Scope of Cardiac Rehabilitation

Scope of Cardiac Rehabilitation JENNIE ARCHER ATWOOD and DAVID H. NIELSEN The focus of this article is on the acute care and rehabilitation of the patient with coronary artery disease. The purpose is to provide an overview of the clinical treatment used at the University of Iowa Hospital, for the practicing physical therapist who may be unfamiliar with this type of patient. The three primary phases of the cardiac rehabilitation program are discussed with emphasis on the treatment of the patient with a post-myocardial infarction. Specific guidelines regarding evaluation and progression of physical activity are provided. Key Words: Exercise therapy, Heart diseases, Rehabilitation. The first symptom is a pretty full pain in my left arm a little above the elbow, and in perhaps half a minute it spreads across the left side of my breast and produces either a little faintness or a thickness in my breathing at least I imagined so, but the pain generally obliges me to stop. At first, it went off instantaneously, but of late by degrees; and if through impatience to wait its leaving me entirely, I resumed my walk, the pain returned. Letter to William Heberdeen Signed unknown Ms. Atwood is Assistant Professor, Physical Therapist Assistant Program, School of Applied and Continuing Education, Washburn University, Topeka, KS 66621 (USA). Dr. Nielsen is Associate Professor, Physical Therapy Education, College of Medicine, The University of Iowa, Iowa City, IA 52242. This clinical description of angina pectoris was presented by William Heberdeen at the College of Physicians in London in 1768. 1 Earlier literature suggests, however, that symptoms of coronary artery disease (CAD) were observed over 2,000 years ago. Today, CAD is the number one killer in the United States and the western world. 2 Over 1 million persons experience a myocardial infarction (MI) each year with approximately 600,000 mortalities. 3 Although these statistics are alarming, we must recognize that a significant number of persons do survive and that a real need exists to provide adequate therapeutic programs for optimal rehabilitation of these individuals. The goal of cardiac rehabilitation (CR) is to restore the individual with CAD to an optimal level of physical, psychological, social, and vocational function. Although the benefits of CR with regard to morbidity and mortality are not proven fully, the effect on quality of life is undisputed. In the past 25 years, CR has moved from discouraging patient activity to the current objective of increasing and in some cases surpassing the patient's premorbid level of activity and exercise. Bed rest is no longer the standard treatment; rather, progressive, low intensity, endurance exercise is stressed. The focus of this article is on the physical therapy involvement in the acute care and rehabilitation of the patient after a MI. The purpose is to provide an overview of the clinical treatment and rationale for treatment for the practicing physical therapist who may be unfamiliar with this type of patient. Although the same principles of treatment may apply to cardiac patients after coronary artery bypass surgery, angioplasty, or streptokinase procedures, the specific type we are discussing is the patient after a MI. OVERVIEW OF CARDIAC REHABILITATION Although exercise is a major portion of the CR program, education and counseling regarding the control of risk factors associated with CAD also is included. Members of the CR team are the physician, nurse, physical therapist, occupational therapist, dietitian, pharmacist, social worker, and vocational rehabilitation counselor. In some settings, an exercise physiologist, a physical educator, and a clinical psychologist also may be involved. Various philosophies and approaches to the physical therapy treatment of patients after a MI are in existence today. The trend, however, is to divide the CR into three phases: Phase I, II, and III, with subdivisions by grades or steps. 