phase I

Cardiac Cardiac RehabilitationRehabilitation

I. Patient & Family EducationI. Patient & Family EducationModification of risk factor profileModification of risk factor profile

treatment of hyperlipidemiatreatment of hyperlipidemiasmoking cessationsmoking cessation treatment of hypertensiontreatment of hypertensioncontrol of diabetescontrol of diabetesregular exerciseregular exercisedietary changesdietary changes

Behavior modificationBehavior modificationstress management at homestress management at homestress management at workstress management at workcreation of hobbies - time outcreation of hobbies - time outconflict resolution skillsconflict resolution skills

Involve the childrenInvolve the childrenThey don’t have pathology yet but They don’t have pathology yet but

they have all of the same stressesthey have all of the same stressesThey also should know how to help They also should know how to help

at homeat home

II. Prevent Deleterious II. Prevent Deleterious Effects Of Bedrest Effects Of Bedrest

Mobilize the patient soonMobilize the patient soonPrevent muscle atrophyPrevent muscle atrophyPrevent blood clot formationPrevent blood clot formationPrevent pneumoniaPrevent pneumoniaPrevent lethargyPrevent lethargy

III. Provide A SafeIII. Provide A SafeDischarge To HomeDischarge To Home

Provide enough physical stamina to Provide enough physical stamina to go home and perform ADL’sgo home and perform ADL’s

Reduce fearReduce fear

Phase I is meant to be preventativePhase I is meant to be preventativeTo have the patient operate within To have the patient operate within

safe limits - not too little exercise safe limits - not too little exercise and not too muchand not too much

The patient must know what The patient must know what activities are safe and okayactivities are safe and okay

Phase I is also diagnosticPhase I is also diagnosticHow large was the infarct ?How large was the infarct ?When do symptoms come on ?When do symptoms come on ?Patients should have had a LLGXT Patients should have had a LLGXT

before discharge.before discharge.

In order for a patient to enter Phase In order for a patient to enter Phase I Cardiac Rehab, they must be I Cardiac Rehab, they must be medically stable.medically stable.

Who Should Be Enrolled In Who Should Be Enrolled In Phase I Cardiac Rehab ?Phase I Cardiac Rehab ?

Stable myocardial infarcts w/ stable Stable myocardial infarcts w/ stable cardiac enzymescardiac enzymes

CABG patientsCABG patients Patients who have had angioplastyPatients who have had angioplasty Patients whoPatients who have had cardiac have had cardiac

transplantationtransplantation Other non-cardiac patientsOther non-cardiac patients

Who Should Not Do Phase I ?Who Should Not Do Phase I ?

Patients with unstable anginaPatients with unstable angina Patients with acute CHFPatients with acute CHF Patient’s with uncontrolled rhythmsPatient’s with uncontrolled rhythms Patients with a systolic BP >200 mm HgPatients with a systolic BP >200 mm Hg

Patients with acute pericarditisPatients with acute pericarditis Patients with recent emboli or clotsPatients with recent emboli or clots Patients with severe cardiomyopathiesPatients with severe cardiomyopathies Patients with uncontrolled DMPatients with uncontrolled DM

Goals Of The EvaluationGoals Of The Evaluation

Clear the patient for any Clear the patient for any musculoskeletal problems - loss musculoskeletal problems - loss of ROM, pectus excavatum, of ROM, pectus excavatum, pectus carinatum, scoliosis, joint pectus carinatum, scoliosis, joint pain & swelling, muscle pain & swelling, muscle strengthstrength

Clear the patient of any Clear the patient of any pulmonary problems - pulmonary problems - auscultate the lungs auscultate the lungs PFT resultsPFT resultsobserve breathing patternsobserve breathing patternslook for scars & restrictions in look for scars & restrictions in

thoracic movement.thoracic movement.

Return the patient home & Return the patient home & prepared to go back to work - no prepared to go back to work - no home-bound invalids.home-bound invalids.

Help the patient to know the Help the patient to know the upper limits of physical upper limits of physical capabilities.capabilities.

Increase the patient’s physical Increase the patient’s physical work capacitywork capacity

Help the patient to feel in charge Help the patient to feel in charge of modifying coronary risk of modifying coronary risk profileprofile

Give helpful information back to Give helpful information back to the cardiac rehab team : the MD, the cardiac rehab team : the MD, nurse, exercise physiologist, nurse, exercise physiologist, psychologist, & dieticianpsychologist, & dietician

The EvaluationThe Evaluation

Medical Chart ReviewMedical Chart ReviewPatient InterviewPatient InterviewPatient ExaminationPatient ExaminationPatient’s Tolerance For ExercisePatient’s Tolerance For Exercise

Medical Chart ReviewMedical Chart Review

Determine the patient’s diagnosis Determine the patient’s diagnosis - MI, CABG, PTCA ?- MI, CABG, PTCA ?

Was the patient defribillated ?Was the patient defribillated ?What does the EKG report say ?What does the EKG report say ?Use of TPA or Streptokinase ?Use of TPA or Streptokinase ?

What do the cardiac enzymes say What do the cardiac enzymes say about the MI ?about the MI ?

