Section 12: Exercise Prescription for Patients with Cardiac Disease

ACSM Guidelines: Chapter 9

HPHE 4450 Dr. Cheatham

Inpatient Rehabilitation Programs

Uncomplicated patients may be seen for only 3 to 4 days before hospital discharge. The goals for inpatient programs:
Offset the deleterious psychological and physiological effects of bed rest during hospitalization. Provide additional medical surveillance of patients. Identify patients with significant CV, physical, or cognitive impairments that may influence prognosis. Enable patients to return to activities of daily living within the limits imposed by their disease. Prepare the patient and support system at home to optimize recovery following hospital discharge. Facilitate patient entry into outpatient CR programs.

Inpatient Rehabilitation Programs

Assessment Prior to Inpatient Cardiac Rehabilitation:
Heart sounds Lung sounds Peripheral pulses Musculoskeletal strength and flexibility AACVPR risk stratification (ACSM Box 2.3) Review of indications/contraindications (Box 9.2)

Inpatient Rehabilitation Programs

Additional Considerations for Inpatient Cardiac Rehabilitation
Exceptions regarding indications/contraindications are based on clinical judgment of physician and rehabilitation team. Short hospital stays allow limited formal rehabilitation. Activities in first 48 hours are restricted to self-care, range-of-motion exercises, and postural adaptations. Proceed to ambulation (assisted, progressing to independent) using RPE as adjunct to heart rate in gauging intensity.

Inpatient Rehabilitation Programs

Adverse Responses to Inpatient Exercise Leading to Exercise Discontinuation

Inpatient Rehabilitation Programs

Exercise Prescription: Frequency

Early mobilization
2 to 4 timesd-1 for first 3 days of hospital stay

Later mobilization
2 timesday-1 beginning day 4 with increased duration of exercise bout

Inpatient Rehabilitation Programs Exercise Prescription: Intensity

Upper limits:
To tolerance if asymptomatic RPE 13 on scale of 6 to 20 Post-MI/congestive heart failure (CHF)
HR 120 beatsmin-1 or HRrest + 20 beatsmin-1

Postsurgery
HRrest + 30 beatsmin-1

Inpatient Rehabilitation Programs

Exercise Prescription: Time (Duration)

Intermittent bouts lasting 3 to 5 minutes as tolerated Rest periods (at patients discretion)
Slower walk Complete rest

Attempt 2:1 exercise/rest ratio

Inpatient Rehabilitation Programs

Exercise Prescription: Progression

Duration
Progress until continuous duration is 10 to 15 minutes.

Intensity
Increase intensity as tolerated when duration above is reached.

Inpatient Rehabilitation Programs

Goals Prior to Discharge
Patient understanding of inappropriate/excessive physical activities Patient understanding of safe, progressive plan of exercise (not to exceed levels observed during inpatient program) Patient encouraged to participate in outpatient exercise programs (information provided) Patient understanding of signs and symptoms of exercise intolerance and need for medical evaluation Patient understanding of modifiable risk factors Patient and family education on other topics as necessary

Outpatient Exercise Programs

Outpatient CR programs may begin as soon as hospital dismissal.

Most patents can begin a supervised exercise program within 1 to 2 weeks of leaving the hospital.

Outpatient Exercise Programs

Outpatient Exercise Programs

Assessments on Program Entry
Medical and surgical history, including most recent event Physical examination with emphasis on cardiopulmonary and musculoskeletal systems Review of recent tests and procedures
12-ECG Coronary angiogram Echocardiogram Stress test (exercise or imaging) Revascularization Pacemaker/ICD

Current medications
Dose Administration route Frequency

CVD risk factors

Outpatient Exercise Programs

Pre-Exercise Assessment at Each Session
ECG surveillance (telemetry or hardwire monitoring, quick-look, or periodic rhythm strips) Blood pressure Body weight Heart rate Symptoms or evidence of change in clinical status Symptoms or evidence of exercise intolerance Medication compliance

Outpatient Exercise Programs

Exercise Prescription: Safety Factors
Clinical status Risk stratification category Exercise capacity Ischemic/anginal threshold Cognitive/psychological impairment that might result in nonadherence to guidelines
Vocational/avocational requirements Musculoskeletal limitations Premorbid activity levels Personal health/fitness goals

Exercise Prescription: Associated Factors

Outpatient Exercise Programs

Exercise Prescription: Frequency

Most days of the week (47 dwk-1) If very limited exercise capacity, multiple short (1- to 10-minute) sessions Encourage independent exercise.

Outpatient Exercise Programs

Exercise Prescription: Intensity
RPE of 11 to 16 on scale of 6 to 20 GXT data available
40% to 80% exercise capacity using HRR, %VO2R, or VO2peak HR below ischemic threshold (if determined)

Concerns: medication effects

Outpatient Exercise Programs

Exercise Prescription: Intensity (contd)
If no GXT data available

Outpatient Exercise Programs

Outpatient Exercise Programs

Exercise Prescription: Time (Duration)

Warm-up (5 to 10 minutes) and cooldown (5 to 10 minutes)
Static stretching Range-of-motion exercises Low-intensity aerobic activities

Aerobic conditioning (20 to 60 minutes)

Outpatient Exercise Programs

Exercise Prescription: Progression
Initial duration of 5 to 10 minutes per session Progress 1 to 5 minutes per session (or increase time 10%20% per week), continuous or intermittent Individualized to patient tolerance considering:
physical fitness level, patient motivation and goals, signs and symptoms, and musculoskeletal limitations.

Outpatient Exercise Programs

Progression for Intermittent Exercise

Outpatient Exercise Programs

Exercise Prescription: Type
Rhythmic, large muscle group activities with emphasis on caloric expenditure to include both upper extremity and lower extremity May include:
ergometers (arm, leg, or combination), elliptical, rower, stair climber, and treadmill.

Outpatient Exercise Programs

Criteria for Appropriateness of Independent Exercise
Cardiac symptoms stable or absent Appropriate ECG, blood pressure, and heart rate responses to exercise Demonstrated knowledge of proper exercise principles Demonstrated awareness of abnormal symptoms Motivation to continue regular exercise without supervision

Resistance Training for Cardiac Patients

Resistance Training for Cardiac Patients

Resistance Training for Cardiac Patients

Resistance Training for Cardiac Patients

Resistance Training for Cardiac Patients

Resistance Training for Cardiac Patients

Resistance Training for Cardiac Patients

Resistance Training for Cardiac Patients