CARDIAC REHABILITATION

Cardiac rehabilitation is an organized, multidisciplinary therapy proven to advance better outcomes for heart failure patients in the areas of exercise capacity and quality of life. In 2014, the Centers for Medicare and Medicaid expanded coverage for cardiac rehabilitation to include patients with stable, chronic HF. This is defined as patients with left ventricular ejection fraction of 35% or less and NYHA functional class II to IV symptoms that occur despite being on optimal medical therapy for 6 weeks or more (AHA, 2021).

Phases of Cardiac Rehabilitation

There are four distinct phases of cardiac rehabilitation:

  1. Acute
  2. Subacute
  3. Intensive outpatient therapy
  4. Independent ongoing conditioning

Phase 1 starts while the patient is in the hospital after an initial occurrence of HF or an exacerbation. This phase consists primarily of education of the patient and family and the introduction of an exercise program. During phase 1 the initial goals are:

  • Assess exercise tolerance and effects of mobility on exacerbation of symptoms
  • Create an individualized plan of care with input from all members of the care team (physicians, nurses, occupational therapists, physical therapists, pharmacist, discharge planners, etc.)
  • Begin preliminary safe exercises to improve mobility and cardiac health
  • Explain and address any risk factors
  • Introduce appropriate assistive devices (see below) and begin use

Phase 2 starts after discharge and takes place in an outpatient setting such as a physician’s office, clinic, or independent physical therapy practice. This phase lasts three to six weeks. Exercise is performed under observation and often during cardiac monitoring to determine the effect of gradually increasing activity on heart rate, exertion level, and heart regularity during exercise. Aerobic exercises are introduced under controlled conditions to establish tolerance. The patient is taught how to check their own pulse for rate and regularity. (An irregular rhythm is indicative of dysrhythmia that may be potentially life threatening.) The exercise program started in the hospital in phase 1 is adjusted to patient tolerance and endurance. The primary goal in this phase is to safely return the patient to functional mobility while being closely monitored for physiologic response (Sears, 2019).

Phase 3 includes more independent and group exercises with more self-monitoring. Increased exercises are practiced under the guidance of a physical therapist to monitor for adverse symptomatic response. The patient is introduced to the concept of rating of perceived exertion (RPE). Exertion parameters include heart rate, respiratory rate, perspiration, and muscle fatigue. The patient may be asked to rate how hard the exercise feels on a subjective scale such as the Borg RPE Scale (see below) (CDC, 2020a; Mayo Clinic, 2021; Sears, 2019).

BORG RPE SCALE
Rating Level of Exertion
(CDC, 2020b)
6 No exertion
7  
7.5 Extremely light
8  
9 Very light
10  
11 Light
12  
13 Somewhat hard
14  
15 Hard (heavy)
16  
17 Very hard
18  
19 Extremely hard
20 Max exertion

Phase 4 includes independent and ongoing physical conditioning to preserve optimal health. This is a self-regulated maintenance phase with ongoing monitoring by healthcare personnel (Sears, 2019).

ADDRESSING PATIENT NEEDS IN ALL AREAS

Cardiac rehabilitation provides information, exercises, and adaptation techniques in activities of daily living to encourage patients with heart failure to perform in an optimal state of function. The various disciplines involved in an individualized cardiac rehabilitation program focus on the following six areas:

  • Physiologic (physicians, nurses, physical therapists, exercise physiologists, occupational therapists, respiratory therapists)
  • Psychological (mental health workers, social workers, nurses)
  • Mental (mental health workers, social workers, nurses, physicians)
  • Spiritual (clergy, nurses)
  • Economic (social workers, nurses)
  • Vocational (occupational therapists)

While the patient’s physiologic needs may be the primary focus of most of the healthcare professionals and take the greatest amount of time, other patients’ needs must be included in an all-inclusive cardiac rehabilitation program (Harding et al., 2020).

Respiratory Therapy

Heart failure patients with respiratory comorbidities in cardiac rehabilitation require the same respiratory services as any chronic respiratory patients. Use of maintenance supplemental oxygen, chest auscultation, lung capacity measurement, medication administration by inhalation and nebulization, and education are all the responsibility of the respiratory therapist in cardiac rehabilitation (Clevenger, 2019).

There is a high prevalence of sleep-disordered breathing (SDB) in patients with heart failure. SDB is known to have a deleterious effect on morbidity and increase mortality in this patient population. The treatment of choice for this disorder is the use of a positive airway pressure device while sleeping. The efficacy of treatment with continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP) is monitored by respiratory therapists and pulmonary physicians (Yamamoto et al., 2020).

