Phase I Cardiac Rehabilitation
I. The Major Objectives Of Phase I Include:
B. Preventing The Deleterious Effects Of Bedrest : This will involve mobilizing the patient as soon as they become medically stabilized. This will involve a low level walking program that will prevent problems of bedrest - muscle atrophy, blood clot formation, pneumonia, and general lethargy. The patient is being prepared to return to home with eventual goal of returning to work or to the normal activities of daily living that the patient was engaged in before they sustained their myocardial infarction.
C. Safe Discharge To Home : Phase I is designed to assess the patient's ability to return home with enough physical stamina to conduct their activities of daily living in a safe manner. This assessment is important for the patient, the family and the physician.
Phase I is meant to be preventative and diagnostic. It is meant to be preventative in the sense that in most cases the patient is medically stable at discharge. The physician wants to clearly understand at what level the patient will function at home. Therefore, Phase I will determine the ADL level at which the patient is expected to function. At discharge, the patient should understand what activities are safe and which activities should be avoided for the next several weeks.
Phase I is meant to be diagnostic because most patients will be required to submit to a low level graded exercise test either at discharge or within two weeks after discharge from the hospital. The physician will assess the heart rate and blood pressure responses to the exercise test and will record at what point during the test the patient states they have symptoms as a result of the exercise intensity such as chest pressure, chest pain, numbness and tingling in the extremities, shortness of breath, fatigue, dizziness, etc. By knowing when symptoms of cardiac ischemia occur, the physician can set the MET level above which this patient's activities at home should not exceed. MET values for most ADL's have been determined. By knowing what the maximal METs at which the patient can reasonably work at home can assure that the ADL's are appropriate for the patient's disease condition. After the low level graded exercise test has been performed and the patient discharged home, Phase II cardiac rehab will shortly commence.
II. Who Should Participate In Cardiac Rehabilitation ?
The patients who are medically stable or who can be stabilized are candidates for cardiac rehabilitation. They include the following :
|Patients With Myocardial Infarctions Who Are Medically Stable|
|Patients Who Have Had A Coronary Artery Bypass Graft Surgery (CABG)|
|Patients Who Have Had Angioplasty|
|Patients Who Have Undergone Cardiac Transplant Surgery|
|Patients With Other Cardiac Diseases Who Are Medically Stable|
|Patients Who Have Several Risk Factors Who Are Hospitalized For Other Reasons|
Who Should Not Participate In Cardiac Rehabilitation ?
|Patients With Unstable Angina - i.e. - Refractory To Pharmacological Management|
|Patients Who Are In Acute Congestive Heart Failure|
|Patients Who Have Uncontrolled Dysrhythmias|
|Patients Who Have Resting BP's >200/100 mm Hg|
|Patients Who Have Moderate To Severe Aortic Stenosis|
|Patients Who Are In Third Degree AV Block|
|Patients With Acute Pericarditis|
|Patients Who Are Being Acutely Treated For Recent Embolic Events|
|Patients With A Resting ST Segment Depression Greater Than 3-4 mm|
|Patients With Uncontrolled Diabetes Mellitus|
|Patients With Moderate To Severe Cardiomyopathies|
|Patients With Orthopedic Problems Which Preclude Them From Exercise|
III. Phase I Goals
2. Clear the patient for any pulmonary problems that would limit activity - i.e. - thoracic deformities, obstructive or restrictive pathologies, presence of adventitious sounds (crackles, wheezes, bronchophony, egophony, whispered pectoriloquy, stridor), etc.
3. Return the patient home and to the workplace with the patient having a clear understanding about what are the safe activities they can participate in without reinjuring their hearts.
4. Decrease the patient's pain and fear of living.
5. Increase the patient's physical work capacity.
6. Help the patient to modify their coronary risk factors through education.
7. Give objective information back to all members of the cardiac rehab team.
IV. Who Makes Up The Cardiac Rehabilitation Team ?
V. The Evaluation
|A. Medical Chart Review|
|B. Patient Interview|
|C. Patient's Examination|
|D. Evaluation Of Patient's Tolerance For Exercise|
Phase I cardiac rehab should begin once the patient has been declared by the primary care physician to be medically stable. In an uncomplicated myocardial infarction (MI) this may be as soon as 1-2 days after being admitted for an MI. It is common in these days of managed care to see an uncomplicated MI patient being discharge to home in 7-10 days after admission. So, time is short and must be filled with pertinent information and physical evaluation for the patient's sake. All members of the rehab team, therefore, are crucial to the patient's safe discharge to home.
