Cardiac Rehabilitation Intro of Pmr in Cv Diseases -Edit

8/10/2019 Cardiac Rehabilitation Intro of Pmr in Cv Diseases -Edit

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Dr. dr. Nury Nusdwinuringtyas, SpKFR-K, MEpid

Email : [email protected]

Weblogs : http://nury-nus.blogspot.com

http://rehab-med.blogspot.comhttp://rehab-med-research.blogspot.com

http://tanpa-pita-suara.blogspot.com

http://laryngectomees.blogspot.com

Citizen journalism : wikimu.com


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Nury Nusdwinuringtyas

Angela BM Tulaar

Deddy Tedjasukmana


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Definition The sum of activities required to influence

favourably the underlying cause of the disease, as

well as the best possible physical, mental and sosialcondition, so that they may by their own effortspreserve or resume as normal a place as possible inthe community. ( WHO 1993 )


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AHA Scientific Statement 1994

Cardiac rehabilitation:

Not limited to an exercise training program Include multifaceted strategies aimed at reducing

modifiable risk factors


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AHA Scientific Statement 2005

Cardiac rehabilitation / secondary prevention programsinclude:

Baseline patient assessments

Nutritional counseling Aggressive risk factors management (i.e., lipids,

hypertension, weight, diabetes & smoking) Psychosocial & vocational counseling Physical activity counseling Exercise training [appropriate use of cardioprotective drugs for secondary

prevention]


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Patients who are candidates for

Cardiac Rehabilitation:- Post MCI

- Chronic stable angina

- CHF- Cardiac arrhytmias

- Post CABG

- Post PTCA- Post cardiac valve surgery

- Post cardiac transplantation


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Cardiac Rehabilitation services

Involves:- Medical evaluation

- Exercise prescription- Modification of risk factors

- Education

- Counselling

- Vocational programs


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Goals of cardiac rehabilitation

General goals:- to optimizethe patients physiologic, phychosocial, and

vocational function;- to reducethe morbidity and mortality of cardiac

disease

Educational program:- lifestyle modificationsuch as low-cholesterol diet,

stress-reduction, and smoking cessation to reduce

the risk factor for heart disease;- reconditioning exercisesto improve safety andtolerance of daily activities (vocational, recreational,and sexual activity)


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Cardiac rehabilitation team:

Physicians

Nurses

Physical therapists

Occupational therapists

Exercise physiologists

Nutritionist

Psychologists

Social worker

Vocational counsellors


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Coronary heart disease (CHD)

Risk factors : Modifiable CHD risk factors :

hypertension, cigarette smoking, obesity, habitually

sedentary lifestye, hypercholesterolemia, high levelLLD, low level HDL, hypertriglyceridemia,hyperinsulinemia, DM

Unmodifiable CHD risk factors:Advance age, gender, family history of premature CHD,

past history of CHD, cardiac event, abnormal ECG, past

history of occlusive peripheral vascular disease or CVD


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Cardiac Evaluation

A. History :

- Chief complaint

- Past history

- Medication history- Functional and occupational history

- Personal history

- Social history- Family history


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Cardiac Evaluation

B. Physical ExaminationGeneralVital signs Cardiovascular:

Inspection Palpation Auscultation :

Heart sounds Heart murmur Pericardial rub

Pulmonary Neurologic and musculoskeletal


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Cardiac EvaluationC. Diagnostic testsChest radiograph

Cardiac tests :

ECG

echocardiography

Laboratory tests

blood tests Cardiac stress tests


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Cardiac rehabilitation Consists of four distinct phase

Each phase of cardiac

rehabilitation has specific goals

with educational or lifestyle

modification component


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Phase I : In-patient cardiac

rehabilitation

In-patient acute phase

(generally lasting from 3- 6 days)

Started as soon as the patientscondition has stabilized


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Phase I : In-patient cardiac

rehabilitation - goals

To prevent the sequelae of immobilization and assist thepatient in tolerating self-care activities and householdambulation

To prepare the patient ( and family ) for a healthy lifestyle To reduce psychologic and emotional disorders that

accompany the cardiac diagnosis

To facilitate adjustment to the acute event and to the

hospital environment To motivate the patient to make a long-term commitment

to the cardiac rehabilitation program


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Phase I program :Education and risk-modification

program :

Hyperlipidemia control Hypertension control

Smoking cessation

DM control Stress management


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Exercise program Low-metabolic demand exercise and activities.

