Prepared By: Floriza P.

de Leon

 Increasing

functional capacity of the patient Changing natural history of the disease to reduce morbidity and mortality

 Leading

cause of morbidity and mortality in the adult population in the US CAD is the number one cause of mortality in men age 45 yrs old and in women aged 75 and older

IRREVERSIBLE RISKS
Male gender Past history of CAD Family History of Premature CAD (before age 55 year in a parent or Sibling Past history of occlusive PVD Past history of CVD

REVERSIBLE RISKS
Cigarrete Smoking Hypertension Low HDL Cholesterol (<0.9 mmmol/L (200 mg/dL))

High Lipoprotein A Abdominal Obesity Hypertriglyceridemia (>2.8 mmol/L (250 mg/dL)) Hyperinsulinemia Diabetes Mellitus Sedentary Lifestyle

PT needs to understand the cardiac response to exercise and the effects of aerobic training in order to design a safe and effective rehabilitation program for any given patient

Aerobic Capacity Physiological term used to measure the work capacity of an individual Represented by the maximum oxygen consumption (VO2 Max)

Table shows relationship between O2 and intensity of work being performed

Cardiac Output Increases with increasing work In early exercise, CO increases due to augmented stroke volume via the Frankstarling mechanism

Relationship between CO and oxygen consumption

Heart Rate Increases in a linear manner when plotted against the VOS or other measures of physical work Limited by the persons age Even with regular exercise there is a linear decrease in the maximum HR with age MHR = 220 - age

Stroke Volume Represents the quantity of blood pumped with each heartbeat Major determinant of SV is the diastoling filling volume, which is inversely related to the HR

Myocardial Oxygen Consumption Actual oxygen consumption of the heart as opposed to the VO2, which represents the oxygen consumption of the whole body (mainly due to skeletal mm) Angina threshold: point where the myocardial oxygen demand exceeds the ability of coronary circulation to meet the demand Activities performed with the LE as opposed to LE generate a higher MVO2 Activities performed supine as opposed to upright generate a higher MVO2 at low intensities and a lower MVO2 at higher intensities Activities that have an isometric component generate a higher MVO2, than a similar activity at the same VO2, without an isometric component

Myocardial Oxygen Consumption

UE

Refers to an exercise program that involves dynamic exercise with large mm groups and of a sufficient intensity, duration, and frequency to alter the cardiopulmonary response to exercise Major contributors to Physical Fitness: 1. Strength 2. Endurance 3. Coordination 4. Flexibility 5. Speed 6. Power

For cardiopulmonary patient, cardiorespiratory endurance is emphasized for maintenance of health and rehabilitation of individuals Aerobic activity Rhythmical Sustained for prolonged periods of time Uses large mm group High impact activities (running and jumping) are not generally recommended for promoting cardiorespiratory endurance because of the increased risk of injury Low impact/non weight bearing activities have a lower incidence of injury and are generally recommended for cardiopulmonary px As in all types of training, to be most effective, it must be specific

 INTENSITY
DURATION FREQUENCY MODE

Overload principle Specificity principle Quantifying intensity

Overload Stress on an organism is greater than the one regularly encountered during daily life Exercise must be above the training stimulus threshold for adaptation to occur
-

Heart Rate VO2 Max Rating of Perceived Exertion

Stimulus threshold stimulus that elicits a training or conditioning response

Specificity - Adaptations in metabolic and physiologic systems depending on the imposed d

Heart Rate Maximum Heart Rate

220-age

Karvonens

Formula

THR= RHR + (MHR - RHR) (60-80%) Deconditioned 40-50% Cardiopulmonary disease 40 60% Healthy individuals 60 80%

For

UE work

MHR = 220 age - 11

Rating of Perceived Exertion Useful for patients with heart rate suppressors e.g. Beta blockers
Original Revised

Rating of Perceived Exertion Original version ( 6-20 )

Remember only the ODD numbers

12-

60% HR range

13 16-

65 70% HR range
85% HR range

7 VERY VERY 9 - VERY 11 - LIGHT 13 SOMEWHAT HARD 15 - HARD 17 - VERY 19 VERY VERY

Rating of Perceived Exertion Revised version ( 0-10 ) 0 nothing at all 0.5 VERY VERY (just noticeable) 1VERY 2WEAK 3 MODERATE 4SOME - WHAT 5STRONG (heavy) 7 VERY 10 VERY VERY