Physical Therapy

There are numerous documented benefits derived from physical therapy in a cardiac rehabilitation program. Regular exercise, particularly when performed after a prolonged period of sedentary behavior, may produce improvement in oxygen capacity, cardiac output, blood lipid levels, blood pressure, coronary artery blood flow, muscle mass, flexibility, psychological state, and weight loss and control (Shoemaker et al., 2020).

Physical therapy goals in cardiac rehabilitation are determined by the patient in conjunction with the physical therapist. Including the patient in setting these goals is likely to promote better compliance with the agreed-upon exercise regime.

BENEFITS

Direct potential benefits of physical therapy for heart failure include:

  • Decrease in the number of hospital admissions
  • Decreased mortality in patients with HFpEF
  • Improved cardiac capacity and reserve flow, both at rest and with exercise
  • Reduced blood pressure both in the short term (i.e., during an exercise session) and long term (i.e., resting blood pressure)
  • Improved coronary circulation and myocardial oxygenation
  • Improved maximum oxygen uptake (VO2 max)
  • Reduction in occurrence and length of depression
  • Improved quality of life
    (Physiopedia, 2021)

PATIENT EVALUATION

During phase 1 of cardiac rehabilitation while the patient is still in the hospital, an acute care physical therapist is added to the rehabilitation team to assess the patient, perform an initial evaluation, and create an individualized exercise plan. The initial physical evaluation may include:

  • Heart rate
  • Blood pressure
  • Oxygen saturation
  • Upper extremity function including strength and range of motion (ROM)
  • Lower extremity strength and ROM
  • Functional mobility such as walking and self-care tasks
  • Heart and lung auscultation
  • Monitoring symptomatic response to exercise
    (Sears, 2019)
FUNCTIONAL TESTS

Standardized functional mobility tests may be included as part of a comprehensive physical therapy evaluation. Examples of commonly-used tests include:

  • Timed Up-and-Go (TUG): Measures walking ability, dynamic balance, functional mobility, and fall risk
  • Six-minute walk distance (6MWD): Measures ADL performance, response to cardiopulmonary exercise, and walking ability
  • Berg Balance Scale (BBS): Measures static and dynamic balance, falls risk, and potential needs for assistive devices
  • Functional Independence Measure (FIM): Assesses physical, psychological, and social function for patients with ADL-related motor impairments (e.g., feeding, grooming, bathing, dressing, elimination)
    (Sears, 2020; Byrd et al., 2019)

TREATMENT PLANNING AND INTERVENTIONS

Physical therapists, in collaboration with the other members of the rehabilitation team, establish an individualized plan of treatments and interventions to help cardiac patients optimize their functional mobility and activity tolerance. Therapeutic exercise programs designed to optimize physical functioning and psychological well-being within a patient’s individual activity tolerance are a key part of physical rehabilitation.

The purpose and goals of individualized therapeutic exercise may include optimizing function in multiple areas of patient function, including (but not limited to) aerobic capacity, circulation, endurance, balance and stability, range of motion, functional strength and mobility, ADL performance, injury prevention and/or reduction, and eventual return to highest possible level of desired activities (Roe, 2021).

In the cardiac rehabilitation setting, physical therapists establish a specific plan of exercise for each patient, including the types and frequency of exercises to be performed. With the goal of helping patients to optimize their cardiopulmonary function, these exercises may include some combination of walking, rowing, cycling, jogging, or other appropriate endurance activities, as tolerated. If indicated, physical therapists may also assist patients with airway clearance techniques, such as specific breathing strategies, body positioning, and manual or mechanical techniques.

Strength and endurance training is also a key component of cardiac rehabilitation, including instructing patients in how to safely and appropriately warm-up, stretch, and gradually build their exercise tolerance to a consistent and beneficial level (Mayo Clinic, 2021; Sears, 2019).

Functional mobility deficits occur frequently in chronically ill patients, including those with HF. Physical therapists may recommend appropriate assistive devices as needed for patients with mobility issues (such as canes, walkers, crutches, wheelchairs, etc.) and provide training in their safe and correct use. An assistive device may ultimately, though not always, become necessary for some HF patients to maintain at least some degree of mobility independence.

Occupational Therapy

Patients with moderate to severe heart failure require some assistance with ADLs. Poor cognitive function and poor physical fitness may impair patients’ abilities to perform complex tasks, causing them to make mistakes. Disabilities with ADLs are a strong predictor of readmission to a hospital, often within the 30-day period that precludes federal or state agencies paying for the additional admissions.

