CARDIAC ISSUES AND ROLE OF PHYSIOTHERAPY

Cardiovascular disease(CVD) is defined as any critical or abnormal condition of the heart itself or its blood vessels, i.e., arteries and veins. One of the significant causes of death worldwide and in the United States is CVD.

It includes coronary heart disease, stroke, peripheral vascular disease, congenital heart diseases such as ASD, VSD, myocardial infarction, and many more.

The interventions and plan of care are customized individually depending upon that particular patient's condition.

Cardiovascular Diseases Include :

• Myocardial Infarction: It is also known as a heart attack, causing permanent damage to the heart muscle. Infarction is actually the death of tissues due to a lack of blood supply.
• Heart failure or congestive heart failure is when the heart doesn't pump blood adequately and results in fluid retention in the lungs.
• Coronary Artery Diseases: When the major blood vessels are damaged by plaque production around arterial walls,

Patients who have undergone Angioplasty and Coronary Artery Bypass Surgery (CABG) may require postoperative physical therapy and rehabilitation.

Cardiac Rehab Program:

Cardiac rehab works to limit psychological and physiological cardiac problems and tends to reduce the mortality rate. A Cardiac Physiotherapist works in a multidisciplinary team that includes the following members.

A Multidisciplinary Team Comprises Of :

• A Cardiologist/Physician and co-coordinator to lead cardiac rehabilitation
• A Clinical Nurse Specialist
• A Physiotherapist
• A Clinical Nutritionist/Dietitian
• An Occupational Therapist
• A Pharmacist
• A Psychologist
• A Smoking cessation counselor/ nurse
• A Social worker
• A Vocational counselor
• A Clerical Administration

Beginning of the Cardiac Rehab by the Physiotherapist :

Cardiac Rehabilitation should start as early as possible, i.e., in the ICU (Intensive Care Unit). Randomized Control Trials (RCTs) and Systemic Reviews prove that the early start of rehabilitation and mobilization improves the patient's physical functioning and return to work after cardiac surgery.

Another Randomized Control Trial improved postoperative function capacity (a 6 min Walk Test). It shortened the mechanical ventilation duration dependence on oxygen therapy and reduced the time of the hospital stay.

Indications For Cardiac Rehabilitation :

• Heart attack or Myocardial Infarction
• Angina
• Angioplasty
• After Coronary Artery Bypass Surgery
• Valvular Surgery
• Heart transplant
• Other cardiac issues that involve cardiac surgery.

Who Is At Risk?

There are two types of risk factors;

1. Non Modifiable Risk Factors Include :

• Age
• Excessive alcohol intake
• Gender
• Any Personal Cardiac Condition
• Hypertension
• Family History of CVD, etc.

2. Modifiable Risk Factors Include:

• Obesity
• Smoking
• Physical Inactivity
• Anxiety
• Depression
• Stress etc.

The Phases Of Cardiac Rehabilitation

Cardiac Rehabilitation consists of 3 main phases that are :

Phase 1: The Clinical Phase

In this phase, the patient's current physical abilities, motivation, and will to start and tolerate the rehabilitation process is checked. The physiotherapist and or the nurse can start rehabilitation by non-strenuous exercises and simple passive movements to avoid complications such as bed sores etc. They should start these passive movements to maintain the patient's range of motion (ROM), achieving ADLs, i.e., activities of daily living. The patient and his family are also educated about his current condition and how to manage it as required.

Phase 2: The Outpatient Cardiac Rehabilitation

When the patient is stable and is marked out of danger by the cardiologist, this phase starts. His functional limitations, painful ranges of motion, and activity are assessed by his physiotherapist. The therapist enhances his mobility by PNF techniques, Passive Exercises, Assisted Exercises, etc., to make the patient perform his daily life activities.

Phase 3: The Post Cardiac Rehab or Return to The Home Phase

After the patient is independent to perform his basic daily life activities, his physiotherapist teaches him strengthening exercises and a few aerobic exercises to improve his endurance while performing his tasks. The patient can continue to perform those exercises at home by himself or with the assistance of his family members.

The Warm-up Period:

Before starting any exercise, there must be a warm-up time for about 5-10 mins in which the patient stretches his limbs and raises the blood supply to the required area.

The Main Class :

Depending on the patient's current cardiovascular and physical state, the therapist makes a plan of care and an exercise regimen followed by the patient regularly. The exercise should be started by following a proper warm-up period guided by the patient's physiotherapist. The aerobic exercises should be of fixed time interval followed by a fixed amount of rest time period between the repetitions; this means that the exercises should be rhythmical and have equal rest intervals. 

The Cool Down Time Period :

After the exercise, there must be a 10 min rest or cool down time given to the patient to bring their body back to the resting phase.

Health And Safety :

If the patient's general health is not stable enough or they are still in a critical state, then the patient should not be advised of proper physical therapy or follow an exercise program. But still, the passive movements (to avoid bed sores and other complications like loss of available range of motion, etc.) should be continued by the therapist or the head nurse as guided by the physiotherapist in charge.

Following are the cardiac symptoms in which any type of exercise must be avoided or discontinued :

• In fever
• If a patient's blood pressure rises or drops significantly
• Resting BP systolic >200 mmHg and diastolic > 110 mmHg
• If the patient has uncontrolled diabetes
• If there is breathlessness
• In lethargy, nausea, and if the patient feels dizzy 
• Chest pain or unstable angina

Assessment And The Outcome Measures :

Measure following values of the patient :

• Heart rate and Blood pressure ( both during rest and during the exercise)
• Bodyweight
• Body mass index
• The waist circumference

Also, the patient's current functional capacity is measured by performing the following tests :

• 6 min walking test
• Shutter walk test
• Chester step test
• Stair climb tests

Types Of Equipment And The Facilitates Required For The Cardiac Rehabilitation :

The minimum equipment necessary for a cardiac patient's rehab are as follows:

• Staff office for the therapists
• Counseling room facility
• Air-conditioned and soundproof room
• Toilet in the near surroundings
• A changing or shower area

To perform exercises, instruments and machines that are required are :

• Stethoscope
• Sphygmomanometer
• Glucometer
• Hand crank
• Treadmills
• Versa climber
• Chairs
• Music system
• Speaker
• Dual cycle Ergometer
• Bicycle Ergometer
• Weights or dumbbells
• Measuring tape
• A rowing machine

There may be 2-3 assistants with the physiotherapist. The normal staff to the patient ratio is 1:5, but it may vary depending on the patient's condition or the situation.

Conclusion

If any person feels pain in the chest, left arm, left shoulder, or back, and if there is a family history of cardiac conditions, one must rule out any cardiac pathology. And a postoperative patient, i.e., after undergoing cardiac surgery, should be in touch with a physiotherapist as soon as shifted to the ICU as it has an excellent prognosis. Also, they can achieve ADLs and active functional activities as early as possible and can avoid any further complications.

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References:

• https://www.ncbi.nlm.nih.gov/books/NBK537196/
• http://www.pnmedycznych.pl/spnm.php?ktory=369
• https://www.nhlbi.nih.gov/health/health-topics/topics/stress/duringphysiopedia
• https://www.ncbi.nlm.nih.gov/books/NBK554410/
• https://my.clevelandclinic.org/health/diseases/16818-heart-attack-myocardial-infarction

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