Cardiac RehabilitationCardiac RehabilitationPhase II - IVPhase II - IV

Dave Zanghi M.S., MBA, ATC/L, CSCSDave Zanghi M.S., MBA, ATC/L, CSCS

Phase IIPhase II

Phase II is the next Phase II is the next stage in cardiac stage in cardiac rehabilitation for the rehabilitation for the patientpatient

It begins after discharge It begins after discharge from the hospital.from the hospital.

It usually occurs in a It usually occurs in a hospital setting where hospital setting where the patient can be the patient can be constantly monitored.constantly monitored.

Goals Of Phase IIGoals Of Phase IICardiac RehabCardiac Rehab

Give the patient a safe, Give the patient a safe, monitored environment monitored environment in which to exercisein which to exercise

Increase the patient’s Increase the patient’s work capacity through work capacity through exercise conditioningexercise conditioning

Teach the patient to Teach the patient to monitor their own monitor their own responses to exercise - responses to exercise - monitor HR and learn to monitor HR and learn to use subjective feelings to use subjective feelings to assess work intensity - use assess work intensity - use of the Borg Scaleof the Borg Scale

Relieve anxiety and Relieve anxiety and fear : reassure the fear : reassure the patient that they can patient that they can live a more normal lifelive a more normal life

Phase II continues to be a time Phase II continues to be a time for patient education - for patient education - seminars on food preparation, seminars on food preparation, medications, smoking medications, smoking cessation, sexual activity, cessation, sexual activity, cardiopulmonary anatomy, risk cardiopulmonary anatomy, risk factor modification and what to factor modification and what to do when symptoms returndo when symptoms return

The patient is monitored The patient is monitored during Phase II with :during Phase II with :

blood pressureblood pressureheart rateheart ratetelemetry EKGtelemetry EKGanginal scaleanginal scaledyspnea scaledyspnea scaleBorg scaleBorg scale

Blood pressure at rest Blood pressure at rest should be less than 160 should be less than 160 mm Hg at rest.mm Hg at rest.

Heart rate at rest should Heart rate at rest should be less than 120 bpm.be less than 120 bpm.

EKG rhythms that prevent EKG rhythms that prevent exercise in Phase II :exercise in Phase II :

atrial flutteratrial flutteratrial fibrillationatrial fibrillationsupraventricular supraventricular tachycardiatachycardia

Mobitz Type II 2nd AV Mobitz Type II 2nd AV blockblock

3rd degree AV block3rd degree AV blockcoupletscoupletstripletstripletssick sinus syndromesick sinus syndrome

Anginal ScaleAnginal Scale

1+ :1+ : faint pain is present - faint pain is present - patient patient can can continuecontinue

2+ :2+ : pain clearly present - pain clearly present - patient patient can continuecan continue

3+ :3+ : pain is very bad - patient pain is very bad - patient must must stop exercise soonstop exercise soon

4+ :4+ : Pain is the worse ever - Pain is the worse ever - exercise exercise must stop now !must stop now !

Dyspnea ScaleDyspnea Scale1+ :1+ : slight breathlessness - slight breathlessness -

patient patient can can continuecontinue

2+ :2+ : moderate breathlessness - moderate breathlessness - patient patient can continuecan continue

3+ :3+ : moderately severe moderately severe breathlessness - breathlessness - patient must patient must stop exercise soonstop exercise soon

4+ :4+ : severe breathlessness - severe breathlessness - exercise exercise must stop now !must stop now !

Borg ScaleBorg Scale

The Exercise ProgramThe Exercise Program

ModeModeDetermined by the Determined by the patient’s pathology - patient’s pathology - stationary bike, stationary bike, treadmill, Nu-Step Bike, treadmill, Nu-Step Bike, UBE or an UE Monarch UBE or an UE Monarch bikebike

Mode is also Mode is also determined by the determined by the intensity or level of intensity or level of monitoring required monitoring required for the patient’s well for the patient’s well being.being.

FrequencyFrequencyUsually 3 times per Usually 3 times per week for 12 weeks - week for 12 weeks - insurance will pay for insurance will pay for Phase IIPhase II

Duration Of Exercise BoutDuration Of Exercise Boutminimum of 15-20 minutesminimum of 15-20 minutes10-15 minute warm-up 10-15 minute warm-up periodperiod

10-15 minute cool-down 10-15 minute cool-down periodperiod

Cool-down periods are Cool-down periods are importantimportant

allows for heart to decelerateallows for heart to decelerate lactic acid disposallactic acid disposalheat dissipationheat dissipationre-uptake of catecholaminesre-uptake of catecholamines

When cool-downs are too When cool-downs are too short or non-existent, short or non-existent, cardiac events are more cardiac events are more likely to happen at the likely to happen at the end of vigorous aerobic end of vigorous aerobic exercise.exercise.

IntensityIntensityIntensity is calculated Intensity is calculated from the GXT data that from the GXT data that the patient’s doctor the patient’s doctor generated at the end of generated at the end of phase I cardiac rehabphase I cardiac rehab

GXT DataGXT Data GXT data is comprised of :GXT data is comprised of :

Resting HRResting HRResting blood pressureResting blood pressureMaximum exercise heart rateMaximum exercise heart rateMaximum exercise blood Maximum exercise blood pressurepressure

Maximimum MET’s achieved.Maximimum MET’s achieved.

