The New Health and Human Services Cardiac Rehab Guidelines::What this means to the Exercise Profession

Introduction

“Exercise of almost any kind, suitable in degree and duration, can and does play a useful role in the maintenance of both physical and mental health of the coronary patient”. This phrase, by Dr. Paul Dudley in the mid 1950’s in many ways summed up the consensus of the benefits of physical activity for cardiac rehab patients. So what, if anything has changed in the past 45 years? Since the goals of cardiac rehab have been, and continue to be the returning of patients with cardiac diseases to optimum function physically, emotionally, socially, vocationally, and economically1,2,7, optimizing both short term and long term rehabilitation needs has always been the primary concern.


In today’s managed care era, short term care in some instances is becoming shorter, and long term programming is not universal, we look for guidance as to how current recommendations will affect future cardiac rehab programs across the US. Therefore, the purpose of this article will identify elements of the recent HHS guidelines in cardiac rehab, present a post rehab program for strength training and complimentary exercise, and predict some trends that may occur within the framework of cardiac rehab in the coming years.

A Review of the Health and Human Services Guidelines

In November of 1995, the US Department of Health and Human Services published volume 17 of their cardiac rehabilitation guidelines7. These guidelines give a general overview of the epidemiology of exercise as it relates to cardiac rehabilitation. The strength of evidence is basically favorable for both observational and randomized studies. Although there are considerable differences in the designs of the studies, the long-term treatment of CHD patients suggests a moderate association between participation in rehab programs and reduction in the morbidity over time as seen with sedentary post-op patients.


The publication also looks at the effects of rehab on lipid status, psychological well-being, return to work, and job safety issues. Information on exercise tolerance, heart failure, body weight maintenance, and alternative approaches to delivery services are also discussed.


The general recommendations made by the council include: expanding the populations who may be served by cardiac rehab programs (women, ethnic groups, lower SES brackets), expanding the outcomes measurements in acute infarct patients and evaluating those outcomes with and without ECG monitoring, developing optimal education strategies, and finally, integrating cardiac rehab into a total lifestyle change in large populations.


Applying Guidelines to Clinical Practice

Testing

Physiological testing is still the cornerstone of cardiac rehabilitation programming, as it initially defines the condition, and sets parameters of acute conditioning. Periodic tests allow practitioners to re-assess cardiac status and modify training protocols. There is some controversy as to the applicability of ECG testing to the many types of conditioning protocols in use, but it is the cornerstone of the cardiologist’s work, and it will always be used to assess current status of the patient6.


Conditioning Protocols

The past decade has seen growth in cardiac rehab programs from basic treadmill and stationary cycles, to strength training, aquatic rehab, yoga, T’ai Chi, and walking. As rehab programs expand their base, incorporating clinical monitoring and progression become more difficult. This section will define some of the elements of conditioning from a clinical and post rehab perspective, keeping close to the new HHS guidelines, but expanding our thought on what post rehab in the cardiac setting may become.


Aerobic conditioning

Specific guidelines for aerobic conditioning vary from individual to individual. Moderate exercise on machines is recommended for patients who have problems with gait, or who need constant supervision and data collection (direct from machines). Aquatic-based programs are beneficial for persons who need the buoyancy of water for conditions such as arthritis or joint pain, but it is estimated that in neck-high water, the heart is approximately 25% more efficient, due in part to improved venous return, and the lessened effects of gravity. Walking programs are most often recommended, but outcomes measurement is difficult, unless time, perceived intensity, or calories can be measured. Modified aerobic dance classes (low impact, chair aerobics, swing dance, etc.) are also beneficial to improve capacity and function in a social atmosphere. They may also improve compliance, as participants wish to exercise with friends and acquaintances who also attend classes4,6.


Strength training

The past decade has seen a change of thought as to the application of strength training to cardiac patients. From McKelvie’s review in 1990,3 the amount of information about both the safety and efficacy of strength programming grown substantially. Perhaps the most important challenge is the actual prescription and progression of strength training programs for the individual. Although each patient differs in their needs, the table below highlights a typical strength program and progression for cardiac patients in three different stages.

