progression of exercise in cardaic rehabilitation

1. CENTER FOR PHYSIOTHERAPY AND REHABILITATION
SCIENCE
JAMIA MILLIA ISLAMIA
Submitted to: Dr. Jamal Moiz
Submitted by:Qurat ul aein

2. By Qurat ul aein
19mpc005
Progression of exercise training
in Early outpatient Cardiac
Rehabilitation

3. Early out patient cardiac Rehabilitation
Phase 2 outpatient cardiac rehabilitation- Organized, supervised outpatient
cardiac rehabilitation has become an important part of the rehabilitation
process and should begin when the patient is discharged from the hospital.
Purpose : The main purpose of this phase is to progressively improve patient's
functional capacity, lower cardiovascular risk factor and prepare the patient
for return of his or her vocation. This phase should include exercise training
and generally should last up to three months.
Exercise training should include progressive light to moderate aerobic and
strength training activities. In addition, Patient should continue to receive
risks factor education as well as psychological support and vocational
guidance.

4. Timing and location - Most experts believe that the first few
weeks after discharge are the most crucial for the patient
with regard to the need for medical supervision as well as
the initial risk factor for intervention program because of
many anxieties and apprehension that exist when the
healing process is incomplete and because medication
dosage is often altered at this time, it is contradictory not to
have a well-planned and well administrated outpatient
program.

5. Exercise prescription for phase-2 - During phase 2, the purpose of the
exercise prescription for the cardiac patient should be the development of
functional capacity. This section addressed the principles of exercise
prescriptions intensity, frequency, duration, mode of training and the rate
of progression as applied to the cardiac patient.
Determination of intensity of training - Four different techniques frequently used to
determine an appropriate training intensity for a cardiac patient are discussed.
Heart rate - the upper limit for the THR in the outpatient program may vary
considerably depending on medical status, symptomatology, personal preference
and whether the patient has performed an SL -GXT
Generally, the THR estimated for hospital discharge can be used for the first 3 to
6 weeks of the outpatient program and for patient with functional capacities of 5
Mets or less.

6. At 3 to 6 weeks following a cardiac event or surgery an SL -GXT is typically
performed to evaluate the patient's medical status. The test results are
used to modify the exercise prescriptions and to further define the patient
risk status example the need for continued ECG monitoring, physical
capacity for return to work, changes in medication etc.
These are three primary methods of calculating the THR.
Method (1) percent of maximal HR (MHR), THR= specified percentage of
MHR.
method (2) percentage of HRMax reserve. THR= resting HR + specified
percentage of the difference between MHR and resting HR.
method (3) percentage of maximal Mets. THR= HR at VO2 that is a
specified percentage of VO2 Max.

7. Rating of perceived exertion- the RPE scale was conceived and introduced by Borg in the
early 1960s and is an important adjunct to monitor the intensity of training is cardiac
patient
The original scale was a 15 grade category ranging from 6 to 20 with a descriptive
maker of subjective physical effort at every odd number the scale was modified by a Dr.
Borg in 1985
A more recent 10 grade category scare with the ratio properties and similar verbal
descriptions has also been developed by Borg and is used with equal success as the
original scale .
Rating of prescribed exertion and HR linearly related to each other and to work intensity.

8. Since RPE increases with increasing workload and fatigue and decreases in
proportion to HR when adaption to training occurs knowledge of patients RPE
informs the exerciser leader of how the participant is adjusting to the exercise
program and then further progression in training should occur.
Although the usefulness of the RPE scale has been clearly shown in many
different populations its value must be interpreted in proper context. In addition,
The exerciser leader should consider that approximately 10% of the population
are either underraters or overraters or simply cannot use the scale with any
accuracy

9. Metabolicequivalent : knowledge of the metabolic cost of certain activities provides
another way of determining the appropriate exercise intensity.
The appropriate range for intensity of conditioning activities for cardiac patient as
recommended by the ACSM is usually 40% to 85% of the patient's maximal function
capacity
since data on the energy cost of most activities now exists, activities that fall within the
prescribed range may provide adequate stimulation for improving cardiorespiratory
function.
When choosing activities the expertise leader will have to take into account that
variability of the energy cost of the activity due to the patient skill , level and
enthusiasm, as well as the climate and geographical location in which the activity will
be performed
Any of these factors may complicate a person's attempt to stay within the prescribed
exercise range. Difficulties in maintaining the prescribed exercise intensity may be
overcome by including additional physiological indicators of intensity like HR and RPE ,
which adjust for personal and environmental changes.

