S3 L1: Cardiac Rehabilitation Part 1 Flashcards by Mind Med

Process by which patients with cardiac disease are encouraged and supported to achieve and maintain optimal physical and psychosocial health.

Cardiac Rehabilitation

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Cardiac Rehabilitation is the process of restoring an individual to the __ compatible with the functional capacity of his heart

Maximum level of activity

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Cardiac Rehabilitation is the process of ___ for cardiac diseases for healthy individuals

preventing risk factors

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Cardiac rehabilitation programs are designed to do the following, except:
a. Limit the physiologic and psychological effects of cardiac illness
b. Reduce the risk of sudden death or reinfarction
c. Control cardiac symptoms
d. Stabilize or reverse the atherosclerotic process
e. Enhance the psychosocial and vocational status of selected patients
f. None of the Above

f. None of the Above

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T/F: Cardiac disease may not only create new emotional issues but also enhance some that might have existed before the cardiac event.

True

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T/F: It is not all cases where the primary patient care remains the responsibility of the referring physician.

False.
In all cases, primary patient care remains the responsibility of the referring physician.

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Heads the Cardiac Rehabilitation Team

Cardiologist

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Rehabilitation Doctors

Physiatrist

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Aims for functional and movement capacity of the patients

Physical Therapist

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Assist the individual in a return to work, or in counseling and referral for training for a different career.

Vocational Counselor

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A physician responsible for overall effectiveness and safety of the program.

Medical Director

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Who oversees all team personnel and facilities. Responsible for developing and revising policy, procedures, and budgets; selects needed equipment; and responsible for coordinating and supervising staff.

Program Coordinator

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Knowledgeable in exercise physiology, pathology, exercise training techniques, monitoring equipment, arrhythmia recognition, cardiopulmonary resuscitation, and Advanced Cardiac Life Support

Exercise Training Professional

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Registered nurses and exercise physiologists fill this role in many programs.

Exercise Training Professional

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Skilled in behavioral evaluation and counseling techniques who is familiar with coping mechanisms, family patterns of interaction, and available community resources

Behavior Specialist

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Screening healthy people to identify and treat risk factors before illnesses develop (Preventing the development of cardiac disorders)

Primary Prevention (IDENTIFY)

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Candidates for primary prevention are those individuals who are at what level of risk of developing CVD?

Moderate or high risk

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Number-one most preventable cause of disease, disability, and death

Cigarette Smoking

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Assessment for cardiovascular risk factors should begin at age __ and be repeated every ___

Age 20 & Every few years

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Specific Components of Primary Prevention

Therapeutic exercise
Dietary Counseling
Stress Management
Smoking Cessation
Pharmacological Management
Education and self-management

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What precaution must be taken before any individual initiates an exercise program?

Administering an activity readiness screening tool, such as the PARQ or PAR-Q+, is a good way to assess general safety or determine whether a physician referral is necessary before beginning exercise

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To improve heart disease risk factors and limit further morbidity and mortality

Secondary Intervention (ADDRESS)

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Components of Cardiac Rehabilitation

Patient Education
Risk Factor Modification
Exercises
Nutrition
Psyxhological Status
Family Relationship
Stress Management
Vocational Adjustment

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ACSM’s Guidelines for Exercise Testing and Prescription that addresses inactivity or sedentary lifestyle

Exercise Training

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ACSM’s Guidelines for Exercise Testing and Prescription component with proper patient education

Risk Factor Modification

ACSM’s Guidelines for Exercise Testing and Prescription component for psychologists and vocational counselors

Psychosocial/Vocational Counseling

ACSM’s Guidelines for Exercise Testing and Prescription component for cardiologists and physiatrist

Medical Surveillance/Emergency Support

Patients that suffer from Angina Pectoris may be suffering from ?

Myocardial Infarction

Appropriate goal for pts with Angina Pectoris

use the training effectively to improve the efficiency of exercise performance below the anginal threshold.