TABLE I: Strength Program














StageExerciseSets/RepsProgressionComments
Phase IIMovement
(basic)
2 sets
10-15 reps
increase sets to
3-4 as patient
improves range
of motion.
Supervised –
1-on-1
ECG during
exercise
Light
dumb bells
1-2 sets
10-15 reps
increase by 1-2
lbs. each week
Elastic/rubber
tubing
1-2 sets
5-10 reps
work on improving
range of motion and
technique each session
Phase II/IIILight
dumb bells
2-3 sets
8-10 reps
increase 2- lbs.
each week on the
upper body, 5-10
lbs. on lower body
Supervised –
1-on-1
Strength
machines

Stretching

1-2 sets
10 reps
improve range of
motion and major
muscle group strength
improve post surgical
area and major muscle
groups
Phase IIIStrength
machines
2-4 sets
10-8-6 reps
Move from basic
exercises to a more
progressive format
Unsupervised
exercise, or
train with
a partner
Free weights2-4 sets
10-8-6, or
multiple
sets of 10
Work on perfecting
exercise form, strength,
and range of motion


Long term Programming

Success over months (and perhaps years) requires a well thought out plan. Outcomes can only be achieved if a progression is known, and followed as closely as possible. Below highlights a one year progression for a combination program in cardiac rehab for a phase IV patient who is post-op for over a year, and sedentary for the entire time.







Aerobic ProgressionResistive ExerciseMonitoring
Week 1-3Walking – stop and go
start with 1/4 mile, and
work up to 1/2 mile
body movement
in planes of action
of actual training
range of motion
*target HR
*blood
pressure
*level of
perceived
exertion


Goals: increase functional abilities without causing increased pain, improving flexibility, and finding the right schedule to guarantee success.






Month 2-4Walking program
increasing time and
terrain
Introduction to
aerobic machines
2-3 days per week
Light dumb bells
and resistance
exercise bands –
work on increasing
intensity and stations
Month 3 – include
work on major muscle
groups on strength
machines
Target HR
(during and
post exercise)
Level of
perceived
exertion

Monitor
blood
pressure
once per
day



Goals: improve abilities by 10-25% in time on aerobics, overall strength, and make necessary changes in schedule to secure success in adherence.





Month 4-6Regular exercise 3-5
days per week in an
individual or group
walking, machine, or
classroom activity
at 55-75% of VO2
2-3 days per week of
general strength work
using major group
stations (chest, hips,
back, thighs, shoulders)
and dumb bell/band
exercises for smaller
muscle groups
Monitor
laboratory
blood lipid
levels

Target HR

Resting BP
once per day


Goals: improvement in flexibility in shoulders, low back, and hip region. Expand types of exercises performed to boredom is minimal. Improvement in strength by an additional 5-10%.





Month 6-83-5 days of 30 minute
aerobic conditioning
8 strength stations
performed for major
muscle groups
2-4 sets of 10-15 reps
on each
HR

BP

RPE


Goals: Maintain a constant program. Find unique and creative ways to keep on a scheduled training regime.






Month 8-10 Coninue 3-5 days of
30 minute training
10-12 strength stations
for major and minor
muscle groups
HR

RPE

Month 10-123-5 days of 30-45
minute training,
aerobic classes,
movement,
stress reduction
strength stations,
aquatic resistance,
increase use of
dumb bells and
free weights
HR

RPE




Goals: Annual medical exam to see changes in lipid status, body weight, aerobic capacity, and other indices that may have improved as a result of regular conditioning.