According to the American Occupational Therapy Association (AOTA, 2020), the following interventions by an occupational therapist serve to reduce the number of hospital readmissions:

  • Providing recommendations and training for caregivers
  • Determining whether patients can live safely independently or require further rehabilitation or nursing care
  • Addressing existing disabilities and fall prevention with assistive devices so patients can safely perform ADLs (e.g., toileting, bathing, dressing, preparing a meal)
  • Performing home safety assessments before discharge to suggest modifications to the patient’s home
  • Assessing cognition and the ability to physically manipulate objects like medication containers and providing training where necessary
  • Assessing the ability to perform social participation and determining strategies to prevent barriers and reduce isolation and depression

Transitional care programs (from facility to home) that include OT have been documented as reducing readmissions up to 45%. Occupational therapists assist patients with heart failure to address both ADLs and instrumental activities of daily living (IADLs), including dressing, feeding, hygiene, cooking, cleaning, shopping, elimination, and more. Instruction in IADLs requires integration of physical and cognitive factors and skills. OTs may also instruct patients in cardiac rehabilitation in the use of adaptive devices to assist them with the ability to conduct ADLs without concurrent activity intolerance (Roberts et al., 2020).

If the patient will be dependent on mobility assistive devices in the long term, environmental accommodations may be recommended for the patient’s dwelling. These modifications may require significant structural changes to the patient’s living space and could take a considerable amount of time and expense.

Other recommended assistive devices for patients with mobility issues may include grab bars in the bathtub, shower, and by the toilet; shower chairs; and elevated toilet seats. The occupational therapist can recommend their use and placement and educate the patient and family about their use.

Noncompliance with medications is a common reason patients with HF exhibit worsening of their symptoms and are readmitted to the hospital. While nurses, physicians, and pharmacologists educate the patient and their family about the medications, occupational therapists help ensure that patients take medications correctly and improve compliance. They explain the use of medication diaries, calendars, and pill sorter boxes. They also work with patients to improve fine-motor control to manipulate devices such as pill sorters.

Severe heart failure (NYHA levels III and IV) may cause cognitive impairment, resulting in a reduced quality of life due to an inability to perform complex cognitive functions and a lack of desire to engage socially. The occupational therapist works with these patients to encourage them to take on as many cognitive and psychomotor activities as they are capable of doing and to educate the patient and their families about the benefits of remaining socially active to maximize participation in meaningful activities and roles. If the degree of the patient’s cognitive impairment necessitates a caregiver, the occupational therapist instructs the caregiver in how to accommodate the patient’s impairment (Roberts et al., 2020).

CASE

Bonnie Stevens is a 68-year-old patient in the telemetry unit at Westside, a small community hospital. She is newly diagnosed with left-sided HF with an acute episode and exhibits dyspnea on exertion; orthopnea; a cough productive of pink, frothy sputum; and severe exercise intolerance. She has a history of degenerative joint disease of the right hip and refuses to consider surgery. She also has a history of moderate hypertension, for which she takes lisinopril.

Bonnie dislikes doctors and hospitals and has resisted seeking medical help for her increasingly worsening symptoms to the point of deteriorating health and function. She also prefers to stay at home alone, saying her hip pain makes it too difficult to enjoy the activities she used to do with friends, such as bridge games, book club, and women’s club dinners. Her son and daughter-in-law eventually convinced her to see their family physician, who admitted her to the hospital to improve her breathing, address her mobility issues, and start her on a treatment program.

Bonnie is admitted to the emergency department, where her vital signs are measured at BP 178/98, HR 120, respiratory rate 32, temperature 99.8 °F, and O2 saturation of 89% on room air and 92% on 2 L of oxygen. She complains of a 4-out-of-10 left-sided chest pain with each inspiration. She’s sitting upright on the hospital gurney, bent forward over the over-the-bed table in obvious respiratory distress. She is placed on a cardiac monitor, has an IV started, is placed on an oxygen cannula on 2 L/m. Labs are drawn, a 12-lead EKG performed, and a portable AP and lateral chest X-ray (CXR) done. Upon review of the results of the lab and diagnostic tests, the cardiologist on call to the ED admits Bonnie to the hospital.

The significant results are:

  • Arterial blood gases on O2 @ 2 L/m:
    • pH 7.29 (7.35–7.45)
    • pCO2 32 (35–45 mmHg)
    • pO2 70 (75–100 mmHg)
    • HCOM3 20 (22–28 mEq/l)
    • Base excess -3 (-2 – +2)
  • BNP 1,542 (100–400 pg/ml)
  • O2 sat 90% (94%–100%)
  • EKG showing sinus tachycardia with rare PVCs
  • CXR showing left-sided pulmonary edema in the base

The cardiologist writes orders for Bonnie for diuretics and additional antihypertensives and to begin cardiac rehabilitation with consultation by physical therapy, occupational therapy, dietitian, and a medical social worker. As part of phase 1 of cardiac rehab, the physician orders occupational therapy and physical therapy consultations for evaluations and recommendations.