A. Medical Chart Review
Here are some questions you should be asking as you do the chart review.
|Enzyme Name||Initial Rise||Time To Peak||Return To Baseline|
|Creatine Kinase (CK)||4-6 Hrs||24-36 Hrs||3-4 Days|
|Aspartate Aminotransferase (AST)||12-18 Hrs||36 Hrs||4-5 Days|
|Lactate Dehydrogenase (LDH)||6-10 Hrs||2-4 Days||10-14 Days|
B. Patient And Family Interview
Ask the patient why they are in the hospital. They may not understand all that is happening to them. Ask the patient what kinds of symptoms they had in the past before their admission to the hospital - i.e. - did they have chest pain, chest pressure, pressure or pain that radiated into the left arm. Were any anginal equivalents ever noticed like jaw pain, navel pain, low back pain, pain that radiated into the right arm, numbness and tingling in the fingers. Anginal equivalents are any sign or symptom that can alert the patient they are having problems with their heart - alternative signs other than chest pain and pressure.
Find out if the patient had any predisposing risk factors like diabetes mellitus, peripheral vascular disease, hypertension, hyperlipidemia, significant family history, etc. Was the patient a smoker and if they were how long did they smoke ? Ask the patient if they have stopped smoking and have them give you a specific date when they stopped. Sometimes they will say they have stopped but they stopped as the ambulance rolled them into the Emergency Department at the hospital.
The patient will often not remember what has been said in the early days of his/her admission. For this reason, it is crucial to include family members in all of the education sessions with the patient. It is important to assess the family to see how willing the extended family, outside of the home, are willing to help once the patient returns home. Does the family love the patient and have a sense of duty to help once he/she returns home. Is the spouse supportive or critical ? A person with good family support will likely recover and rehabilitate sooner.
If the MI is not too severe, the patient may well be able to return to his/her vocation. Try to assess the patient's willingness to return to work. The patient may have been employed as a manual laborer. Does the patient acknowledge that manual labor may not be appropriate anymore ? How willing is he/she to undergo job retraining in order to continue being the financial support to the family ?
Does the patient have hobbies and interests that may sustain them in leisure times ? What is the psychological profile of your patient ? Do they need a psychiatric consult to help them over times of depression and denial ?
C. Patient's Physical Exam
D. Evaluation Of The Patient's Tolerance Of Exercise
Next, the Physical Therapist needs to do the self care evaluation on the patient. Essentially this involves determining if the patient can do a variety of self care activities in the supine position, sitting up at the edge of the bed and in standing. This involves such activities as brushing your teeth, combing your hair, washing your face, shaving, putting on your clothes, socks and shoes. If the patient can do all of the standard self care activities in supine, sitting and standing without having any complaints of dizziness, unusual fatigue, syncope, chest pain, or the appearance of an exaggerated heart rate, blood pressure or an EKG dysrhythmia, then the patient has passed the self-care evaluation.
Now, the patient can begin a walking program that is heavily monitored and progresses slowly. It looks something like this :
At the end of Phase I, the patient will be walking several times a day with increasing distances in a patient with an uncomplicated MI. If the patient displays unusual symptomatology during the walking times - EKG dysrhythmias, shortness of breath, the development of crackles in the lungs where none existed prior to exercise, sharp increases in HR and BP with light activity, onset of syncope, vertigo, and other stress symptoms - they must be referred to their primary care physician before additional exercise times are undertaken.
If all has gone well for the patient, they will be discharged to home after the completion of a low level graded exercise stress test. The test looks something like this :
|Stage||Speed (mph)||% grade||Duration (min)||Met Level|
|I||1.7 mph||0%||3 minutes||2.3 METs|
|II||1.7 mph||5%||3 minutes||3.5 METs|
|III||1.7 mph||10%||3 minutes||4.6 METs|
|IV||2.5 mph||12%||3 minutes||6.8 METs|
Most patients with an uncomplicated moderate sized MI will be able to complete stage IV. Often, the physician will give the patients about two weeks at home for additional recovery and then have the patient submit to a Bruce treadmill protocol. The Bruce protocol is significantly more aggressive than the low level graded exercise stress test. The patient has now completed Phase I cardiac rehab and will progress now on to Phase II cardiac rehab.