Changes in Cardiac Rehab Practices

Out-patient based programs

The past two years have seen a shift from the traditional cardiac rehab setting (hospitals, clinics, etc.) to a more out-patient program. There are cardiac programs in health clubs under the title of post-rehab (or After Care, post Med Care, etc.). These programs are staffed by exercise physiologists who are ACSM certified, or physical therapists who have all or part of their practice within the health club. The advantage to this program is a larger facility, more equipment, long term membership contract (at a lower price than initial treatment), and a non-clinical environment to exercise in.


Disadvantages include lack of diagnostic and assessment equipment, and usually no emergency protocols for specific cardiac events, should they occur. Health clubs (who are seeing more and more special population groups join their ranks), are betting against the likelihood of adverse events by teaching only post-rehab programs, where symptomatic patients would usually not be a participant. By working with the phase III/IV client, their liability is reduced.


Louisiana Clinical Exercise Bill

There are two new “twists” in the prescription of exercise in the cardiac rehab setting. In July of 1995, the state of Louisiana passed a clinical exercise physiology licensure bill for those who primarily work in the cardiac rehab setting. This bill has had major ramifications in the sports medicine organizations, as other states (California in particular) are now organizing for the regulation of the profession state by state. This process may have an impact on who may supervise cardiac rehab programs, where this supervision may take place, and how much medical intervention (ie: cardiologist evaluation and prescription) may be included in the overall rehab process.


HMO wellness contracts

The second “twist” is the dramatic change seen in the HMO reimbursement process. Over the past year and a half, a small but significant number of health care agencies have formed to directly negotiate with HMO’s for wellness contracts for health clubs. This shift in expenditure is a plus for those who have historically been involved in the wellness and health promotion arena, but its impact on traditional programs such as cardiac rehab remain unclear. In an interview with Dr. Barry Franklin, director of cardiac rehab and exercise science at William Beaumont Hospital in Royal Oak, MI, he states that even with the expansion of HMO services, there may be no real change in the upcoming years in the reimbursement for classic phase I and II programs. They will continue to receive payment for up to 18-36 sessions (depending on the geographic area). However the advent of HMO contracting will make phase III and IV programs more likely to be reimbursed depending on how the contract is formulated, where the service is taking place, and who is conducting the program (exercise specialist, cardiac nurse, etc.).


Conclusions

It is clear that cardiac rehab services are undergoing changes in terms of new information, insurance reimbursement, staffing, and long term applications for patients. Short term changes will occur in the type of programming, moving from traditional aerobic machines to complimentary forms of training, and the type of practitioner who is performing those services. Long term changes in cardiac rehab may entail contractual agreements with HMO’s, health club programs, and reimbursements for home-based exercise. One realistic long term goal would be to have outcomes measures on persons who participate in multi-year exercise programs to see the benefits physiologically, socially, and from a cost-savings standpoint.


References

1. Gattiker, H, Goins, P, Dennis, C. Cardiac Rehabilitation: Current status and future directions. Western Journal of Medicine. 1992, 156:183-88.

2. Hertzeanu, HL, Shemesh, J., Aron, LA, et al. Long term rehabilitation limits ventricular arrhythmia after myocardial infarction. American Journal of Cardiology. 1993, 71:24-27.

3. McKelvie, RS, McCartney, N. Weightlifting training in cardiac patients. Considerations. Sports Medicine. 10;6:355-64, 1990.

4. McGinnis, K. Exercise guidelines for working with post rehab clients. IDEA Personal Trainer. 1994, Nov. pg. 11-15.

5. Mittleman, MA., MaClure, M., Tofler, GH, Sherwood, JB, et al. Triggering of acute myocardial infarction by heavy physical exercise. New England Journal of Medicine. 1993, 329:1677-83.

6. Wenger, NK. Rehabilitating the elderly coronary patient. Geriatric Consultant. 1992, Nov. pg. 27-30.

7. Wenger, NK., Froelicher, ES, Smith, LK, et al. Cardiac Rehabilitation. Clinical Practice Guidelines, Number 17. US Department of Health and Human Services. Rockville, MD, October, 1995.

Avatar Written by Eric P. Durak MSc

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