Included in the physical therapy evaluation is the TUG exam to help determine Bonnie’s functional mobility and risk of falling. After these tests, Jack, the physical therapist, provides gait training in order to teach Bonnie the safe and appropriate use of a front-wheeled walker in order to allow her to offload weight from her painful hip while ambulating. Bonnie reports that using the walker significantly reduces her pain while walking, whereupon Jack recommends she continue to use it after returning home. Since Bonnie’s front porch has four stairs, Jack also provides stair safety training using the practice stairs in the physical therapy department. He instructs Bonnie in how to use a “step-to” pattern, leading with the nonpainful leg when ascending and with the painful leg when descending, as well as how to safely manage the walker on the stairs by carrying it folded in one hand while holding the handrail with the other.

Monica, the occupational therapist, discusses with Bonnie the option of using the powered scooter that is available at most grocery stores to do her shopping. She educates her on using a pill sorter and the calendar application on her smartphone to remind her when to take the new medications her doctor has prescribed to treat her HF.

Tammy, the registered dietitian, discusses a 2 gm sodium diet and a 1,500 ml daily fluid restriction with Bonnie and her family. She teaches them how to read the labels on all grocery products and to set up a beginning diet that will include healthy varieties of as many of Bonnie’s favorite foods as possible to promote compliance with the diet.

Tran, the social worker, discusses resources in the community such as cardiac rehabilitation exercise classes at the local YWCA and explains the importance of continuing social activities to prevent depression, encourage an active lifestyle, and promote better quality of life.

Follow-up after Discharge / Prevention of Readmission

Check-up calls after discharge are usually performed by the nurse. Whether the HF patient is seen in the emergency department, an acute care hospital setting, or a physician’s office, follow-up calls to inquire about vital signs (BP and heart rate), edema, shortness of breath, increased fatigue, or a sudden weight gain may alert the primary care practitioner to the need for adjustments in treatment. Timely changes in dosages of medications or other treatment may forestall the patient having to be seen in the emergency department or readmitted to the hospital.

NURSE NAVIGATORS

A nurse navigator is a clinician (usually an RN, a nurse practitioner, or a clinical nurse specialist) who integrates long-term healthcare for complex and chronically ill patients. While more common among cancer patients, nurse navigators who specialize in cardiology may serve in this capacity for chronic cardiac diseases such as HF. The purpose is to improve health outcomes and reduce the recurrence of hospital admissions by eliminating short-term, episodic, or fragmented care. The nurse navigator reviews orders and the clinical pathway to promote effective communication with patients and their families, patient advocacy, holistic patient assessments, improved health literacy, self-management, reduced hospital lengths of stay, and reduction in the number of hospital readmissions (Byrne et al., 2020).

HOME HEALTH

The use of home health nurses in conjunction with follow-up physician visits within one week after discharge has shown to reduce hospital readmissions for HF patients. When home health nurses continue education on acute HF symptoms, risk factors for exacerbations of HF acuity, reinforcement of medication regimes, and support of patient self-management, the avoidable occurrence of hospital readmissions may be reduced. This model of nursing care includes detection of disease exacerbation, judging deterioration in patients, ascertaining conditions needing immediate intervention, observation of the patient’s appearance, listening to patients’ concerns and questions, continued management of the patient postdischarge, and instructing patients and families (Taniguchi et al., 2020).

HOME TELEHEALTH

Home telehealth can be included in an existing care pathway as an alternate service delivery model for a HF patient following a hospital admission for HF exacerbation. An electronic device monitors daily weight, BP, pulse, and glucose and transmits this data to the patient’s primary care provider’s smarphone. Needed interventions, such as medication dosage adjustment and dietary changes, can then be initiated quickly to prevent further deterioration of physical stability.

For instance, amid the public health crisis secondary to COVID-19, when continuity of patient care was maintained via telehealth in spite of necessary reductions in face-to-face meetings between patients and caregivers, patients expressed satisfaction with the delivery of care and showed improvement (Zahoransky & Lape, 2020).

LAB VALUES

Certain laboratory values must be monitored periodically in HF patients. Early detection and treatment of abnormal laboratory values will promote the patient’s well-being. B-type natriuretic peptide (BNP) is repeated to determine if the HF is worsening. A drop in red blood cells, particularly hemoglobin, could compromise systemic oxygenation. BUN and creatinine values are used to assess renal function. Other common blood tests include electrolytes (including magnesium, calcium, and potassium), glucose, albumin, ferritin, and liver tests. Urine sodium levels could be an indication that ACE inhibitors or diuretics are working (Merck & Company, 2020).

BODY WEIGHT

A precipitous increase or decrease in body weight is indicative of fluid shifts. Any gain or loss of more than 1 to 2 pounds in a single day suggests retention or release of a large amount of fluid rather than an actual gain or loss of body weight.