5-10 minute (progressed up to 20-30 minutes), 2-4 times daily,

Activity < 4 mets

Not raise HR above 20 bpm

Passive or active assistive ROM exerciseactive exercise insupine, sitting, upright position

Ankle pumping exercise

Exercise parameter : pulse, BP, ECG, activity-induce symptoms

Exercise testing At the end of phase I or prior to starting phase II

Exercise


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Stop Exercise ifSigns and symptoms:

angina, light-headedness, nausea, dyspnea, fatigue,

pallor, cyanosis, ataxia, hypoxia, altered mental status,peripheral circulatory insufisiency, bradicardia (dropin HR of more 10 bpm), activity-induce BP changes,SBP > 220 mmHg, DBP >110 mmHg, activity-induced

ECG change


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Phase II : Outpatient

Conducted in an outpatient setting or towards the endof hospitalization

if the patient is discharged from the hospitalphase

II start within 1 - 2 weeks and last for 8 -12 weeks By end of phase II, patient should be able to perform

the daily self-administered exercise program safely,have adequate knowledge of his or her disease and

symptoms to persue vocational , recreational, andsexual activities safely


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Phase II : Outpatient

Goals : To enhance cardiovascular function and physical work

capacity (strength,endurance,flexibility)

To detect ECG changes during exercise To teach the patient proper techniques of exercise and

provide him/her with guidelines for long-term exercise

To establish healthy lifestyle in patient and family

To enhance the patients psychologic function andprepare him or her for return to work and resumption ofnormal familial and social roles


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Phase II program :Education and risk-modification

program

Exercise : The patient is given individualized prescription of

intensity,duration, frequency, mode activity

Physical reconditioning, begin with dynamic-rhytmic or aerobic exercise at a level of 5 mets

Exercise involve upper and lower limb


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Phase II program :Exercise : Equipment : treadmills, bicycle ergometers, arm ergometers,

wall pulleys, steps, rowing machines

Exercise session lasting 1 hour (including warming-up andcooling-down), 3 times a week

Exercise goal : target HR for at least 20-30 min for training

adaptation

Intensity is increased on a weekly basis, progressing to 8

mets before starting phase III


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Phase II program :

Return to work program Patient are prepared to return to their

original job

7 Metswithout any abnormalresponses, generally patients should

be able to return to most jobs exceptheavy industrial work


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Phase III : Maintenance

Phase III usually last from 3 - 6month and generally includes

clinical supervision andintermittent ECG

Exercisein outpatient setting,

then progress to a community orhome setting


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Phase III The Goals of phase III are similar to those of phase II

Phase III is designed to provide a smooth transitionfrom structured, closely supervised to individually

suited program Program include :

- Education and risk modification

- Exercise : aerobic exercise, resistance

training, aquatic exercise program (water

temp. 26-33C)


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Phase IV : Long term cardiac

rehabilitation

Education and risk-modification program Exercise (at least 3 times per week for 30-60

min, target HR 80% max HR, progress

gradual until 85%)Aerobic exercise Resistance trainingAquatic exercisewater exercise

Goal : to continue in improving andmaintaining fitness and a healthy lifestyle


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Cardiovascular Prognosis

Regular physical activity of at least moderate intensityreduces the risks of coronary events ( physical

inactivity is a major CHD risk factor )

Endurance exercise program may improve aerobiccapacity

Strength training (at least 30 minutes / week) mayreduce the risk of an initial coronary event

Penilaian Kapasitas Fungsi


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Kapasitas Fungsi Physical Fitness

Aerobik =

O2maksimal

Nilai sesungguhnya Prediksi

SubmaksimalSteady state

Astrand

(1965)

Gosselink (1999) dan ATS (2002)

Uji Jalan Enam menit

Tabel Digital Jarak tempuh

Prediksi jarak tempuh Prediksi O2Maks

Rumus Cahalin

(1995)

Rumus Nury (2011)

Penilaian Kapasitas Fungsi

Rumus Paul Enright (1995)

Rumus Nury (2011)


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3

30 cm 30 cm

1

2

Metode Berputar 3 Langkah

Uji Jalan 6 Menit di Lintasan Biodex gait trainer


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Protokol Uji Jalan NuryLintasan Uji Jalan Metode Berputar 3

Langkah


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Keterangan : * 0= laki- laki; 1= perempuan

Jarak tempuh dalam satuan meterUmur dalam satuan tahun

Tinggi Badan dalam satuan sentimeter

Berat badan dalam satuan kilogram

Denyut jantung maksimal uji jalan dalam satuan kali/menit dengan menggunakan Polar RS300X

VEP1dan KVP dalam satuan liter

Rumus VO2= 0,053 (jarak tempuh) + 0,022 (umur) + 0,032 (TB) -

0,164 (BB) - 2,228 (jenis kelamin) -2,287

RumusTotal distance (m) = 586.254 + 0.622 BW (kg)0,265 BH (cm)63.343 gender*

+ 0.117 age

Rumus VO2max

Rumus Prediksi Jarak Tempuh


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Cardiac Rehabilitation Intro of Pmr in Cv Diseases -Edit

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