Cardiac Rehabilitation Benefits of cardiac rehabilitation: Improve quality of life. Decrease risk fetal heart attack. Decrease severity of angina Decrease the need of medication. Decrease blood pressure. Increase the ability to exercise longer. Decrease cholesterol level. 1

Who can benefits? Heart attack Heart Failure. Chest pain. Valve replacement. Coronary artery disease. 2

Pre exercise test: Before starting cardiac rehabilitation to estimate cardiac state ; risk assesement is done to determine heart health and type of exercise. 1-Resting ECG. 2-Stress test; how heart response to exercise. 3-Echo: an image of the heart show; how heart is pumping and how valves are working. 4-Ambulatory ECG : heart activity during usual daily activity, the heart problem may occure during eating, sex, bowel, emotional sress. 3

Monitoring during the exercise: To detect the response of the patients to the exercise: 1-Heart rate: Target Heart rate: ranged heart rate reached during exercise which enable one heart and lung to receive the most benefits from the exercise. - THR= { (HR max – HR rest) X Intensity } + HR rest. - The intensity ranged from 40% in phase I. 70% in phase II. 85 % in phase III. 4

2- Respiratory rate. 3- Blood pressure. 4- Chest pain. 5- Shortness of breath. 5

Goals of phase I. 1-Initiate early physical therapy activity to: Development of patient confidence. Decrease anxiety and depression. To set-off the prolonged bed recumbence. Return to ADL activity. 6

2-To start patient and family education. Outline the course of physical therapy. Habit modification= decrease stress 3- Upper limb exercise and shoulder girdle exercise to: Minimize adhesion formation. Minimize muscle shortening Minimize muscle Atrophy. 7

Principles: Low intensity exercise. Passive to active assisted. Distal to proximal. Lower limb, then upper limb then trunk. From supine to sitting, standing, walking. Start with short duration, high frequency then vice versa 8

Program: II.7 days program 1 st day: Breathing ex. Ankle ex. R.O. M ex. "passive" 2 nd day: Active ex for upper & lower limb. "supine" 3 rd day: Active ex. From sitting Calisthenics ex. Walking 10 feet 9

4 th day: Calisthenics Walking 2-3 ms. 5 th day: Calisthenics Walking 5 ms. Walking down stairs. 6 th day: Calisthenics Walking 7 ms. - Walking down flight. 7 th day: Calisthenics. - Walking upstairs. 10

Phase II "Out patient, Convalescent" Duration: vary according to the patient medical history and current condition; ranged from months. Exercise Guidelines: Take care about; 1-Medical history 2-Clinical status 3-Rate of recovery, which depends on; age, gender, other health conditions. 4-Symptoms, the patient are categorized into; high, moderate, low risk patients, according to ‘’stress test results". 11

High risk patient; 1-Exercise test < 5 METS 2-Exercise induced anginal pain or 2 mm or more st segment depression or dyspnea. 3-Ventricular arrhythmias increase or appear with exercise. 4-Decrease in systolic BP of mm Hg. 5-Recent myocardial infraction "less than 6 months". 12

Intermediate risk members: 1-Exercise test limited to Exercise induced ischemia. 3-Depression of ST segment less than 2mm. 4-Un-complicated myocardial infraction. 13

Low risk members: Exercise test limited to greater than 9 METS. 14

Exercise Program in Phase II General Principles: I.High risk patient: - 36 session of supervised ex. with continuous monitoring. - Educational program for risk factors. - If no complication in 1 st 3 week, create an individual home program 15

Intermediate risk members: 24 sessions without continues ECG. Low-risk members: 6 session + risk factor reduction education + supervised exercise. 16

II.The Program: 1-ECG monitoring to evaluate progress. 2-Education: A-Basic heart anatomy. B-Risk factors modification. C-Managing high blood pressur D-Medication. E- Life style change. F -Nutrition counseling. 17

3-Exercise A-Exercise progression: Start with the lower limit of moderate intensity exercise. 5-6 weeks – moderate ex. After 4 months upper rang of moderate exercise. Until maintenance stage. 18

B-Supervision: High and intermediate risk members should be supervised and ECG monitored during 8-12 weeks until safety exercise prescription established Low risk patient; Monitored during the 1 st 6-weeks. Then self-home monitored exercise program established. N.B.: The METS value of this phase is "5". 19

Aerobic Exercise -Walking or cycling. -Warm up and cool down. -Never exercise at intensity that cause shortness of breath. -Drink fluids. -Avoid extreme weather 20

Phase III: Home Program Duration: along life. Goals: Reducing risk of future heart conditions "Maintenance phase" Continue exercising to regain physical function. Learn lifestyle changes to lower risk of future heart problems "smoking, nutrition, stress". 21

Guidelines: Patients should learn how to: 1-Monitor pulse; 2-Monitor other symptom of heart disease. 3-How fast the heart should beats. 4-Join exercise group and follow education and support instruction from nurses and P.T. 22

The program includes: I. Flexibility Exercise A part of warming up and cooling down. - Aims’ 1-Length of the exercise time. 2-Relaxation. - Guidelines: -3 times per weeks sec/ once. 3-5 repetition. 23

II. Aerobic exercise Exercise that involve one or more type of exercise. Gradually increase the intensity ~ as long as you feel comfortable. THR = up to 85 % Progression: increase HR, increase duration and increase Intensity. 24

III. Strength Exercise -Aimes Increase ms strength and endurance. Decrease coronary risk factors. -Guidelines: Avoid holding breath. Warm-up and cool down. Full rang of movement. Emphasis on trunk. Start with large ms. Strength day by day. 25

Emotional training The aimes of cardiac rehabilitation is not only getting back to your physical strength, but also getting back to your emotional and mental well-being ~ recover physically and mentally and emotionally. How -Keep patient and his family around. -Be affectionate with your family and friends. -Deep breathing = relax. -Psychotherapy. -Medication 26

What to expect after cardiac rehabilitation? Returning to work. Resuming recreational activity. Resuming normal sex. 27

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