KNGF Guideline Diagnostic process for physical therapy

Cardiac Rehabilitation History-taking

presenting
Examination
assessment of
Analysis
1. assessment of health
Designing treatment plan
Rehabilitation goals
problem / target impairments, status and current 1. exploring own limits
activity level (PSC) activity functional exercise 2. learning to cope with physical
assessment of limitations, capacity limitations
Coronary heart disease activity level participation 2. physical impediments 3. optimizing exercise capacity
before current restrictions 3. other (internal or 4. diagnostic: evaluating changes
health problem and health external) factors in exercise capacity over
arose problems that impeding recovery time and relations between
(acute) cardiac event
assessment of may influence 4. future target situation symptoms and objectifiable
health status the choice 5. can impediments be defects
(nature, course, of exercise reduced? 5. overcoming fear of physical
Clinical Phase: Phase I Preoperative phase (CABG / valve replacement) prognosis) activities in the 6. opportunities to exertion
assessment of rehabilitation reduce health 6. developing / maintaining
current state program problem, i.e. improve physically active lifestyle
Screening for risk of developing PPC other information assessment functions, activities
- personal of functional and participation
details (social, exercise
environment) capacity (SWT
CCU ICU Surgery no increased risk - motivation or 6MWT)
- need for
information
Relative rest yes
pulmonary physical therapy if
necessary Therapeutic process

Medically stable IMT Relevant information for physical therapist

breathing exercises medical diagnosis
airway clearance techniques relevant diagnostic and prognostic referral information on patients physical condition
all individual rehabilitation goals, especially goals for physical exercise and possible impediments to physical exercise,
such as anxiety, dysfunctional coping style and comorbidity
settings of ICD or pacemaker, if present (safe heart rate range for exercise)
Mobilization phase on ward Final outcome criteria
results of maximum or symptom-limited exercise test
active mobilization moderate intensity exercise ( 34 METs)
risk profile
some knowledge about heart disease
all medications (type, dosage)
Beware of signs of excessive strain coping with heart disease
diagnosis for physical therapy
information on occupational situation (so rehabilitation can be adapted to this) and prognosis
any relevant further information about family
Rehabilitation phase: Phase II

Informing / advising Tailored exercise program Relaxation program

Medical referral information from patients Screening and intake Interventions improving patients understanding patients wishes / abilities reducing tension
cardiologist by professional from MDT, usually information program of heart disease and rehabilitation patients exercise capacity promoting body
medical diagnosis the cardiac rehabilitation exercise program* in relation to physical functioning patients individual goals awareness
relevant diagnostic details coordinator relaxation program encouraging compliance, active
results of maximum or symptom-limited behavior modification program lifestyle and work resumption
exercise test lifestyle program promoting suitable way to handle
relevant comorbidity psychological program symptoms (including anxiety
prior history, cardiac & non-cardiac reduction)
medication (type, dosage)

Selecting priorities for exercise practicing skills and activities

1. Physical functioning affected /
threatened?
2. Psychological functioning
affected / threatened?
3. Social functioning affected /
threatened?
4. What is the cardiovascular risk
profile?
5. Any unhealthy behavior?
MDT program training aerobic (general) exercise capacity
rehabilitation coordinator training local strength endurance
cardiac rehabilitation cardio- training functions / activities to develop enjoyment of exercise
logist training to reduce risk factors (hypertension, diabetes mellitus,
nurse overweight / obesity, inactivity)
dietician
physical therapist
social worker Selecting exercise activities practicing functional skills and activities for ADL, work or hobbies /
health psychologist field exercises / sports and games / fitness / aerobics / swimming /
other disciplines if necessary ergometers / exercising in water / relaxation

Supplementary intake by
different disciplines
* The exercise program is part of the multidisciplinary cardiac rehabilitation.
Selecting exercise variables aerobic exercise: intensity / frequency / duration / work/rest intervals
/ structure of exercise program
strength training: external resistance / speed / number of repetitions
and sessions / recovery intervals

Implementing program
6MWT = Six-minute walk test; CABG = coronary-artery bypass graft; CCU = coronary care unit; ICD = implantable cardioverter defibrillator; ICU =
intensive care unit; IMT = inspiratory muscle training; MDT = multidisciplinary cardiac rehabilitation team; MET = metabolic equivalent of task;
PPC = postoperative pulmonary complications; PSC = patient-specific complaints; SWT = shuttle walk test; VO 2max = maximum oxygen uptake
interim and final evaluation, adjusting program if necessary

Consultations with MDT and start of aftercare phase (Phase III)

monitoring lifestyle after 6 and 12 months
maintaining physically active lifestyle
inactive lifestyle? see KNGF guidelines for exercise intervention for coronary heart disease (KNGF-standaard
V-08/2011 KNGF Beweeginterventie Coronaire Hartziekte; in Dutch)
Consult the full Guideline on www.kngfrichtlijnen.nl
KNGF Guideline
Cardiac Rehabilitation

