Cardiac Rehabilitation

1. Cardiac Rehabilitation DPT 732 S. Scherer Spring 2009

2. Objectives • Identify common impairments & functional limitations in patients following CAB surgery • Select outcome measures for patients following CAB surgery or MI • Discuss aspects of plan of care for these patients • Describe components of comprehensive cardiac rehabilitation

3. Statistics • CV disease • # 1 cause of death • 1 death every 33 seconds • Coronary Artery Bypass CAB Surgery • > ½ million surgeries per year • Clinical practice is changing

4. Changes in Surgical Management • Anesthesia procedures • Minimally invasive procedures • Smaller incision • Off pump • Shorter hospital length of stay

5. Clinical Course • Traditional • Acute Care (phase 1) • Outpatient (phase 2) • Wellness (phase 3) • Contemporary • Acute Care (phase 1) • Inpatient • Medical rehabilitation • Skilled nursing • Home health PT • Outpatient PT • Outpatient CR (phase 2) • Maintenance (phase 3) • Additional PT for comorbidities

6. Post CAB Complications • Myocardial injury • Blood loss • Incision infections • Atrial fibrillation • Pneumonia • Cognitive impairments • Bypass machine impairments • Microemboli • Cerebral hypoperfusion

7. PT considerations • Prevention of pulmonary complications – Upright positioning & early mobilization – Deep breathing – Airway clearance techniques prn • Incisional precautions for 2 wks – No submersion in water; running water OK – No cream or lotion directly in incision

8. PT considerations-- Sternal Precautions • Do not lift more than 8 pounds. (A gallon of milk weighs 8 pounds.) • Do not push or pull with your arms when moving in bed and getting out of bed. • Do not flex or extend your shoulders over 90°. • Avoid reaching too far across your body. • Avoid twisting or deep bending. • Do not hold your breath during activity. • Brace your chest when coughing or sneezing.  This is vital during the first 2 weeks at home. • No driving.  • Avoid long periods of over the shoulder activity. • If you feel any pulling or stretching in your chest, stop what you are doing.  Do not repeat the motion that caused this feeling. • Report any clicking or popping noise around your chest bone to your surgeon right away. 

9. Outcome Measures • Medical – Morbidity – Mortality – Complication rates – Hospital LOS – Ejection fraction – Quality of life • Rehabilitation – Quality of life – ADL performance – Symptom impact – Habitual physical activity level – Balance

10. Impairments & Functional Limitations following CAB • Incisional (sternotomy and donor graft leg) pain and drainage • Continuous pain from the shoulders and neck • Thoracic pain • Respiratory problems • Feelings of weakness • Sleeping difficulties including chest wall pain with side lying, waking frequently and early, more nightmares than usual • Problems with wound healing • Dissatisfaction with postoperative supportive care • Problems with eating • Ineffective coping • Depression

11. Functional Outcomes After CAB • Comparison groups • CAB --- Surgical • AMI, PTCA, Angina --- Nonsurgical • Functional outcome measurements • 6 Minute Walk Test --- Endurance (Performance-based) • Duke Activity Status Index --- ADL/Endurance (Self-report) • RAND 36 Health Survey --- Health-related QoL (Self-report) (Lapier, 2003)

12. Surgical & Non surgical Outcomes Lapier, Journal of Cardiopulmonary Rehabilitation 2003;23:203-207.

13. Conclusions—Functional Status • Functional limitations immediately after CAB are significant • CAB surgery limitations > less invasive procedures • Inability to perform ADLs is closely related to self reported QOL • After 1 year, 36% report self care as unsatisfactory (Lapier, 2003, Dimateo, 2003)

14. Goals of Cardiac Rehabilitation • Limit the adverse physiologic effects of cardiac illness • Limit the adverse psychological effects of cardiac illness • Reduce the risk of sudden death or reinfarction • Control cardiac symptoms • Stabilize or reduce atherosclerosis • Improve functional capacity • Enhance psycho-social and vocational status

15. Core Components Cardiac Rehabilitation “All cardiac rehabilitation/secondary prevention programs should contain specific core components that aim to optimize cardiovascular risk reduction, foster healthy behaviors and compliance with these behaviors, reduce disability, and promote an active lifestyle for patients with cardiovascular disease.” • Balady GJ, Williams MA, Ades PA, et al. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: A scientific statement from the American Heart Association exercise, cardiac rehabilitation, and prevention committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, epidemiology and prevention, and nutrition, physical activity, and metabolism; and the American Association of Cardiovascular and Pulmonary rehabilitation. Circulation. May 22 2007;115(20):2675-2682.