 Exercising

at a high intensity elicits a greater improvement of the VO2 max

higher the intensity, the longer the exercise intervals, the faster the training effect

The

Exercising

at high intensities increases the risk for CV complications and musculoskeletal injury

Goal Achievement of intensity 60-90% MHR OR 5085% VO2 Max Beginners: 50-60% VO2 Max Average: 60-70% VO2 Max Fit: 75-85% VO2 Max Maximum oxygen consumption (VO2 Max) BEST measure of exercise intensity

Dependent on Total work performed Intensity Frequency Fitness level

HIGH

intensity LOW intensity

SHORT duration LONG duration

 Poor

functional capacity

5 - 10 minutes 10 - 20 minutes 15 - 45 minutes 30 60 minutes

Beginners

Average

Fit

Moderate to Minimal intensity 20 30 minutes High intensity 10 15 minutes

Exercise longer than 45 minutes increases the risk for musculoskeletal complications

 Dependent

on the health and age of the

individual
LOW

intensity HIGH intensity

HIGH frequency LOW frequency

 POOR

Daily Every other day

Beginner

Optimal

frequency

3-4 times a week 2 times a week does not generally evoke CV changes for well population Increase in frequency beyond optimal range, increases risk for musculoskeletal complications 30-45 mins 3x a week protects against CV disorders

3 5 sessions / week Greater than 5 METS Daily or multiple daily sessions Less than 5 METS

 Large

muscles Rhythmic Long duration Lower extremity versus Upper extremity exercise

Lower extremity
Larger

Upper extremity
Smaller

muscle mass Higher VO2 max HR increases linearly as a function of increased workload / VO2 max HR plateaus just before maximal VO2 max Systolic BP increases Diastolic BP remains the same

muscle

mass Lower VO2 max than LE exercise HR higher Stroke volume lower Systolic AND Diastolic BP higher

Warm-up Aerobic exercise period Cool-down

 Muscle
NCV

temperature

Vasodilation Adaptation

of respiratory centers Venous return

components Graduated low intensity warm-up (5-10 minutes) of total body movement

HR increase 20bpm

Flexibility

exercises

 Should

NOT cause fatigue Decreases

Risk for ECG changes (arrythmias) Musculoskeletal disorder

 Continuous
Interval Circuit Circuit-interval

 Submaximal

and sustained Achievement of the steady state Duration; 20 60 minutes Intensity: 60 85% VO2 Max Most effective in increasing endurance for healthy individuals

Two types: Intermediate Slow Distance

20-60 minutes continuous exercise Most commonly used for managing weight

Long

Slow Distance

Longer than 60 minutes for athletic training Provided after 6months of successful ISD

 Designed

to improve strength and power more than endurance Incorporates recovery after continual exercise Useful for beginners Work rest - work

 Exercise

period is followed by rest interval

Rest relief (Passive recovery) Work relief (Active recovery)

Work

recovery ratio

1:1 to 1:5

: 1.5 work interval allows the succeeding exercise interval to begin before recovery is complete

Aerobic Interval Training For patients with poor CV fitness 2-15 minutes at 50-80% functional capacity
Anaerobic Interval Training For patients with high CV fitness 30 sec 4 minutes at 85-100% functional capacity Usually results in greater lactic acid concentrations

 Series

of exercise activities Several exercise modes Improves both strength and endurance

 Stresses

both aerobic and anerobic systems Delays the need for glycolysis and lactic acid production

 Prevents

Pooling of blood Post-exercise syncope Ischemia, arrythmias, and other complications

Increases

oxidation of metabolic waste Length of cool-down phase proportional to intensity and length of the conditioning phase Typical 30-40 aerobic exercise period

Warrants a 5-10 minute cool-down phase

 In-patient

phase Out-patient phase Maintenance phase

In px groups: uncomplicated myocardial infarctions, post-operative CV, pulmonary, PVD and any others that may benefit from such services while in the hospital Includes supervised ambulatory therapy Staff to px ratio 1:1 ECG monitoring equipment must be available for determining appropriate exercise response and an emergence team should be available on the premises 1-2 METS in CCU; 3-4 METS in ward Begins in the CCU once the px is medically stable 1-2 wks in duration