Chronic heart failure Therapeutic process

Relevant information for physical therapist

Diagnostic process
(medical) diagnosis
relevant diagnostic (e.g. > 3 weeks hemodynamically stable) and prognostic referral information on patients physical
Medical referral Screening and intake Interventions MDT condition
information from all individual rehabilitation goals, especially goals for physical training and possible impediments to physical training,
patients cardiologist by professional from information program cardiac rehabilitation such as anxiety, dysfunctional coping style, decompensation risk and comorbidity
MDT, usually the training program* coordinator results of maximum or symptom-limited exercise test with gas analysis
medical diagnosis cardiac rehabilitation relaxation program cardiac rehabilitation settings of ICD or pacemaker, if present (safe heart rate range for training)
relevant diagnostic coordinator behavior modification cardiologist all medications (type, dosage)
details program nurse information relevant to work resumption (mostly for younger patients), prognosis and familiy information (social support)
results of maximum lifestyle program dietician diagnosis for physical therapy
or symptom-limited psychological program physical therapist
exercise test social worker
relevant comorbidity health psychologist Informing / advising Tailored training program Relaxation program
prior history, cardiac & other disciplines if
non-cardiac necessary improving patients understanding patients wishes / abilities reducing tension
medication (type, of heart disease and rehabilitation patients exercise capacity regulating breathing
dosage) regarding physical functioning patients individual goals promoting body awareness
1. Physical functioning lifestyle information / education physical improvements to be expected
Supplementary intake by
affected / threatened? recognizing signs of deterioration
different disciplines
2. Psychological of heart failure (decompensation)
functioning affected / encouraging compliance, active
threatened? lifestyle and work resumption
3. Social functioning promoting suitable way to handle
affected / threatened? symptoms and exertion in daily life
4. What is the (dyspnea and fatigue)
cardiovascular risk
profile?
5. Any unhealthy Selecting priorities for exercise practicing skills and activities
behavior? program training aerobic (general) exercise capacity
and encouraging physical activity
training (local) strength endurance
of peripheral muscle groups and / or
Diagnostic process for physical therapy
inspiratory muscles
training functions / activities to develop
enjoyment of exercise, reduce physical
History-taking Examination Analysis Designing treatment plan inactivity and reduce risk factors

presenting problem assessment of 1. assessment of health Rehabilitation goals

/ target activity level
(PSC)
assessment of activity
level before current
health problem arose
assessment of health
status (nature, course,
prognosis)
assessment of current
state
other information:
- personal details
(social, environment)
- motivation
- need for information
* The training program is part of the multidisciplinary cardiac rehabilitation. For locations of cardiac rehabilitation see the Preface and the
introduction to the Verantwoording & Toelichting (review of the evidence) document.
impairments, activity status and current
limitations and health functional exercise
problems that may capacity
influence the choice of 2. physical impediments
exercise activities in the 3. other (internal or
rehabilitation program external) factors
assessment of functional impeding recovery
exercise capacity (SWT) 4. f uture target situation
5. i s target situation
feasible within the
limits of patients
abilities?
6. o pportunities to reduce
health problem, i.e.
improve functions,
activities and
participation
Selecting training activities practicing functional skills and activities
specific goals for ADL, work and/or hobbies / field
1. optimizing exercise training / sports and games / fitness
capacity / aerobics / swimming / ergometers /
2. balancing exertion with exercising in water / relaxation
physical abilities
3. reducing dyspnea,
fatigue and inactivity
Selecting exercise variables aerobic training: intensity / frequency /
duration / work/rest intervals / structure of
general goals training program
1. exploring own physical strength training: external resistance
limits / speed / number of repetitions and
2. learning to cope with sessions / recovery intervals
physical limitations
3. overcoming fear of
physical exertion Implementation of program
4. d eveloping /
maintaining a physically
active lifestyle
interim and final evaluation, adjusting
program if necessary
Consultations with MDT and start of aftercare phase (Phase III)

ICD = implantable cardioverter defibrillator; MDT = multidisciplinary cardiac rehabilitation team; PSC = patient-specific complaints; monitoring lifestyle after 6 and 12 months
SWT = shuttle walk test; VO 2max = maximum oxygen uptake maintenance training 60% VO 2max
- primary care physical therapy practice / certified exercise facility
maintenance training < 60% VO 2max
- independently
- primary care physical therapist / certified exercise facility
network including primary care practice and hospital or rehabilitation center where cardiac rehabilitation took place
V-08/2011 Consult the full Guideline on www.kngfrichtlijnen.nl KNGF