Transcript Guidelines for Cardiac Rehabilitation

Cardiac Rehabilitation
DPT 732
S. Scherer
Spring 2009
Objectives
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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
Statistics
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CV disease
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# 1 cause of death
1 death every 33 seconds
Coronary Artery Bypass CAB Surgery
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> ½ million surgeries per year
Clinical practice is changing
Changes in Surgical
Management
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Anesthesia procedures
Minimally invasive procedures
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Smaller incision
Off pump
Shorter hospital length of stay
Clinical Course
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Traditional
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Acute Care (phase 1)
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Contemporary
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Acute Care (phase 1)
Inpatient
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Outpatient (phase 2)
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Wellness (phase 3)
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Medical rehabilitation
Skilled nursing
Home health PT
Outpatient PT
Outpatient CR (phase 2)
Maintenance (phase 3)
Additional PT for
comorbidities
Post CAB Complications
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Myocardial injury
Blood loss
Incision infections
Atrial fibrillation
Pneumonia
Cognitive impairments
Bypass machine impairments
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Microemboli
Cerebral hypoperfusion
PT considerations
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Prevention of pulmonary complications
– Upright positioning & early mobilization
– Deep breathing
– Airway clearance techniques prn
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Incisional precautions for 2 wks
– No submersion in water; running water OK
– No cream or lotion directly in incision
PT considerations-- Sternal
Precautions
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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.
Outcome Measures
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Medical
– Morbidity
– Mortality
– Complication rates
– Hospital LOS
– Ejection fraction
– Quality of life
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Rehabilitation
– Quality of life
– ADL performance
– Symptom impact
– Habitual physical
activity level
– Balance
Impairments & Functional
Limitations following CAB
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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
Functional Outcomes After CAB
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Comparison groups
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CAB --- Surgical
AMI, PTCA, Angina --- Nonsurgical
Functional outcome measurements
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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)
Surgical & Non surgical
Outcomes
Surgical
Non surgical
6MWT
853 ± 324
965 ± 321
DASI
14.7 ± 7.5
18.5 ± 7.0
QOL total
40.0 ± 47.2
47.2 ± 12.4
QOL physical function
34.2 ± 19.6
45 ± 23.2
QOL role physical
1.4± 4.9
12.5 ± 25
Lapier, Journal of Cardiopulmonary Rehabilitation 2003;23:203-207.
Conclusions—Functional Status
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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)
Goals of Cardiac
Rehabilitation
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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
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.”
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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.
Cardiac Rehab Components
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Comprehensive long-term services
Medical evaluation
Prescribed exercise
Cardiac risk factor modification
Counseling
Behavioral interventions
Phases of Cardiac Rehabilitation
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Phase I : Inpatient
Phase II: Outpatient EKG monitored
Phase III: Outpatient with decreasing
monitoring
Phase IV: Community based,
independent exercise
Inpatient Cardiac
Rehabilitation Principles
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Goals
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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)
Initiating Inpatient Cardiac Rehab
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Post-MI, Post-surgery, Post-stent (no
MI), CHF, heart transplant
Patient may begin if:
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MD approval/order
No chest discomfort (8 hours)
No new signs of decompensated heart
failure
No abnormal EKG changes (8 hours)
Surgical vs. Medical Patients
limitations to activity
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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
Activity Progression in Cardiac
Rehabilitation
Example of Activity Progression
Day Location
Activity
MET Level
HR response
1
OOB to chair (sitting)
1.5-2 MET
5-15 bpm above resting
2-3 MET
10-15 bpm above
resting
2-3 METs
15-20 bpm above
resting
3-4 METs
15-20 bpm above
resting
CCU
Bedside commode
2
Telemetry
ADL/self care
Sitting leg and arm range of motion
Walking in room
3
Tele
OOB as tolerated
Standing warm up exercise
Walking 5-10 minutes
4
Tele
Shower seated
Ambulate level, up stairs ½ level or
down 1 level
Monitoring
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HR
BP
SaO2
EKG
Symptoms
At each change in
position
Cardiac Rehabilitation Programs
Outpatient
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Exercise Training performed by:
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Exercise Physiologist
MD supervised
Physiotherapist
Nurse
Risk Factor Modification provided by:
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Nurse/educator
Dietician
Behavioral support
Safety
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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
Exercise Risk
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Risk of sudden death is low in cardiac patients, but
still higher than healthy individuals
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Vigorous & uncontrolled exercise risk of death:
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Cardiac arrest: 1: 111,966 person-hours
Risk of death 1: 783,972 person-hours
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)