Rate of ProgressionRate of ProgressionRate of progression is Rate of progression is determined by the determined by the patient’s starting fitness patient’s starting fitness level, progression of level, progression of disease, and time since disease, and time since diagnosis.diagnosis.

Using The GXT DataUsing The GXT Data

Intensity is the crucial Intensity is the crucial element in any exercise element in any exercise prescription. It is key to prescription. It is key to be able to determine the be able to determine the proper intensity from the proper intensity from the GXT data that was given GXT data that was given to you.to you.

Example GXT DataExample GXT Data

Mrs Springer’s data :Mrs Springer’s data :Resting HR = 80 bpmResting HR = 80 bpmResting BP = 128/60Resting BP = 128/60Maximal Ex. HR = 172 bpmMaximal Ex. HR = 172 bpmMaximal Ex. BP = 190/88Maximal Ex. BP = 190/88Max MET’s obtained = 9 Max MET’s obtained = 9 METsMETs

Karvonen’s FormulaKarvonen’s Formula

Max HR-Rest HR) x (A.F.) + Rest Max HR-Rest HR) x (A.F.) + Rest HRHR

(Max HR-Rest HR) x (.4 -.7)+ (Max HR-Rest HR) x (.4 -.7)+ Rest HRRest HR

With Mrs. Springer’s With Mrs. Springer’s Data...Data...

Tr HR = [(172-80) x .6] + Tr HR = [(172-80) x .6] + 8080

Tr HR = [(92) x .6] + 80Tr HR = [(92) x .6] + 80

Tr HR = 135 bpmTr HR = 135 bpm

Mrs. Springer’s exercise Mrs. Springer’s exercise intensity will be no intensity will be no greater than 135 bpm greater than 135 bpm for the first 1-2 weeks for the first 1-2 weeks of Phase II cardiac of Phase II cardiac rehab.rehab.

As she develops more As she develops more aerobic capacity, aerobic capacity, stronger and more stronger and more endurant musculature, endurant musculature, then the intensity can be then the intensity can be gradually increased.gradually increased.

A ReasonableA ReasonableRate Of ProgressionRate Of Progression

Week 1-2 : treadmill @ 0% x 3.5 mph Week 1-2 : treadmill @ 0% x 3.5 mph

HR @ 135 x 20 minHR @ 135 x 20 min Week 2-4 : treadmill @ 0% x 3.8 mphWeek 2-4 : treadmill @ 0% x 3.8 mph

HR @ 140 x 30 minHR @ 140 x 30 min Week 4-6 : treadmill @ 2% grade x 3.8 Week 4-6 : treadmill @ 2% grade x 3.8

mphmph

HR @ 140 x 40 minHR @ 140 x 40 min Week 6-8 : treadmill @ 4% grade x 3.8 Week 6-8 : treadmill @ 4% grade x 3.8

mphmph HR @ 140 x 45 minHR @ 140 x 45 min

After 12-Weeks OfAfter 12-Weeks OfPhase II, What Next ?Phase II, What Next ?

Once Mrs. Springer has Once Mrs. Springer has graduated from 12-graduated from 12-weeks of Phase II cardiac weeks of Phase II cardiac rehab, she will enter rehab, she will enter Phase III cardiac rehab.Phase III cardiac rehab.

Phase III Cardiac RehabPhase III Cardiac Rehab

Phase III is an exercise Phase III is an exercise program that is usually program that is usually held at a athletic club or held at a athletic club or the YMCAthe YMCA

It is characterized by a It is characterized by a much lower level of much lower level of monitoring.monitoring.

Personnel present in a Personnel present in a Phase III program are Phase III program are the exercise leader and the exercise leader and a nurse with a crash carta nurse with a crash cart

Monitoring may involve :Monitoring may involve :An initial BP taken before An initial BP taken before warm-up exercises or...warm-up exercises or...

An initial defibrillator An initial defibrillator paddle look at the heart - paddle look at the heart - analysis of the resting EKGanalysis of the resting EKG

Fifteen minutes of stretching Fifteen minutes of stretching and light exercises will begin and light exercises will begin the exercise sessionthe exercise session

Patients will then exercise for Patients will then exercise for 30-60 minutes doing walk-jog, 30-60 minutes doing walk-jog, easy basketball, or whatever easy basketball, or whatever exercise routine they have exercise routine they have planned out - rowing, biking, planned out - rowing, biking, rebounding, etc.rebounding, etc.

Cool-down is a much Cool-down is a much lower level of exercise lower level of exercise activity decelerating to a activity decelerating to a slow, ambling walk and slow, ambling walk and followed by a few followed by a few minutes of stretching minutes of stretching exercises.exercises.

In Phase III, the patient In Phase III, the patient is largely responsible for is largely responsible for self monitoring HR, self monitoring HR, subjective feelings and subjective feelings and symptomatology.symptomatology.

Currently, re-Currently, re-imbursement from imbursement from insurance is variable. insurance is variable. Many times the patient Many times the patient must sustain the cost.must sustain the cost.

Phase IV Cardiac RehabPhase IV Cardiac Rehab

Phase IV is a lifelong Phase IV is a lifelong commitment to regular commitment to regular exercise. It is generally exercise. It is generally run as a club experience.run as a club experience.

The Phase IV club The Phase IV club experiences could involve experiences could involve swimming, badminton, swimming, badminton, tennis, walk-jog, biking, tennis, walk-jog, biking, hiking, Tai-Chi in the park, hiking, Tai-Chi in the park, etc.etc.