D/t poor LV function, these patients have increased complications compared to CABG or post-MI population

Cardiomyopathy

T/F: In HF pts, normal physiological response to exercise is often absent, and there can be a decline in ejection fraction, a decrease in SV, with resultant exertional hypotension, and syncope

True

In the most severe cases of HF, CO may not increase sufficiently to generate a __ at all

dynamic exercise response

These are patients who underwent surgery to replace blood vessels of the heart

Coronary Artery Bypass Graft

T/F: CABG pts are poor candidates for cardiac rehabilitation

False. They are excellent candidates

These are benefits of a CABG pts who will undergo cardiac rehabilitation, except: a. Increased ischemic threshold b. improved left ventricular function c. decreased coronary collaterals d. improved psychological status e. NOTA

C. Decreased Coronary Collaterals

Why is cardiac rehabilitation easier in Coronary Angioplasty than post CABG pts?

No significant postoperative recovery

These patients have issues on their conduction system

Pacemaker Implant

This must be done to patients with stenosed valves or regurgitated valves

Valvular Replacement

Patient with replaced hearts

Cardiac Transplant

one of the risk factors for development of cardiac disorders

Age

T/F: Pulmonary patients are also candidates for cardiac rehabilitation

True

Set up for unstable conditions, close monitoring, pre & post-surgery

In-patient Setup

Set up for stable conditions

Outpatient Setup

Patients may be treated at home (eg: Home therapy) or facility they belong with. Therapist will visit the patient.

Home/Facilities

Statement 1: Patients with a diagnosis of stable chronic heart failure who have recently been discharged from the hospital are not eligible to enter cardiac rehabilitation until 6 weeks after discharge from the hospital Statement 2: But they are candidates for a home-based program with physical therapy and nursing monitoring their weight, symptoms, and perceived exertion with activities. TF FT TT FF

Setup for healthy individuals

Wellness Centers

The ultimate goal (not just for cardiac rehabilitation, but for any condition that physical therapists treat)

Increase the functional capacity of the patient

In preventive stage, ___ is the main goal

reversing the pathological processes

Exercises also contribute to retarding the atherosclerotic formation as it allows

proper blood flow, control of blood pressure

comprises the parameters for the interventions for patients and clients

FITT Principle

Recommended Warm Up

5-10 min of light-to-moderate intensity cardiorespiratory and muscular endurance activities

transitional phase that allows the body to adjust to the changing physiologic, biomechanical, and bioenergetic demand

Warm up

T/F: A static flexibility exercises is superior to dynamic, cardiorespiratory endurance exercise warm-up

False. A dynamic, cardiorespiratory endurance exercise warm-up is superior to static flexibility exercises

Recommended duration for conditioning

20-60 min of aerobic, resistance, neuromotor, and/or sports activities

Recommended duration and exercise for cool-down

5-10 min of light-to-moderate intensity cardiorespiratory and muscular endurance activities

Purpose of the cooldown

to allow for a gradual recovery of heart rate (HR) and blood pressure (BP) and removal of metabolic end products from the muscles used during the more intense exercise conditioning phase.

Prevent pooling of the blood in the extremities by:

continuing to use the muscles to maintain venous return.

Prevent fainting by:

increasing the return of blood to the heart and brain as cardiac output and venous return decreases.

What happens if the patient immediately engages in endurance properly without performing warm-up?

Sudden rise/increase of the heart rate of vital signs = not good for the patients as it is difficult to control

What happens when warm-up is done prior to endurance proper?

Heart rate or vital signs will gradually increase the intensity up until the grey area is reached

At least 10 min of stretching exercises performed after the warm-up or cool-down phase

Stretching

Goal: to increase ROM in the major muscle/tendon groups according to individualized goals

Flexibility Exercises

This can be improved by engaging in flexibility exercises, especially when combined with resistance exercise

Postural Stability and Balance

T/F: More effective when muscle temperature is increased through warm-up exercises

True

Form of exercise that is made with gross motor movements

Calisthenics

This exercise is recommended for sedentary adults (walking leisurely, cycling, aqua-aerobics, slow dancing)

Endurance activities

This type of exercise is recommended for physically active adults (jogging, running, aerobics, fast dancing)

Vigorous intensity endurance activities requiring minimal skill

Exercise recommended for adults with aquired skill (under training) like swimming and skating

Endurance activities requiring skill

Exercises recommended for adults with regular exercise (Basketball, soccer, hiking)

Recreational Sports

Design of a training program needs to consider the activities and muscle groups exercise based on the needs of the particular patient, based on known vocational and recreational activities