 Goals:
Provide

additional medical surveillance To return px to activities of daily living To offset the deleterious physiological and psychological effects of bed rest Prepare px and families for stages of cardiac rehabilitation and life at home that will follow

 Role

of PT: Evaluating the physiological response to exercise Supervising the exercise and ambulation Accurately charting and recording patients progress and responses preparing the patient for discharge and remaining phases of rehabilitation program

In-Patient Exercise Prescription Methods 1-3 Days post MI: low intensity activities (2-3 METS) Reduce the risk of thrombi Self care activities, selected arm and leg exercises Lying to sitting to standing Orthostatic stress Protective chair posture (high back rest and low seat) which reduces cardiac output by 10% compared to supine Increased duration of sitting Use of bedside commode which loads the heart with only up to 3 METS unlike bed pan which increases load up to 4.7 METS PROM 1.5 METS only AROM 1.7 METS only for the UE and 2 METS only for the LE 3-5 days Post MI Walking, treadmill, cycle ergometer 5-10 mins of exercise session Most of the time exercise intensity is low and session so short that warm up and cool down are not applicable Calisthenics, self-care, early ambulation around the bed

 Stress

Test for Prognostic Stratification Should be submaximal Pxs with more than 40 years of age; limit HR to 130 bpm and workload to 5 METS Pxs with less than 40 years of age; limit HR to 140 bpm and workload to 7 METS

Should begin immediately after dismissal from the hospital: 2nd or 3rd wk after MI or open heart surgery Important time for continued medical surveillance as well as beginning intervention programs for lifestyle changes Outpatient versus home or community based facility 4-7 METS Highly supervised 0-3 mos in duration
Goals: Improve functional or exercise capacity Enhance cardiac functions Promote early return to normal activity Promote positive lifestyle changes Decrease risk factors

Activities: Interval conditioning Circuit conditioning Circuit interval conditioning Continuous training
Intensity: with functional capacity of greater than 5 METS> prescriptive techniques using heart rate and RPE Frequency: 3-4 sessions per day Duration: 10-15 mins and progress to 30-60 mins Progression rate: 1 MET/2 wks Discharge planning: Aerobic capacity of at least 5 METS Pxs ability to self monitor his or her exercise program Stability of px(absence of contraindication to exercise) Psychologic and emotional status of the px

Stress Testing Should be maximal Treadmill or bicycle ergometer

Criteria for Terminating Stress Test Px is exhausted Px has dyspnea Px is experiencing cramps(leg fatigue) Px has pain over LE mm Excessive chess pain Circulatory insufficiency ECG changes

 Contraindications
Acute

for Stress Testing

MI Unstable angina pectoris Acute myocarditis/pericarditis Coronary artery lesion Stenosis HPN (225/110 mm Hg) Acute systemic illness Congestive heart failure

Participants: 6-12 wks post hospital discharge Clinically stable or decrease angina Medically controlled dysrhythmias Knowledge of symptoms Ability to self-regulate their exercise Minimum functional capacity of 5 METS

During the 1st 3-6 mos Intensity is 50-85% of functional capacity Duration: 45 mins Frequency: 3-4 sessions/wk

 Goals:
Maintenance

of function Compliance of exercise program Risk factor education and modification Promote long term fitness
Physical

Training: includes recreational activities

 Physiological

Effects: Decreased HR Increased SV Decreased CO at each submaximal work level Increased ability to extract O2 from the blood Increased size and number of mitochondria Increased myoglobin Decreased O2 utilization by myocardial cells Improved contractility of heart mm

 Clinical

Effects: HR decreases at rest Workload performed at a maximal level would be increased Heavier workload, increased endurance
Criteria

for discharge: same as Phase II, with the functional capacity of individual, consistent with vocational and recreational requirements/goals of the individual

 Those

who can tolerate 5 METS or more Orgasm expenditure = 5 METS Px who can climb 2 flights of stairs can return to sexual activities