3 " 5 Phase I of CR begins when the patient is admitted to the hospital and ends on discharge, which is usually 7 to 10 days later. The goal of exercise in Phase I is to avoid the deleterious effects of bed rest by making a gradual transition from passive range of motion (PROM) to active range of motion (AROM) exercise and low intensity, short duration ambulation. An exercise prescription, including intensity, duration, frequency, and mode of exercise, is given before discharge. Exercise and work precautions and guidelines are discussed. Phase II of CR begins when the patient is discharged from the hospital and continues for six weeks to six months, depending on the facility. This phase covers unsupervised home exercise or supervised monitored exercise located in an outpatient cardiac rehabilitation center (OCRC). The exercise program is usually a continuation of the program begun in Phase I, until a reevaluation by the physician is completed six to eight weeks post-mi. Following reevaluation, a new exercise program is prescribed. At the physician's discretion, the patient will remain in the monitored OCRC program or may progress to Phase III of CR. Phase III of CR begins to resemble the exercise guidelines recommended for healthy adults. The patient is now eight weeks to six months or more post- MI and probably has achieved a reasonable level of fitness. This phase of CR may be accomplished with an organized program provided by a YMCA or other public facility or with an unsupervised home program. A maintenance program for CR emphasizes the achievement of self-regulated physical activity by the post-mi patient as the goal. Phase III of CR continues indefinitely, and the 1812 PHYSICAL THERAPY

patient is followed on a regular basis by his local physician. PHASE I Physical Therapy Evaluation On admission to the hospital, with a suspected diagnosis of MI, the patient usually is sent to the Cardiac Intensive Care Unit (CICU). After the patient's condition has stabilized (usually in two to three days for an uncomplicated MI), the patient is transferred to our Cardiac Rehabilitation Step Down Unit. If the patient's condition is too critical to allow transfer out of the intensive care area, the CR program may be initiated while the patient is still in the CICU. The patient evaluation is a dynamic process. Each day, new test results and evaluation procedures provide additional information. The patient may have new complaints or problems; he or she may have changes on physical examination. The physical therapist must monitor these changes, reevaluate the patient's condition, and make necessary changes in the physical therapy as indicated. The patient evaluation includes a review of the chart with collection of the patient data base, subjective information provided by patients and family, and objective information gathered in the physical examination by the physical therapist. Specific components of the data base, subjective information, objective information, and the assessment and goals are given in the following list: Data Base Current patient status. The present state of health, including the date of the MI, any complications, and recent medical and surgical events, are considered. The patient's current state of stability should be noted. Medications. An awareness of the drugs administered and their actions is important in assessing the patient's present status and response to exercise. Vital signs. Trends in blood pressure, heart rate (HR), and respiratory rate should be recorded in the physical therapy data base. Chest roentgenogram. Signs of acute or chronic heart failure and pulmonary disease may be provided by the chest roentgenogram. 2, 6 Arterial blood gases. Blood gases provide information about acute or chronic pulmonary insufficiency. 2,6 ' 7 Hemoglobin-hematocrit. The oxygen carrying capacity is related directly to hemoglobin concentration. If the patient is anemic, the coronary circulation may be compromised further. If blood volume is low (decreased hematocrit), hypotension may be noted with resulting decrease in perfusion of the coronary arteries. All factors would contribute to exercise intolerance. Serial enzyme studies. Serial measurements of the percentage of lactate dehydrogenase (LDH), serum glutamic oxalocetic transaminase (SGOT), and creatine phosphokinase-m band isozyme (CPK-MB), particularly the peak levels, provide information about the approximate date and severity of the MI. 2, 8 Electrocardiogram. The area of infarction, dysrhythmias, rate, and ischemic patterns may be evident by ECG. 9 Cardiac catheterization and coronary angiography report. The location and severity of the coronary occlusion are reported. Resting and exercise isoventriculogram. The ejection fraction provides information about the functioning of the left ventricle. An ejection fraction greater than 65% is considered normal, less than 37% is found with a severely damaged left ventricle, and an ejection fraction of 10% to 20% may be found in patients with severe cardiac failure. 