Law of Specificity of Conditioning

Determinants of Intensity/Parameters/Methods

Heart Rate Method Oxygen Consumption

Target HR (THR) = [(HRmax/peak − HRrest) × % intensity

HRR Method

Target VO2R = [( VO2max/peak − VO2rest) × % intensity desired + VOrest

VO2R Method

Target HR = HRmax/peak × % intensity desired

HR Method

Target VO2 = VO2max/peak − % intensity desired

VO2 Method

Target MET = [( VO2max/peak) / 3.5 mL · kg−1 · min −1] × % intensity desired

MET Method

The commonly accepted range of training heart rate is

70% to 85% of maximal heart rate or 50% to 85% of maximal oxygen consumption

How to compute using the Heart Rate Method

1. Monitor the pulse 2. Compute Target Heart Rate (THR) using Karvonen’s Formula

When using this method, the prescribed intensity should be between 60% to 70% of the VO2max ● Equivalent to HRmax ● 60-70% VO2max = HRmax

Oxygen Consumption Method

HRmax = 220 – age ● 60-80% (HRmax) for normal individuals ● <60% (HRmax) for cardiac patients

Maximum Heart Rate

HRR = HRmax – HRrest 0-60% (HRR) for cardiac patients 60-80% (HRR) for normal individuals

HEART RATE RESERVE (HRR/HRReserve)

Most preferred % = tells the exercise intensity

TARGET HEART RATE (KARVONEN’S FORMULA)

T/F: Exercise prescription is NOT effective if the patient is NOT reaching the THR

True

# THR Rating THR = 80-95% (HRR) + HRrest a. Normal b. Athletes c. Cardiac Patients

b. Athletes

# THR Rating THR = 60-80% (HRR) + HRrest a. Normal b. Athletes c. Cardiac Patients

a. Normal

# THR Rating THR = 40-60% (HRR) + HRrest a. Normal b. Athletes c. Cardiac Patients

c. Cardiac Patients

Amount of oxygen consumed by the body to perform a physical activity at a given time

METABOLIC EQUIVALENT (MET)

1 MET =

3.5 ml of O2 / kg of BW / min

Cardiac Patient = --% of the maximally achieved METs on a graded exercise test

50-60%

# MET Equivalent Lying Quietly

1.0

# MET Equivalent Walking 1 mph

2.3

# MET Equivalent Sitting, writing

1.9 – 2.2

# MET Equivalent Heavy housework

3.0 – 6.0

# MET Equivalent Standing at ease

1.4 – 2.0

# MET Equivalent Light housework

1.7 – 3.0

# MET Equivalent Sitting at ease

1.2 – 1.6

Adjunct to HR monitoring

RATE OF PERCEIVED EXERTION (RPE)

In term of exercise prescription, if pt is still within this range of RPE (11-13) = --% of HRmax

60-70%

To improve aerobic and anaerobic capacity of the body, progress RPE to?

Progress: RPE (14-16) = 70-90% of HRmax

For athletes (Higher intensities = more challenging exercises) thus progress RPE to?

For athletes: RPE (17-20) = 90-100% of HRmax

Most adults are recommended to accumulate 1. [?] min of moderate intensity exercise 2. [?] min of vigorous intensity exercise daily (or combination of moderate and vigorous intensity exercise)

1. 30-60mins 2. 20-60mins

Exercise duration may be accumulated in one session or __ over the course of the day

in bouts of >10 min

T/F: For weight management and individuals with sedentary lifestyles, longer duration of exercise (~60 min) may be needed

False (>60-90 min)

Statement 1: A 20- to 30-minute session is generally optimal at 60% to 70% maximum heart rate. Statement 2: Intensity is below the heart rate threshold, a 45-minute intermittent exercise period may provide the appropriate overload. a. TF b. FT c. TT d. FF

a. TF Continuous exercise

Statement 1: With high-intensity exercise, 10- to 15-minute exercise periods are adequate Statement 2: Three 5-minute daily periods are effective in some deconditioned patients a. TF b. FT c. TT d. FF

c. TT

Dependent on intensity & duration ↑ intensity or ↑ duration = ↓

Frequency

Aerobic exercise is recommended on __ for most adults, with the frequency varying with the intensity of exercise

3–5 d · wk−1

Statement 1: Frequency may be a more important factor than intensity or duration in exercise training. Statement 2: Optimal frequency of training is generally three to four times a week. a. TF b. FT c. TT d. FF

b. FT Less important factor

Frequency for in-patients

Daily (usually bid)

Frequency of outpatients

3-5x/wk

Frequency for exercise >5 METs

3-5x/wk

Frequency for exercise <5 METs

Multiple daily sessions (usually bid)

Moderate intensity aerobic exercise done at least __

5 d · wk−1

Vigorous intensity aerobic exercise done at least

3 d · wk−1

T/F: Duration is increased first before the intensity

True

Progress intensity if:

HR is lower than THR RPE is lower Sx of ischemia do not appear

Muscular strength may be maintained by training muscle groups as little as 1d * wk-1 as long as __?