16. Cardiac Rehab Components • Comprehensive long-term services • Medical evaluation • Prescribed exercise • Cardiac risk factor modification • Counseling • Behavioral interventions

17. Phases of Cardiac Rehabilitation • Phase I : Inpatient • Phase II: Outpatient EKG monitored • Phase III: Outpatient with decreasing monitoring • Phase IV: Community based, independent exercise

18. Inpatient Cardiac Rehabilitation Principles • Goals • normal cardiovascular response to changes in position and ADLs • reach 3-4 MET activity level by discharge • Activity--Slow progression of activity intensity (increase by 1 MET/day)

19. Initiating Inpatient Cardiac Rehab • Post-MI, Post-surgery, Post-stent (no MI), CHF, heart transplant • Patient may begin if: • MD approval/order • No chest discomfort (8 hours) • No new signs of decompensated heart failure • No abnormal EKG changes (8 hours)

20. Surgical vs. Medical Patients limitations to activity • Post-MI: HR < 120 beats/min or 20 beats above resting allowed with activity • Post-surgery: 30 beats above resting is allowed • Surgical patients may have sternal precautions

21. Activity Progression in Cardiac Rehabilitation

22. Monitoring • HR • BP • SaO2 • EKG • Symptoms • At each change in position

23. Cardiac Rehabilitation Programs Outpatient • Exercise Training performed by: • Exercise Physiologist • MD supervised • Physiotherapist • Nurse • Risk Factor Modification provided by: • Nurse/educator • Dietician • Behavioral support

24. Safety • Selection of appropriate patients • Proper monitoring • All professional exercise personnel must be able to do basic life support, including defibrillators • Emergency procedures must be specified • Warm up and cool down are required

25. Exercise Risk • Risk of sudden death is low in cardiac patients, but still higher than healthy individuals • Cardiac arrest: 1: 111,966 person-hours • Risk of death 1: 783,972 person-hours • Vigorous & uncontrolled exercise risk of death: • Cardiac: 1: 60,000 person-hours (1 event for 384 people @ 3 hrs/ week) • 1: 565,000 person-hours for healthy (1: 3122 people) • Principle role of cardiac rehab is to define exercise mode & intensity that are SAFE & EFFECTIVE VanCamp (1986), Fletcher (1990)

26. Exercise Prescription • Patients should be tested on dosage of medication they will be taking during exercise • Beta-blockade blunts HR response, but % VO2 reserve and RPE may be used • Below threshold of angina ( use exercise test)

27. Cardiac Rehab Phase II • Supervised outpatient program 6-8 wks • Exercise test performed prior to rehab • EKG monitoring every session • Goals - increase exercise capacity to 5 METS • Patient education on HR, exercise, symptoms

28. Pre-requisites • Exercise Testing Prior to starting program

29. Components of Phase II 50% HRR, 3x/week, 60 minute sessions including warm-up and cool-down

30. Physical Activity Core Components • Evaluation • Assess current PA level • Assess readiness to change behaviors • Interventions • Advice, support, counseling, follow-up • Advise activities • Expected Outcomes • Increased participation in physical activity • Increased aerobic fitness, well-being

31. Exercise Training Core Components • Evaluation • Symptom limited exercise test • HR, rhythm, ST segment changes, hemodynamics, signs, symptoms, perceived exertion, exercise capacity • Risk stratify for level of supervision • Interventions • Individual exercise program (aerobic & resistance) • F-I-T-T and progress • Expected Outcomes • Increased aerobic capacity, strength, flexibility • Reduced symptoms, improved risk factor profile, improved QOL

32. Phase III Outcomes • Functional capacity goals > 8 METS or 2x energy requirements of work • Training effects expected • No cardiac symptoms • EKG monitoring happens occasionally, or when increasing activity parameters • Patients learn self-monitoring of HR and symptoms