2 Echocardiogram. Important information is provided concerning the state of the valves, presence or absence of a pericardial effusion, congenital heart disease, hypertension, or myocardial disease. 2 ' 8 Pulmonary function tests. Taken at an earlier date, these tests may be included in the chart and provide information concerning underlying pulmonary pathology. 7 Graded exercise test. The purpose of this test is to identify exercise-induced arrhythmias or ischemic changes and to assess the patient's functional work capacity so that a safe, individualized exercise prescription can be given. 4, 10, 11 (Such exercise test data usually are not available on new patients.) Subjective Information The patient should describe the pain and symptoms and the activities that precipitated the pain. Previous, present, and desired activity levels and social and occupation information should be determined. Objective Information Physical Exam The patient's general appearance during the initial evaluation and subsequent treatment sessions is noted. Observe the monitoring equipment and assistive devices that are present. Note the breathing pattern and work of breathing. Peripheral trophic changes, edema, skin lesions, and areas of ecchymosis are noted. The skin is palpated for temperature, pulses, and chest wall pain. Auscultation for the presence of heart sounds and breath sounds is done at this time. An assessment of the cough includes the effectiveness, control mechanism, and the sputum production. Vital signs, blood pressure, and HR are taken in supine, sitting, and standing positions. Posture, gross joint range of motion, functional muscle strength, and coordination are noted. For an assessment of exercise tolerance, HR, blood pressure, ECG changes, and subjective responses to exercise are noted. Assessment and Goals From the preceding information, an assessment of the patient's status is made, and short- and long-term goals are established. The goals of the treatment vary from patient to patient depending on the severity of the MI, previous life style, other medical problems, and the patient's goals for rehabilitation. The staffs common short-term goals for all patients usually are to clear secretions as indicated, promoting pulmonary independence; provide the patient and nursing staff with present activity guidelines; minimize the deconditioning effects of physical inactivity and promote reconditioning of the cardiovascular and musculoskeletal systems; promote relaxation; assist the patient in understanding his or her disease entity and the resulting capabilities and limitations for activity; and instruct the patient in a home exercise program with recommendations for recreational and occupational guidelines. The common long-term goals for all patients are to maintain or improve muscle strength and endurance; provide the patient with home exercise and ac- Volume 65 / Number 12, December 1985 1813

TABLE 1 Metabolic Equivalents of Various Activities a METs b Exercise Occupational Recreational Activities of Daily Living 1.5-2 Active ROM Walk 2 mph (30 min/mile) (176ft/min) desk work typing operating calculator playing cards sewing knitting table games reading watching TV writing feed self wash hands/face brush teeth fingernail care shaving comb hair polish shoes peel potatoes 2-3 Walk 2-3 mph (30-20 min/mile) (176-264 ft/min) Bike 5 mph (level) car repair (tune-up) radio-tv repair bartending machinist store clerk driving truck crane operator light assembly line pool, billiards bowling 0 skeet shuffleboard light woodworking powerboat driving golf (power cart) canoeing (2.5 mph) horseback riding (walk) bait casting playing piano riding lawnmower dressing washing dishes sweeping ironing showering driving car 3-4 Walk 3-3.5 mph (20-17 min/mile) (264-308 ft/min) Bike 6 mph brick laying c plastering wheelbarrow c (220 lb) machine assembly driving tractor driving trailer truck (in traffic) welding c horseshoe pitch golf (bag cart) c archery (noncompetitive) sailing (handling small boat) fly-fishing (standing with waders) horseback riding (trot) badminton (social doubles) energetic musician sex (with familiar partner) ceramics powerboat driving swimming (slowly) pushing light mower 0 mop floors make beds walking up 10 steps (slowly) washing windows vacuuming 0 4-5 Walk 3.5-4 mph (17-15 min/mile) (310-352 ft/min) Bike 8 mph painting masonry light carpentry milking stock shelves (light objects) auto repair table tennis golfing (carrying clubs) c dancing (foxtrot) tennis (doubles) badminton (singles) raking leaves hoeing weeding climbing stairs (slowly) power lawn mower waxing floors (slowly) carrying objects (15-20 lb) c tivity guidelines, precautions, and limitations; and increase cardiorespiratory fitness. Plan Cardiac rehabilitation does not lend itself well to a cookbook approach. Each patient must be evaluated and treated individually. The specific physical therapy plan should include the type and intensity of exercise, the duration and frequency of the treatment session, and the mode of exercise prescribed. Most programs include range-of-motion exercises, ambulation or cycling, stair climbing, and patient education programs. The education programs focus on understanding the normal and diseased state of CAD and the general principles and rationale for exercise. Modification of risk factors, including dietary and smoking habit changes, are discussed. Potential changes in work and recreational activities are addressed. Additionally, individual and family counseling usually is available in the CR setting. Physical Therapy The physical therapy of the patient who is post-mi begins when the patient is medically stable, usually in one to two days post-mi for the patient with no complications. Various graded activity 3,4, 11, 12 programs have been published. Appendix 1 outlines a suggested activity progression developed at The University of Iowa. The exercise session usually begins with PROM progressing to AROM and calisthenics with or without weights, slow walking or stationary cycling, and stair climbing. In the first few days post-mi, the physical therapy session may be tolerated for short periods only; frequent visits of short duration may be optimal. Defining the activity progression in terms of the number of days post-mi is not practical because each patient is different in progression. In general, the activity is incremented approximately 0.5 metabolic equivalent (MET)* per session. 11, 12 Appendix 2 gives exercise precautions and indications for altering the progression of exercise intensity. * 1 MET = 3.5 mlo 2.kg -1.min -1 10, 11. 1814 PHYSICAL THERAPY

TABLE 1 (continued) METs b 5-6 6-7 7-8 8-9 10+ Exercise Walk 4-5.5 mph (15-13 min/mile) Bike 10 mph Walk/Jog 4.5-5 mph (13-12 min/mile) Walk/Jog 5 mph (12 min/mile) Bike 12 mph Jog 5.5 mph (11 min/mile) Bike 13 mph Jog 6 mph (10 min/mile) Occupational digging garden (easy) c shovel light earth shoveling dirt c carpentry (exterior home building) pneumatic tools chopping with axe c hitch and unhitch wagons c sawing hardwood c shoveling (31 lb, 10/min) tending furnace digging ditches 0 pick and shovel lumberjack 0 heavy laborer shoveling (35 lb, 10/min) a Modified from published energy cost charts and tables. 3,4,10,11 b Includes resting metabolic needs. Activities requiring a large isometric component. Recreational horseback riding (trot) stream fishing (walking in light current) ice skating (9 mph) roller-skating (9 mph) touch football badminton (competitive) tennis (singles) square dancing water-skiing light backpacking horseback riding (gallop) swimming (breaststroke) light downhill skiing ski touring (loose snow) basketball football paddleball canoe 4 mph mountain climbing ice hockey downhill skiing (vigorous) canoeing rowing machine basketball (vigorous) swimming (crawl stroke) handball (social) squash (social) ski touring (4 mph) handball (competitive) rope jumping squash (competitive) ski touring (5+ mph, loose snow) Activities of Daily Living climbing ladder hard lawnmower splitting wood 0 snow shoveling 0 hand lawn mowing c carrying objects (30-60 lb) c climbing stairs carrying objects (60-90 lb) 0 carrying objects (over 90 lb) climbing stairs (quickly) At each exercise session, blood pressure, HR, ECG changes, signs, and symptoms are monitored and documented. Any adverse signs or symptoms are brought to the attention of the physician. Heart rate is used as an index and means of regulating the relative exercise intensity. The safe limit recommended for Phase I of CR in most facilities is an increase in HR not more than 24 bpm above resting and 120 bpm as the maximum value. 