Cardiac Rehabilitation

Definition

“Comprehensive long-term services involving medical evaluation, prescribed exercise, cardiac risk-factor modification, health education, counseling, and behavioral interventions ” – US Department of Health and Human Services¹ 

• Structured
• Physician-supervised
• Includes multidisciplinary cardiac rehabilitation programs
• Includes secondary prevention programs
• Intended to reduce the risk of recurrence, progression, or mortality in clients with known cardiovascular disease.

Goals² 

Short-term goals

• Control cardiac symptoms
• Enhance functional capacity
• Limit unfavorable psychologic and physiologic effects of cardiac conditions
• Improve psychosocial and vocational status

Long-term goals

• Alter the natural history of CAD
• Reduce morbidity and mortality
• Lower the risk of sudden death and reinfarction
• Stabilize or reverse the progression of atherosclerosis

Phases³ 

All phases aim to facilitate recovery and to prevent further cardiovascular disease.

Phase 1 – Inpatient

• Initiated while in the hospital
• Progressive early mobilization
• ADLs advancing to simple IADLs
• “Inpatient cardiac rehabilitation programs are mostly limited to early mobilization to make self-care possible by discharge, and brief counseling about the nature of the illness, the treatment, risk factors management and follow-up planning.”³ 

Phase 2

• Supervised ambulatory outpatient program
• 3-6 months
• Outpatient monitored exercise
• Aggressive risk factor reduction

Phase 3

• Lifetime maintenance
• Emphasis of physical fitness and additional risk factor reduction
• Exercises are either home- or gym-based
• The goal of continuing the risk factor modification and exercise program learned in phase 2.

Medicare and Medicaid

• Estimated to be more than 16 million Americans
• Most expensive medical condition in the US.⁴ 

Reasonable and Necessary Cardiac Rehabilitation

• Acute myocardial infarction (MI)
• Coronary artery bypass graft surgery (CABG)
• Stable angina pectoris
• Heart valve repair/replacement
• Percutaneous transluminal coronary angioplasty or coronary stent
• Heart or heart-lung transplantation

Core Components of Cardiac Rehabilitation

• Patient assessment
• Lipid management
• Hypertension management
• Smoking cessation
• Diabetes management
• Nutritional counseling
• Weight management
• Physical activity counseling
• Psychosocial management
• Exercise training

OT Implications

• Psychosocial identification and management of depression⁵ , anxiety, anger, substance abuse, family distress, social isolation, and sexual dysfunction.
• Engage caregivers and family members.
• Promote physical activity with occupations (e.g., IADLs, leisure, and socialization).
• Improve overall and psychosocial well-being and prevent disability.
• Sexual counseling for the fear of triggering a heart attack during intercourse.⁶ 
  • “the absolute risk increase associated with 1 hour of additional physical or sexual activity per week was estimated as 2 to 3 per 10 000 person-years for MI.”⁷ 

Exercise

• Delay time for exercise² 
  • 6 weeks after a CABG
  • 4-5 weeks after an acute MI
  • 3 weeks after a percutaneous coronary intervention
• Promote exercise that is enjoyable with realistic goals.
• Use of large muscle groups (walking, jogging, swimming, cycling) is preferred.
• Strength training is recommended after tolerating endurance training for several weeks.
• The American Heart Association method for cardiac rehabilitation patients is to exercise at 70%-85% of maximal attainable HR on their symptom-limited stress test, but may only be able to initiate the program at 50% of peak HR, depending on their level of conditioning.⁸ 
• Intensity using Borg RPE: exercise at a rating from 11-15.⁹ 
• Duration: 20-30 minutes at target HR or progressing to 30-60 minutes four to six times per weeks.
  • For deconditioned clients, they should begin with 3-10 minute interval training 2-3 times daily at target intensity of 40-50% maximum heart rate.¹⁰ 
• Format: warm-up, increase joint readiness, prevent sudden changes in peripheral resistance before maximum contraction of the skeletal muscles. Then proceed to the training phase to exercise at the prescribed intensity and duration. End with a cool-down of a gradual reduction in exercise intensity.⁸ 

Risks of Cardiac Rehabilitation

• The risk of an adverse cardiac event (MI, cardiac arrest, death) is 1 in 60,000-80,000 hours of supervised exercise.¹¹ 
• Conditions that are high risk include postoperative angina, left ventricular ejection fraction less than 35%, grade III or IV CHF, ventricular tachycardia, systolic blood pressure drop of 10+ points with exercise, excessive ventricular ectopy with exercise, and those with myocardial ischemia with exercise.

Precautions and Contraindications

• Avoid strength training in patients with CHF, uncontrolled arrhythmias, systolic >160, diastolic >100, valvular disease, or unstable angina due to risk of decompensation.¹² 
• Avoid high-intensity isometric exercises due to an increase in afterload.
• Initiate cardiac rehabilitation 6 weeks after an Automatic Implantable Cardioverter Defibrillator (AICD) implantation.
• Conditions that are contraindicated for exercise training include:¹³ 
  • Unstable angina
  • Resting systolic blood pressure higher than 200 or diastolic higher than 110
  • New or uncontrolled tachycardia greater than 120 beats/min
  • Orthostatic hypotension
  • New or uncontrolled arrhythmias
  • Uncompensated heart failure
  • 3rd degree heart block without a pacemaker
  • Active myocarditis/pericarditis
  • Significant aortic stenosis
  • Acute systemic illness or fever
  • Recent pulmonary or other embolism
  • Thrombophlebitis
  • Uncontrolled diabetes
  • Severe co-morbidities preventing participation (physical or psychologic)

Sternal Precautions

e.g., after a CABG

General sternal complications include infection, non-union, and instability.^14 15 16 

Traditional sternal precautions immediately following sternotomy involve not using the upper extremities for tasks such as bed transfers or lifting objects for 6-12 weeks.