Exercise Prescription
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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)
Cardiac Rehab Phase II
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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
Pre-requisites
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Exercise Testing
Prior to starting
program
Components of Phase II
50% HRR, 3x/week, 60 minute
sessions including warm-up
and cool-down
Physical Activity Core
Components
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Evaluation
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Interventions
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Assess current PA level
Assess readiness to change behaviors
Advice, support, counseling, follow-up
Advise activities
Expected Outcomes
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Increased participation in physical activity
Increased aerobic fitness, well-being
Exercise Training Core
Components
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Evaluation
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Interventions
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Symptom limited exercise test
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HR, rhythm, ST segment changes, hemodynamics, signs,
symptoms, perceived exertion, exercise capacity
Risk stratify for level of supervision
Individual exercise program (aerobic & resistance)
F-I-T-T and progress
Expected Outcomes
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Increased aerobic capacity, strength, flexibility
Reduced symptoms, improved risk factor profile, improved
QOL
Phase III Outcomes
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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
Cardiac Rehab Phase IV
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Unsupervised program
Community Based
Expected Outcomes
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Improved exercise tolerance
Return to work
Improved Quality of life
Decreased risk factors (secondary
prevention)
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Weight loss
Low cholesterol with dietary changes
Smoking cessation
AHCPR Cardiac Rehabilitation
Recommendations
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Exercise Training (A evidence)
Strength Training (B evidence)
Exercise habits (B evidence)
Aerobic Capacity and Endurance
Goals
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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)
Additional effects of Exercise
Training
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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.
Effects of Exercise Training
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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
Other Effects of Exercise Training
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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)
Resistance Training in Cardiac
Rehabilitation
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AACVPR states patients may begin:
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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
Secondary Prevention
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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
Return to Work
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Work rates 49-93% after MI
20% do not return to work after
revascularization
Factors that influence return to work
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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)
Utilization of Cardiac Rehab
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15% of qualified patients who have
had MI or CABG participate
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Lack of physician referral
Poor patient motivation
Logistics
Financial
DeBusk, (1993)
Adherence to Cardiac Rehab
(Exercise Programs)
Factors contributing to
80
70
60
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50
40
% partic
30
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20
10
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0
3
mos
12
mos
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decreased adherence
Lack of attention to
individual needslimited feedback
Inconvenient location
or schedule
Inadequate leadership
Sedentary occupation
or leisure time
Long-Term Effects of Two Psychological
Interventions on Physical Exercise….
Sniehotta, 2005
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Treatment 1: Detailed
action plans & Strategy
aimed at barriers
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Treatment 2: Detailed
planning AND Weekly diary
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Both interventions enhance
physical activity
participation.
General physical activity for 3 groups and 3 times.
Sniehotta, 2005
Billing Issues
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Centers for Medicare & Medicaid
Services (CMS) cardiac rehab
coverage (link)
Conditions:
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Post MI, stent, CHF, valve replacement
18 weeks– 36 sessions
Incident to Physician service
Cardiac rehab billing codes
Peripheral Arterial Disease
Rehabilitation
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Peripheral Arterial
Disease (PAD)
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Atherosclerosis in
the peripheral
vessels, usually the
femoral/iliac which
causes decreased
blood flow to the
legs
PAD with IC
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Intermittent Claudication
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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
Diagnosis of PAD
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Ankle-Brachial
Index (ABI)
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Highest ankle
systolic blood
pressure divided by
highest arm blood
pressure
Normal 0.91-1.3
How big a problem is PAD?
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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
Typical outcome measures
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Maximal walking time
Absolute Claudication
Distance (ACD)
Pain-free walking time
Initial Claudication
Distance (ICD)
Self-reported walking
limitations
Peak VO2
Quality of Life
Graded protocols for
Quantifying Claudication
3 minute stages
Stage 1
Stage 2
Stage 3
Stage 4
Protocol 1
2 mph
2 mph
2 mph
2 mph
0%
3.5%
7%
10.5%
Protocol 2
2 mph
3 mph
3 mph
3 mph
Labs EH, et al. Vasc Med 1999.
Hiatt et al, J Cardiopulmonary Rehabil 1988.