11 The patient is taught to regulate exercise intensity by monitoring his or her radial pulse. Medication will alter the normal response to exercise and should be taken into consideration. For those patients on beta blockers, exercise intensity may need to be prescribed based on speed of walking and ratings of perceived exertion (RPE). 13-16 By the end of Phase I, the patient is usually tolerating ambulation or cycling at a work load of 3 to 3.5 METs, with a RPE of 10 to 11, for a duration of 10 to 12 minutes twice daily. He is performing 10 repetitions of AROM or calisthenics with 1- or 2-lb weights in each hand daily. The patient is ambulating ad lib in the halls, is stair climbing 12 to 14 steps, and is independent in self-care skills of feeding, showering or bathing, shaving, and dressing. Before discharge from the hospital, the patient usually has a predischarge low level graded exercise test (LL-GXT). The standard test used may be a modified Bruce or Balke protocol. The end point for the test is usually a target HR of 120 to 130 bpm or target workload of 5 to 6 METs. The test is prematurely terminated if abnormal signs or symptoms are precipitated. The prognostic value of the predischarge LL-GXT for recurring cardiac events has been reported in the literature. 17 Based on the results of the LL-GXT, the team determines an exercise prescription with precautions and limitations. This exercise program prescribed at the end of Phase I is carried out in Phase II until the physician reevaluates the patient's exercise tolerance during a follow-up visit at six to eight weeks postdischarge. The exercise prescription defines the exercise intensity, duration, frequency, and mode of exercises. The peak exercise intensity is described by the peak HR achieved safely on the LL-GXT. This exercise HR is called the training HR (TrHR). If a LL-GXT is not done, TrHR is designated at a fixed rate (eg, Volume 65 / Number 12, December 1985 1815

TABLE 2 Recommended Training Duration and Frequency According to Training Intensity Calculated Training (Tr) Intensity (Tr LOA/min -1 ) 3.50 3.25 3.00 2.75 2.50 2.25 2.00 1.75 1.50 1.25 1.00 0.75 110-120 bpm or 30-40 bpm above the resting HR). If the patient is on beta blockers and does not have a LL-GXT, the exercise intensity can be prescribed by speed of walking and RPE; the results usually fall within the 12 to 13 range (fairly light to somewhat hard exercise intensity). The total duration time of each walking or cycling session begins at 10 to 12 minutes and progresses to 30 to 40 minutes in six weeks. Each exercise session is divided into warm-up, training, and cool-down periods. The warm-up and cool-down periods each last at least five minutes at a HR 12 to 18 bpm lower than the TrHR, which is at the upper limit of the patient's tolerance. The suggested frequency is two times daily, five to six times per week. The modes of exercise usually prescribed are walking and stationary cycling. Additionally, to maintain strength andflexibility,the patient is instructed to continue the calisthenics (10 repetitions, twice daily) begun in the hospital with weights, beginning with 1- to 2-lb weights for each upper extremity and progressing to 5 to 7 lb over the next six weeks. The risks associated with overexertion and overexcitation are dicussed with the Tr min/session a (Tr Freq = 3 x w) 14 min 15 min 17 min 18 min 20 min 22 min 25 min 29 min 37 min 40 min 50 min 60 min a 300 kcal, 3 w 900 kcal/w: 1 L0 2 = 5 kcal, 5-10 min warm-up 25 kcal, 5-10 min cool-down 25 kcal, Training duration sufficient to use 250 kcal. Total = (25 kcal + 25 kcal + 250 kcal) 3 w 900 kcal/w. b 250 kcal, 3 w 1,000 kcal/w: 1 L0 2 = 5 kcal, 5-10 min warm-up 25 kcal, 5-10 min cool-down 25 kcal, Training duration sufficient to use 150 kcal. Total = (25 kcal + 25 kcal + 150 kcal) 5 x w 1000 kcal/w. Tr min/session b (Tr Freq = 5 x w) 9 min 9 min 10 min 11 min 12 min 13 min 15 min 17 min 20 min 24 min 30 min 40 min patient during the predischarge physical therapy consultation at the end of Phase I. Precautions and limitations to exercises are discussed as outlined