The training intensity or the resistance lifted is held constant

Using the FITT-VP, what is the recommended frequency for moderate exercise?

≥5 d * wk

Using the FITT-VP, what is the recommended frequency for vigorous exercise?

≥3d*wk

Using the FITT-VP, what is the recommended frequency for combination of moderate and vigorous exercise?

≥3-5 d * wk

Using the FITT-VP, what is the recommended intensity for most adults?

Moderate and/or vigorous intensity

Using the FITT-VP, what is the recommended intensity for deconditioned inviduals?

Light-to-moderate intensity exercise

Using the FITT-VP, what is the recommended time for a purposeful moderate exercise?

30-60 min * d

Using the FITT-VP, what is the recommended time for a purposeful vigorous exercise?

20-60min

Regular, purposeful exercise that involves [1] and is [2] in nature is recommended.

1. major muscle groups 2. continuous and rhythmic

Target Volume recommended

≥500-1000 MET-min * wk

T/F Exercise may be only performed in one continuous session to reach the desired duration and volume of exercise per day.

False

Phase in Cardiac Rehab Requires closer monitoring Checking if condition is really stable already

Phase 1

Phase in Cardiac Rehab Maintenance (lifetime)

Phase 4

Phase in Cardiac Rehab No longer in hospitals (out-pt set up) Pt is already stable and D/C from the hospital

Phase 2 & 3

Phase in Cardiac Rehab Early Post-discharge

Phase 2

Phase in Cardiac Rehab Late Recovery Phase; Training and Maintenance Phase (Sustain)

Phase 3

Phase in Cardiac Rehab Long-term maintenance of exercise and other lifestyle changes

Phase 4

Upon admission until discharge averagely lasts for?

7-14 days

Name at least 3 Main Goals for Phase 1

1. Offset the deleterious physiologic & psychological effects of bed rest 2. Provide medical surveillance / monitoring 3. Evaluate and prepare patients to safely return to ADLs within the limits 4. Prepare the patient and support system at home or in a transitional setting 5. Facilitate physician referral and patient entry into an outpatient cardiac rehabilitation program

What are the indications for modifying the program?

1. Large infarction 2. Resting tachycardia (>100 bpm) or inappropriate HR increase with self-care ADLs 3. BP failing to rise or decrease with self-care ADLs 4. ECG revealing >6-8 PVC/min or progressive heart block with self-care ADLs 5. Angina or undue fatigue with self-care ADLs

What the contraindications for the program?

1. Severe Pump Failure 2. Recurrent malignant arrhythmias 3. Angina at rest 4. 2nd-3rd degree heart block 5. Persistent hypotension (<90 mmHg) even with vasopressors (meds) 6. Rapid atrial rhythm 7. Unstable angina pectoris within 24 hours

Whenever one of the following occurs, the event should be documented appropriately:

1. Unusual HR increase 2. BP indicative of HTN 3. Drop in systolic BP 4. Signs of pallor, cold sweat, ataxia 5. Changing heart sounds/lung sounds with activity 6. ECG abnormality,

# General Exercise Guidelines Low intensity exercises (2-3 METs) → _ METs by discharge

5 METs

What is given prior to discharge and determines the maximum capacity of the pt?

Exercise Tolerance Test

# FITT Recommendation for Inpatients Frequency

Mobilization: 2-4x.day for the first 3 days

# FITT Recommendation for Inpatients Intensity for MI

Seated or standing HRrest +20 bpm

# FITT Recommendation for Inpatients Intensity for Heart Surgery

Seated or standing HRrest + 30 bpm (with upper limit of ≤120 bpm

# FITT Recommendation for Inpatients Time

Goal 2:1 exercise/rest ratio; can begin with 1:2, then 1:1, then 2:1

# FITT Recommendation for Inpatients Type

Walking Can be bedside ambulation then progress to hallway ambulation

# FITT Recommendation for Inpatients Progression

Continuous exercise (10-15 min) Increase intensity (based on HR and RPE)

In Cardiac ICU care, unconsious patients are recommended what exercise?

passive exercise

In Cardiac ICU care, consious patients are recommended what exercise?