• No pushing or pulling
• No lifting more than 5 pounds
• No lifting one arm above the head (can lift both at the same time)
• No reaching behind the back¹⁷ 

The rationale is to promote osteosynthesis and bone healing by minimizing the forces and amount of motion between the sternal edges, which can cause non-union and/or infection.¹⁸ 

Due to sternal precautions being restrictive for daily function, some studies have shown that modified (less restrictive) sternal precautions had similar effects on physical recovery, pain, and health as traditional sternal precautions.¹⁹ 

Examples of less restrictive sternal precautions from research¹⁹ 

• Use pain and discomfort to guide the use of arms.
• Avoid pushing or pulling with one arm.
• Keep both arms close to the body while lifting.
• Avoid stretching both arms backward at the same time.
• When coughing, support the sternum with a cushion or use a self-hugging position.
• When getting out of bed, roll onto your side, ease legs over the edge of the bed, and carefully use the arms to help sit you up from a lying position.

Bookmark

1. Wenger NK, Froelicher ES, Smith LK, et al: Cardiac Rehabilitation. Clinical Practice Guideline no. 17. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, and the National Heart, Lung, and Blood Institute. 1995. AHCPR Publication No. 96-0672[↩]
2. Braverman, D. L. (2011). Cardiac rehabilitation: a contemporary review. American journal of physical medicine & rehabilitation, 90(7), 599-611.[↩][↩]
3. Mampuya, W. M. (2012). Cardiac rehabilitation past, present and future: an overview. Cardiovascular diagnosis and therapy, 2(1), 38.[↩][↩]
4. Roger VL, Go AS, Lloyd-Jones DM, et al: Heart disease and stroke statistics 2011 update: A report from the American Heart Association. Circulation 2011;123:e18-209[↩]
5. Caulin-Glaser T, Maciejewski PK, Snow R, et al: Depressive symptoms and sex affect completion rates and clinical outcomes in cardiac rehabilitation. Prev Cardiol 2007;10:15-21[↩]
6. Mitchell ME J Rehabil. 1982 Oct-Dec; 48(4):15-8.[↩]
7. Dahabreh, I. J., & Paulus, J. K. (2011). Association of episodic physical and sexual activity with triggering of acute cardiac events: systematic review and meta-analysis. JAmA, 305(12), 1225-1233.[↩]
8. Piepoli MF, Corra U, Benzer W, et al: Secondary prevention through cardiac rehabilitation: Physical activity counseling and exercise training. Key components of the position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation. Eur Heart J 2010;31:1967-76[↩][↩]
9. Buckley J: Exercise physiology and monitoring of exercise in cardiac rehabilitation. In: Thow MK, ed. Exercise Leadership in Cardiac Rehabilitation. West Sussex, England; Whurr Publishers Limited: 2006:47-95[↩]
10. Hambrecht R, Walther C, Möbius-Winkler S, et al: Percutaneous coronary angioplasty compared with exercise training in patients with stable coronary artery disease: A randomized trial. Circulation 2004;1371-8[↩]
11. Thompson PD, Franklin BA, Balady GJ, et al: Exercise and acute cardiovascular events placing the risks into perspective. A scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism and the Council on Clinical Cardiology. Circulation 2007;115:2358-68[↩]
12. Dingwall H, Ferrier K, Semple J: Exercise prescription in cardiac rehabilitation. In: Thow MK, ed. Exercise Leadership in Cardiac Rehabilitation: An Evidence Based Approach. West Sussex, England: Whurr Publishers Limited; 2006:102-18[↩]
13. Ross A, Campbell M: Risk stratification and health screening for exercise in cardiac rehabilitation. In: Thow MK, ed. Exercise Leadership in Cardiac Rehabilitation. West Sussexx, England: Whurr Publishers Limited; 2006:33[↩]
14. Australian Institute of Health and Welfare. ASCT data Secondary ASCT data 2013. www.aihw.gov.au. (accessed 02/02/2018).[↩]
15. L. Cahalin, T.K. Lapier, D.K. Shaw
    Sternal precautions: is it time for change? Precautions versus restrictions – a review of literature and recommendations for revision Cardiopulm Phys Ther J, 22 (2011), pp. 5-215[↩]
16. D. El-Ansary, R. Adams, A. Ghandi Musculoskeletal and neurological complications following coronary artery bypass graft surgery: A comparison between saphenous vein and internal mammary artery grafting Aust J Physiother, 46 (2000), pp. 19-25[↩]
17. Cahalin, L. P., Lapier, T. K., & Shaw, D. K. (2011). Sternal Precautions: Is It Time for Change? Precautions versus Restrictions – A Review of Literature and Recommendations for Revision. Cardiopulmonary physical therapy journal, 22(1), 5–15.[↩]
18. L. Cahalin, T.K. Lapier, D.K. Shaw Sternal precautions: is it time for change? Precautions versus restrictions – a review of literature and recommendations for revision Cardiopulm Phys Ther J, 22 (2011), pp. 5-215[↩]
19. Katijjahbe, M. A., Granger, C. L., Denehy, L., Royse, A., Royse, C., Bates, R., … & El-Ansary, D. (2018). Standard restrictive sternal precautions and modified sternal precautions had similar effects in people after cardiac surgery via median sternotomy (‘SMART’Trial): a randomised trial. Journal of physiotherapy, 64(2), 97-106.[↩][↩]