in Appendix 3. In addition to the exercise prescription described above, occupational and recreational guidelines are recommended based on the LL-GXT. Until the reevaluation, the staff usually recommends the patient not return to work; to keep recreational activities less than or equal to 3 to 4.5 METs, depending on the results of the LL-GXT; and to avoid all isometrics, including lifting more than 10 lb. Table 1 presents the METs of various activities. The peak HR during all activities should be at least 12 to 18 bpm less than the TrHR prescribed in the exercise program. Sexual activity guidelines are discussed with the patient before discharge. In terms of relative exercise intensity, sexual activity has been compared to physical activities such as brisk walking or climbing a flight of stairs. 1819 The patient is encouraged to consider the same precautions and limitations given for exercise described in Appendix 3. The patient may have to assume a less active role and avoid weight bearing on the upper extremities. PHASE II Early Phase The outpatient program, Phase II, begins when the patient is discharged from the hospital and may continue for six weeks to six months, depending on the patient's medical condition and the facility's available program. During this phase of CR, the patient progresses from a restricted, low level training program to a less restricted, moderate level training program. Phase II may be organized through a hospital or a community facility, through a freestanding program, or as an individually conducted home program. 512 The hospital-based and freestanding programs include telemetry monitoring of ECG and blood pressure measurement at each exercise session. The community facility program may or may not have monitoring capabilities. The individual exercising at home is instructed to call a physician or go to the local emergency room should complications arise. The exercise program prescribed at the end of Phase I is used for the first six to eight weeks of the outpatient program. The patient usually attends the program three days a week and completes the rest of the exercise sessions at home. Late Phase Six to eight weeks after the MI, the patient returns for a follow-up visit during which a symptom-limited maximum graded exercise test (SL-GXT max) is performed. After receiving the results of the SL-GXT max, the physical therapist gives a new exercise prescription. Training Intensity Several methods for computing the exercise intensity for training have been reported. 3, 10,12 The method we use at The University of Iowa was adopted from Amundsen. 20 Accordingly, TrHR and training work load in METs (Tr- METs) can be calculated as follows: 1. Resting HR, peak HR, and peak METs are obtained from the SL- GXT. 2. The TrHR and TrMETs are calculated from the following equations: 1816 PHYSICAL THERAPY

TrHR = rest HR + AcFr x (peak HR - rest Hr) (1) and TrMET = AcFr x peak METS (2) where activity fraction (AcFr) = 0.60 + peak METs/100. For patients who have significant ST segment depressions at low exercise intensities during the SL- GXTs, the TrHR is obtained by subtracting 10 to 15 bpm from the HR at which the ST segment depression was 21, 22 observed. Training Duration and Frequency Past research studies have demonstrated that at the appropriate exercise intensity, training for 15 to 25 minutes per day, three to five days per week, produces optimal cardiorespiratory training effects. Current literature suggests that the duration and frequency of training can be based on caloric expenditure. 10, 23-26 According to this method, the frequency of training should be three or five times per week with varying duration so that the total energy expenditure approximates 900 to 1,000 kcal per week. The appropriate duration and frequency can be determined as follows: 1. Obtain patient's body weight in kilograms (WtKg). 