Acitve Assitive Exercises

one of the most common problems in the ICU

Orthostatic Hypotension

In Post-PTCA, when will exercise be appropriate?

Exercise after 2 weeks to allow inflammation process to subside

In Post-CABG, what should be limited?

Limit UE exercise while sternal wound is healing (up to 90° shoulder elevation only) | Wound healing will take about 8-12 weeks

In Post-CABG, what should be avoided?

Lifting, pushing, pulling or 4-6 weeks post-op

CHF: Slight limitation in physical activities (up to 4.5 METs)

Class 2

CHF: Unable to carry-out functional activities without any discomfort or Sx

Class 4

CHF: Marked limitation in physical activities (up to 3.0 METs)

Class 3

CHF: Mild; slight limitation in physical activities (up to 6.5 METs)

Class 1

For Class 1-3 CHF, prescribe mostly __?

active exercises depending on the METs of the pt

If FBG (fasting blood glucose) is > 250 mg/dL, exercise should be avoided until __?

blood glucose levels are controlled

If FBG falls to <100 mg/dL, exercise should be __?

avoided and ask pt to take carbohydrate snack

An insulin reaction in the acute stage due to abnormal low level of the blood glucose

Hypoglycemia

Common symptoms of Hypoglycemia

confusion, sudden generalized weakness, irritability

For CAD patients, non-pharmacologic management (PT exercises are included) is initiated if __?

LDL-C is >100 mg/dL

For non-CAD patients, non-pharmacologic management is initiated if __?

LDL-C is >160 mg/dL

Duration of Early Post-Discharge

2-12 weeks of out-patient program

Goals in Early Post-Discharge

1. Improve cardiovascular fitness to levels that allow resumption of usual activities 2. Develop and assist the patient to implement a safe and effective formal exercise and lifestyle physical activity program 3. Provide adequate supervision and monitoring 4. Provide on-going medical surveillance data to the patient’s health care providers 5. Return the patient to vocational and recreational activities or modify 6. Provide patient and family education

When to do Strength Training in Phase 2 cardiac rehabilitation

After 3 weeks cardiac rehabilitation

When to do Strength Training in Phase 2 post MI

After 5 weeks

When to do Strength Training in Phase 2 post CABG

After 8 weeks

How to do Strength Training in Phase 2

Use elastic band and light weights (1-3 lbs initially) 12-15 reps, 1 set

Usual exercise during Phase 2

Endurance exercises with the use of a treadmill, bicycle Can also do strengthening and flexibility exercises

# FITT Recommendations for Phase 3 Frequency

At least 3 days per week

# FITT Recommendations for Phase 3 Intensity

HR below the ischemic threshold

# FITT Recommendations for Phase 3 Time

Warm-up/cool-down: 5-10 min Exercise proper: 20-60 min

# FITT Recommendations for Phase 3 Type

Aerobic exercise (rhythmic, large muscle group activities) Aerobic Internal Training (AIT)

# FITT Recommendations for Phase 3 Progression

Individualized

Duration of Phase 3 (Late Recovery Phase)

Lasts up to 4-6 months Less direct supervision

PHASE III: LATE RECOVERY PHASE Goals

1. Increase exercise capacity further 2. Reinforce steps for risk factor modification 3. Provide fun and recreation 4. Provide social interaction and support

PHASE III: LATE RECOVERY PHASE Done at the 6th month (To check for any changes on how the body reacts)

Exercise Tolerance Test

PHASE III: LATE RECOVERY PHASE Prescription

● RPE: 12-14 ● 50-75% of functional capacity ● 20-45 min, lesser time because exercises are more intense and advanced ● 3-5x/week

PHASE IV: MAINTENANCE Duration

Lasts indefinitely as the patient maintain a hearty and healthy lifestyle and dietary habits

PHASE IV: MAINTENANCE Goals

Patients will expend at least 1000 kcal/week (equivalent to 20 min walk everyday) with exercise for the development and maintenance of a desirable functional capacity

In obesity, once an individual gains weight we can intervene by __

increasing their activity level

S3 L1: Cardiac Rehabilitation Part 1 Flashcards

(182 cards)