33. Cardiac Rehab Phase IV • Unsupervised program • Community Based

34. Expected Outcomes • Improved exercise tolerance • Return to work • Improved Quality of life • Decreased risk factors (secondary prevention) • Weight loss • Low cholesterol with dietary changes • Smoking cessation

35. AHCPR Cardiac Rehabilitation Recommendations • Exercise Training (A evidence) • Strength Training (B evidence) • Exercise habits (B evidence)

36. Aerobic Capacity and Endurance Goals • Improved with appropriately prescribed and supervised exercise training program • Peak VO2 Increased + 11-66% after 3 months training • Increased submaximal exercise endurance (longer at given rate with lower HR & BP) • Decreased exercise induced ischemia at same cardiac work (Rate-pressure product) • Increased participation in exercise (does not continue after end of rehab program)

37. Additional effects of Exercise Training • 27% decrease in all cause mortality • 31% decrease cardiac mortality • No effect on MI recurrence Taylor, R.S., A. Brown, S. Ebrahim, et al., Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. American Journal of Medicine, 2004. 116(10): p. 682-92.

38. Effects of Exercise Training • Does not limit atherosclerosis process • No effect on development of collateral circulation • Decreases myocardial ischemia • Little effect on ejection fraction • Elderly patients have exercise trainability similar to that of younger patients • Minimal adverse events

39. Other Effects of Exercise Training • BP reductions • HDL + 5-15%, no effect of LDL & total cholesterol • Inconsistent effect on controlling body weight (nutrition intervention better) • No effect on smoking cessation • Improves psychological well being (effect occurs with and without other counseling services)

40. Resistance Training in Cardiac Rehabilitation • AACVPR states patients may begin: • Minimum of 5 weeks post MI, including 3 weeks of participation in cardiac rehab • Minimum 8 weeks post CABG, including 3 weeks of participation in cardiac rehab • Resistance training defined at > 50% of 1RM • Theraband, light weights (1-3#) may be initiated sooner if indicated

41. Secondary Prevention • Education is important in the management of hypertension • Education, counseling and behavioral modification do not improve exercise capacity • Alternative approaches (home telemetry monitoring) useful for clinically stable patients

42. Return to Work • Work rates 49-93% after MI • 20% do not return to work after revascularization • Factors that influence return to work • Demographic & socioeconomic factors only 50% • Physical/emotional functioning 29% • Medical factors 20% • Patients perception of own activity status very predictive of return to work Mark, DB (1992)

43. Utilization of Cardiac Rehab • 15% of qualified patients who have had MI or CABG participate • Lack of physician referral • Poor patient motivation • Logistics • Financial DeBusk, (1993)

44. Adherence to Cardiac Rehab (Exercise Programs) Factors contributing to decreased adherence • Lack of attention to individual needs- limited feedback • Inconvenient location or schedule • Inadequate leadership • Sedentary occupation or leisure time

45. Long-Term Effects of Two Psychological Interventions on Physical Exercise…. Sniehotta, 2005 • Treatment 1: Detailed action plans & Strategy aimed at barriers • Treatment 2: Detailed planning AND Weekly diary • Both interventions enhance physical activity participation. General physical activity for 3 groups and 3 times. Sniehotta, 2005

46. Billing Issues • Centers for Medicare & Medicaid Services (CMS) cardiac rehab coverage (link) • Conditions: • Post MI, stent, CHF, valve replacement • 18 weeks– 36 sessions • Incident to Physician service • Cardiac rehab billing codes

47. Peripheral Arterial Disease Rehabilitation • Peripheral Arterial Disease (PAD) • Atherosclerosis in the peripheral vessels, usually the femoral/iliac which causes decreased blood flow to the legs

48. PAD with IC • Intermittent Claudication • Aching or cramping pain that occurs in the legs with walking, forcing the person to stop walking, and decreases with rest. Re-occurs consistently with the same level of activity

49. Diagnosis of PAD • Ankle-Brachial Index (ABI) • Highest ankle systolic blood pressure divided by highest arm blood pressure • Normal 0.91-1.3

50. How big a problem is PAD? • 12-14% of USA population • Up until age 65, more prevalent in men • Associated with CHD and CVA • Disabling “ you don’t know how lucky you are to be able to walk” • Walking limited to under one block