2. Express training intensity (TrMETs) in liters of O 2 per minute (L02/min). Convert TrMETs to mlo 2. kg -1. min -1 TrLO 2 /kg min = (TrMETs) (3.5mLO 2. kg -1. min -1 ) (3) Convert TrmLO 2. kg -1. min -1 to TrLO 2. min -1 TrLO 2. min -1 = TrmLO 2. kg -1. min -1 x WtKg xl. 10-3. ml -1 (4) 3. Determine the training minutes per session (Tr min/session) and frequency per week (Tr freq/w), three times per week (3 x w) or five times per week (5 x w) from Table 2: If TrLO 2 min- 1 2.25 LO 2.min -1, refer to 3 x w protocol (training intensities at this level occur very infrequently in our cardiac patients). If TrLO 2. min -1 2.0 L. min -1, refer to 3 x w or 5 x w protocol, depending on patient's preference. Mode of Exercise The two principal modes of exercise training are walking-jogging and cycling. Depending on the desired exercise intensity, the patient may not be able to raise the HR to the target TrHR just by level walking. With physician clearance, the walking program can be appropriately supplemented with jogging exercise. The exercise session begins with walking; short bouts of jogging are added at regular intervals with continuous HR monitoring. Commensurate with training adaptations over the weeks or months of exercise, the total walking time can be decreased as the total jogging time is increased. Calisthenics from the early phase of Phase II may be continued. Strength training can now be emphasized. Pushups, sit-ups, and other activities with a significant isometric component, however, are not recommended. Some programs use a circuit training method, which incorporates a combination of leg stations (stationary cycling, treadmill walking, bench stepping) and arm stations (rowing, arm cranks, wall pulleys, TABLE 3 Summary Comparison of Phases I, II, and III of Cardiac Rehabilitation Phase 1 Phase II Phase III Time frame Facility Goal of exercise Exercise intensity Exercise duration Exercise frequency Mode of exercise Exercise test inpatient: 7-10 days in uncomplicated Ml hospital cardiac intensive care area; step down unit avoid deleterious effects of bed rest; maintain range of motion and muscle strength resting HR + 12-24 bpm (modified if on beta blockers); 1-3.5 METs c up to 8-12 minutes; begin with intermittent program, progress to continuous bid-tid, 6-7 times per week range of motion; calisthenics; upper and lower extremity exercises with 1-2 lb cuff weights; ambulation; stationary cycling functional capacity assessment or SL-GXT b outpatient: begins at discharge; lasts 6 weeks to 6 months may be unsupervised home exercise or monitored exercise in an outpatient cardiac rehabilitation center improve cardiorespiratory fitness determined by LL-GXT a or resting HR + 12-24 bpm to a maximum HR of 120-130 bpm; 3-5.5 METs c begin with 8-12 minutes; progress to 30-45 minutes of continuous exercise bid to daily; 6-7 times per week calisthenics, upper and lower extremity exercises with 5-7 lb, 12-15 lb in some patients during late phase; ambulation; stationary cycling; swimming; circuit training (including arm cranks, wall pulleys, leg stations) SL-GXT b 6-8 weeks post-mi, and before progression to Phase III outpatient: follows completion of Phase II; continues indefinitely may be unsupervised home exercise or directed, nonmonitored exercise at a YMCA or other public facility maintain/improve cardiorespiratory fitness approximately 70%-85% peak HR achieved on SL-GXT b ; training METs c determined by SL-GXT b 30-50 minutes of continuous exercise 3-7 times per week calisthenics, upper and lower extremity exercises with 15 lb or less, or physician determined; ambulation, walk/job; jog program; stationary cycling, swimming, circuit training SL-GXT b yearly or as prescribed by physician a Low level graded exercise test. b Symptom-limited graded exercise test. c Metabolic equivalent units = energy cost of rest = 3.5 mlo 2.kg -1.min -1. Volume 65 / Number 12, December 1985 1817

and light weights). 12 This method of training produces improvement in both aerobic fitness and upper body strength and endurance. 12 Patient Consultation Based on the results of the SL-GXT max, we make occupational and recreational recommendations. The staff needs a good understanding of the environmental and emotional stress factors and the energy cost requirements of the patient's job and leisure time activities. The recommended intensity of occupational activities is approximately one third of the maximum MET level obtained on the most recent SL-GXT (Tab. I). 