0%
0%
2.5%
5%
Characteristics of Individuals
with Symptomatic PAD
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Adult mean age 65
Peak VO2 50% of age-predicted
normal
ICD 110 meters
Sedentary
Effective interventions
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Medication to control risk factors
Medication to improve claudication
Surgery (angioplasty or bypass)
Exercise Training
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Home
Supervised
Dynamic
Supervised Treadmill
Exercise vs Control
TM
protocol
Dahllof
4 km/hr
0% grade
Number of % Change
Months
in ACD
6
+117
Mannarino 2 km/hr
6
+67
12% grade
Hiatt 1990 6.4 km/hr
graded
3
+ 123
1974
1989
Supervised vs Home exercise
TM
protocol
Regensteiner 6.4 km/hr
1997
graded
Patterson
1997
3.3 km/hr
10% grade
Number %
of Months Change in
ACD
3
+137 TM
+ 5 home
6
+195 TM
+ 83 home
Pre-Post Supervised
Programs
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Increases of ICD and ACD 44-200%
Hiatt et al
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ACD + 123%
Peak VO2 +30%
ICD + 165%
Drug Therapy
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Cilostazol (Pletal)
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Pentoxifylline
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Vasodilation, inhibit platelet aggregation
Methylxanthine derivative lowers plasma
fibrinogen
L-carnitine
Drug therapy vs Placebo
Number % change in
of months ACD
Money
1998
Cilostazol
4
+47 drug
+ 13 placebo
Brevetti
1999
L-carnitine
12
+ 62 drug
+ 42 placebo
Patients with ACD <
250 meters benefited
most
Exercise vs. surgery
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Angioplasty has initial increase in
ACD, but same as exercise group after
12 months
Exercise has no adverse effects
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Creasy 1990
Components of Effective Exercise
Programs
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3x/week
At least 30 minutes
Walk until onset or moderate pain
Rest until pain subsides
Repeat…
Increase grade when can do 10
minutes
weeks
Exercise Program Example
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Warm up (5 min), 50 min intermittent exercise,
cool-down
Week 1 – 2 mph 0% grade 3 min x 8 intervals
Week 2 – 2 mph 0% grade 6 min x 8 intervals
Week 3 – 2 mph 0% grade 10 min x 3 intervals
Week 6 –3 mph 5% grade 10 min x 3 intervals
Summary
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Supervised Exercise programs are
beneficial in improving exercise
tolerance in patients with cardiac or
vascular disease
Other components of cardiac
rehabilitation also produce beneficial
effects on depression, risk profile and
quality of life.
Application
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Describe the key components of
cardiac rehabilitation for patients post
CAB surgery using concept map
Determine ability to charge for cardiac
rehabilitation for case example
Advocate for cardiac rehabilitation care
for patient example
Cardiac
Rehabilitation
Cardiac Rehabilitation Case DPT
732 2009
Elizabeth is a 52 year old woman who comes to your clinic 8 weeks after a double bypass
surgery for coronary artery disease. She has been religiously observing her sternal
precautions. Elizabeth now has lost shoulder ROM and complains of shoulder stiffness
than limits her dressing, reaching, bathing. Elizabeth also complains of pain in her knees
when walking.
Elizabeth has been referred to cardiac rehab phase II to start as soon as possible and has
been referred to your clinic for PT to increase shoulder ROM and function. She received
her stress test for cardiac rehab and is scheduled to start cardiac rehab at a hospital in
town next week. She asks you if you can do the cardiac rehab here as well as the PT for
her shoulders so she won’t have to drive to 2 separate facilities. Even though she can’t
work because of her shoulders, she has a 10 year old at home. You have been considering
whether to start a cardiac rehabilitation program at your clinic, so this is a push to start
thinking about it.
Patient was prescribed these medications: Inderal, Aspirin, Plavix, Zestril , Zocor
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She reports she is only taking the aspirin
Question 1:
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Which impairments do you
hypothesize are related to the sternal
precautions and are not a common
limitation following CAB surgery?
a.
b.
Decreased Shoulder ROM
Knee pain with walking
Question 2:
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What should the PT do about Elizabeth’s
medications?
a.
b.
c.
d.
Tell her to take them all as the doctor
ordered
Ask why she is not taking all her
medications as prescribed
Educate her on the purpose of the
medications
Talk with her pharmacist about her not using
the medications
Question 3:
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What is the best way to get Elizabeth
to have PT and cardiac rehabilitation
services?
a.
b.
c.
PT can see Elizabeth for PT and cardiac
rehab and charge for each service
PT can see Elizabeth for PT and refer to
cardiac rehabilitation
PT to see Elizabeth for PT and cardiac
rehab and charge as PT services