EnzymeName

InitialRise

Rise ToPeak

Back ToBaseline

CK 4-6 h 24-36 h 3-4 d

AST 12-18 h 36 h 4-5 d

LDH 6-10 h 2-4 d 10-14 d

Look at lipid panels - HDL, TGs, Look at lipid panels - HDL, TGs, LDL, VLDL, CholesterolLDL, VLDL, Cholesterol

Look at EKG reportLook at EKG reportwall motion - hypokinesiswall motion - hypokinesisejection fractionejection fractionwall thicknesswall thickness

Catheterization lab report - what Catheterization lab report - what percentage of vessels blockedpercentage of vessels blocked

Read the PFT reportRead the PFT report

Patient’s medications ?Patient’s medications ?beta blockersbeta blockerscalcium channel blockerscalcium channel blockersnitratesnitratesantiarrhythmicsantiarrhythmicsdiureticsdiuretics

Patient & Family Patient & Family InterviewInterview

Does the patient understand Does the patient understand what has happened to them ?what has happened to them ?

Did they have chest pressure or Did they have chest pressure or pain or anginal equivalents ?pain or anginal equivalents ?

Did the patient have any Did the patient have any predisposing risk factors - DM, predisposing risk factors - DM, HTN, PVD, hyperlipidemia, HTN, PVD, hyperlipidemia, family hx. ?family hx. ?

Did the patient smoke ?Did the patient smoke ?How long ago did they stop How long ago did they stop

smoking - @ the emergency smoking - @ the emergency room’s doors or 10 yrs. ago !room’s doors or 10 yrs. ago !

Is this the first admission ?Is this the first admission ?Is there a supportive family Is there a supportive family

network ?network ?Is the patient willing to return to Is the patient willing to return to

work ?work ?

Will the patient need to be Will the patient need to be vocationally retrained ?vocationally retrained ?

Does the patient have hobbies ?Does the patient have hobbies ?

Is the patient in denial as to what Is the patient in denial as to what has happened to them ?has happened to them ?

Does the patient need psychiatric Does the patient need psychiatric help ?help ?

The Patient EvaluationThe Patient Evaluation

ROM eval. - passive & activeROM eval. - passive & activeGross muscle strengthGross muscle strengthSkin - normal color ?Skin - normal color ?Pulse checkPulse check

pedal, femoral, popliteal, carotidpedal, femoral, popliteal, carotid

Surgical sites ?Surgical sites ?Tender points on palpation of Tender points on palpation of

thorax ?thorax ?Breathing patterns - do the ribs Breathing patterns - do the ribs

flare, does the thorax rise flare, does the thorax rise appropriately ?appropriately ?

Auscultate the lungsAuscultate the lungsBlood pressure on right & left Blood pressure on right & left

arms in supine, sitting & arms in supine, sitting & standing - bilaterally equal ?standing - bilaterally equal ?

Observe the EKG monitor when Observe the EKG monitor when sitting and standingsitting and standing

Self Care EvaluationSelf Care Evaluation

Can the patient do the following Can the patient do the following things first in things first in supinesupine, next in , next in sittingsitting and finally in and finally in standingstanding ? ?Through a total arm and leg Through a total arm and leg

ROM actively and passively - ROM actively and passively - positional perturbationspositional perturbations

comb hair, brush teeth, shave, comb hair, brush teeth, shave, perform a limited bed bath, wash perform a limited bed bath, wash the underarms and genital regions, the underarms and genital regions, wash the ankles and feet, etc.wash the ankles and feet, etc.

can the patient dress - pants, shirt, can the patient dress - pants, shirt, sockssocks

Can the patient do all of these things Can the patient do all of these things while being monitored on the while being monitored on the telemetry unit in the critical care telemetry unit in the critical care unit for : BP, EKG changes, HR.unit for : BP, EKG changes, HR.

What about the patient’s subjective What about the patient’s subjective symptoms ?symptoms ?

Next….Move Out Of BedNext….Move Out Of Bed

While monitoring the patient for While monitoring the patient for EKG changes, BP & HR :EKG changes, BP & HR :come to eob & come to standingcome to eob & come to standingcan the patient support their own can the patient support their own

body weight without assist ?body weight without assist ?can the patient walk in place ?can the patient walk in place ?

Can the patient do a SPT into a Can the patient do a SPT into a bedside chair or commode ?bedside chair or commode ?

Can the patient walk in place or Can the patient walk in place or in the room ?in the room ?

Can the patient sit UIC x 15 - 30 Can the patient sit UIC x 15 - 30 minutes at a time ?minutes at a time ?

Next….Move Out Of The Next….Move Out Of The RoomRoom

While the patient is being While the patient is being monitored continuously by EKG monitored continuously by EKG telemetry, for BP & HR :telemetry, for BP & HR :walk 25 feet & rest - do it againwalk 25 feet & rest - do it againprogress overtime as able with progress overtime as able with

EKG, BP & HR unremarkableEKG, BP & HR unremarkable

GraduationGraduation

Uncomplicated MI’s go home in Uncomplicated MI’s go home in 5-10 days5-10 days

Graduate from Phase I Cardiac Graduate from Phase I Cardiac Rehab having either :Rehab having either :Low Level GXTLow Level GXTFull GXT laterFull GXT later

Stage Speed Grade Time METs

One 1.7mph

0% 3 min 2.3

Two 1.7mph

5% 3 min 3.5

Three 1.7mph

10% 3 min 4.6

Four 2.5mph

12% 3 min 6.8

If the patient doesn’t get a If the patient doesn’t get a LLGXT in the hospital before LLGXT in the hospital before discharge, then usually they go to discharge, then usually they go to their physician’s office 1-2 weeks their physician’s office 1-2 weeks later for a modified Bruce later for a modified Bruce protocol.protocol.