11 The patient usually is able to return to work at this stage. If he will be unable to return to his previous job, further arrangements with a vocational rehabilitation counselor may be necessary. PHASE III The physician may refer the patient directly to Phase III after the SL-GXT max given at the six- to eight-week reevaluation. If the clinical and physiological responses to the test necessitate continued, supervised, moderate intensity exercise, the patient should remain in the Phase II program. On completing the next SL-GXT max (two to six months post-mi), the physician may refer the patient to Phase III. Phase III of CR may be conducted through an organized and supervised community-based setting or in an unsupervised home or community program. 5 Phase III patients have had more time to recover from their MI and are generally more medically stable. Appropriate patient monitoring, however, still is recommended. At this phase of training, the exercise prescription for the post-mi patient becomes similar to that recommended for the healthy adult. The intensity of training is based on the patient's medical and physical status and on the results of the most recent SL-GXT max. The TrHR and TrMET level is determined as described in Phase II. As the patient progresses in the program, the exercise intensity can be adjusted upward by using up to 85% of peak HR or using an AcFr of 0.7 + max METs/100 in the formula described previously. The exercise intensity is not adjusted upward until another SL-GXT max test is performed (usually three to six months after the patient enters the program). The same variety of endurance activities used in Phase II can be used for training in Phase III of CR. If the patient has a functional capacity of 8 to 10 METs, he or she may be placed in a jogging regimen. The duration of training is usually between 15 to 60 minutes, depending on the available time and the intensity of training. The warm-up and cool-down segments remain crucial and should be 5 to 10 minutes in duration. The goal is to fit the program into the patient's schedule and to increase the total work (kilocalories used) toward a 300 kcal level per training session and 1,000 kcal per week. If the patient is training at a low intensity, either or both GRADE I GRADE II GRADE III the duration and frequency of training should be increased to expend the 1,000 kcal per week. Table 2 is a good source to simplify the determination of the optimal combination of exercise frequency and duration. Once the patient is reconditioned post-mi, the focus of Phase III is on a maintenance program. The patient is encouraged to have annual follow-up evaluations that include exercise tests. The exercise prescription remains relatively constant with the goal of regular physical exercise as part of the patient's daily routine. The patient should have a realistic understanding of his or her disease limitations and the relative importance of compliance with the CR program, especially as it relates to physical activity. APPENDIX 1 Cardiac Rehabilitation Phase I Activity Progression a Bed rest Stepl: Step 2: Sitting Step 3: Step 4: Step 5: Walking Step 6: Step 7: Step 8: (1 MET) b Complete bed rest with nursing care Bed rolled to 45 if desired May turn self Feed self with assistance as needed Passive range-of-motion exercises Bed rest with bedside commode privileges Partial self-care in bed Dangle legs times 1 Active range-of-motion exercises (1-2 METs) Dangle legs, tid Sitting in chair at bedside, less than 20 min/bid Bedside commode Partial self-care at bedside Active range-of-motion exercises Dangle prn Sitting in chair at bedside, 30-40 min/qid Partial bath (assistance with legs, feet, back) at bedside Calisthenics (1.5-2 METs) 2-5 min/bid Sitting at bedside, ad lib Sponge bath, independent Calisthenics (2 METs) 5-10 min/bid Ambulation (or stepping up/back) 2 METs for 2-5 min/bid Walk to bathroom, if less than 10 ft (2-3.5 METs) Ambulation or cycling (2.5 METs) 2-5 min/bid Stair climbing 2-4 steps Calisthenics (2-2.5 METs) 5-10 min/bid Walk ad lib in room Shower using shower chair, or tub bath with transfer assist Ambulation or cycling (3 METs) with warm-up and cool-down 5-10 min total, bid Stair climbing 6-10 steps Shower, independent Walk on nursing unit, independently 2-5 min/qid Ambulation or cycling (3.5 METs) 7-11 min/bid Stair climbing 12-14 steps Walking ad lib on nursing unit a Program developed by the Cardiopulmonary Division of the Physical Therapy Department of the University of Iowa Hospitals and Clinics, Iowa City. b MET = basal oxygen requirement of the body at rest per kilogram of body weight; usually 1 MET = 3.5 mlo 2.kg -1.min -1. 1818 PHYSICAL THERAPY