10. Anaerobic threshold- Cardiopulmonary Exercise
testing (CPX) to evaluate the functional capacity of
cardio patient has gained in popularity in recent
years. knowledge of the cardiac and pulmonary
responses of exercise testing have led to more safer
exercise prescriptions. In addition Some programs
have begun to use the anaerobic threshold for the
prescription of exercise for CAD patients

11. However sophisticated equipment is needed to determine the AT and even with
such equipment and an experienced clinician the AT remains difficult to
determine . if the AT can be accurately identified from an exercise test it may
have important implications for patients for whom high intensity exercise is
contradicted training intensities should be prescribed slightly below that HR that
correspond to the AT, ensuring that a patient is performing aerobic work.
As a result of training adaptation, the AT tends to occur at higher workload
which would be considered by the exercise specialist when adjusting the
exercise prescription. However, given the uncertainties of measuring defining or
describing the AT, its use in exercise prescription is limited until further research
has demonstrated adequate reproducibility or understanding of the phenomena
across a broad spectrum of patients. the use of the AT method to prescribe
exercise should be done only in conjunction with the standard and accepted
method of prescription.

12. A clear understanding of the patients needs, medical history and present
medical and psychological status is necessity to prescribe exercise safely and
adequately because patient vary greatly in health status, physical fitness,
body composition, age and motivation.
It needs an individual approach to exercise prescription is recommended.
To be most effective each exercise prescription should have specific
guidelines concerning the frequency, intensity, duration, mode and progression
of the exercise program.
In addition, a well rounded program should be emphasized. The well-
rounded program includes aerobic activity for the development or
maintenance of cardiorespiratory fitness and proper weight control and
strength and muscular endurance activities, and flexibility exercises
develop and maintain strength and flexibility.

13. • Frequency :1-2 times day
• Intensity:MI:RHR+20:RPE13,CABG:RHR+20:RPE13
• Duration:MI:20-60min, CABG:20-60mi
• Activity:ROM, treadmill(walking, walking-jogging) biking,Arm ergometer,
calisthenics, weight training.

14. 3 supervised exercises sessions in an organized outpatient
program and 4 addition session at home each week. For
patients who are not stable who's medications are still being
adjusted, whose risk status has not been determined, or who are
at high risk the home program would not be recommended.
The exercise session during early stages of phase II program
are of short duration (15 min to 20 min) depending on medical
status and fitness level ,some patients may require an extra
exercise session each day during the early stages of
rehabilitation If their calorie expenditure is not sufficient

15. As the patients progress, the duration of the exercise
session can gradually increase in 5 minutes session
per week until a 45-minute session is attained.
Once a 45-minute duration of training has been attained
frequency of training can be reduced or maintain
between 3 to 5 times per week. for most patients this
may take 4 to 6 weeks .
The standard formal outpatient program usually
consists of 3 visits per week and includes both the
exercise and educational components of rehabilitation.

16. Mode of training - there are many activities that provide adequate
stimulation for improving cardiorespiratory function, Flexibility
ROM and strength.
When choosing an activity, the cardiac rehabilitation specialist
should take into account the patient's medical status, level of fitness
interests and needs as well as the available equipment’s, facilities,
climate and geographical location.
At this stage of rehabilitation highly competitive activities should be
avoided, as they may result in inappropriate cardiovascular and
hemodynamic responses. Participation in a variety of activities as it
recommended to ensure a better-rounded program.

17. The continuous training methods usually walking ,cycling or a
combination impose a submaximal energy requirement that is
maintained throughout a training period. The advantages of this
type of training are too easy of prescribing exercise and the
ability to monitor the patient
Circuit training has been shown to be an excellent method of
conditioning to improve both muscular strength and
cardiovascular endurance in cardiac patient.
Circuit training incorporates the combination lower body
(stationary cycling, treadmill walking and stair climbing) and
upper body exercise like (rowing , lightweight and wall pulleys).