cardiac rehabilitation intro of pmr in cv diseases -edit
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Dr. dr. Nury Nusdwinuringtyas, SpKFR-K, MEpid
Email : nury_nus@yahoo.com
Weblogs : http://nury-nus.blogspot.com
http://rehab-med.blogspot.comhttp://rehab-med-research.blogspot.com
http://tanpa-pita-suara.blogspot.com
http://laryngectomees.blogspot.com
Citizen journalism : wikimu.com
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Nury Nusdwinuringtyas
Angela BM Tulaar
Deddy Tedjasukmana
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Definition The sum of activities required to influence
favourably the underlying cause of the disease, as
well as the best possible physical, mental and sosialcondition, so that they may by their own effortspreserve or resume as normal a place as possible inthe community. ( WHO 1993 )
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AHA Scientific Statement 1994
Cardiac rehabilitation:
Not limited to an exercise training program Include multifaceted strategies aimed at reducing
modifiable risk factors
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AHA Scientific Statement 2005
Cardiac rehabilitation / secondary prevention programsinclude:
Baseline patient assessments
Nutritional counseling Aggressive risk factors management (i.e., lipids,
hypertension, weight, diabetes & smoking) Psychosocial & vocational counseling Physical activity counseling Exercise training [appropriate use of cardioprotective drugs for secondary
prevention]
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Patients who are candidates for
Cardiac Rehabilitation:- Post MCI
- Chronic stable angina
- CHF- Cardiac arrhytmias
- Post CABG
- Post PTCA- Post cardiac valve surgery
- Post cardiac transplantation
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Cardiac Rehabilitation services
Involves:- Medical evaluation
- Exercise prescription- Modification of risk factors
- Education
- Counselling
- Vocational programs
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Goals of cardiac rehabilitation
General goals:- to optimizethe patients physiologic, phychosocial, and
vocational function;- to reducethe morbidity and mortality of cardiac
disease
Educational program:- lifestyle modificationsuch as low-cholesterol diet,
stress-reduction, and smoking cessation to reduce
the risk factor for heart disease;- reconditioning exercisesto improve safety andtolerance of daily activities (vocational, recreational,and sexual activity)
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Cardiac rehabilitation team:
Physicians
Nurses
Physical therapists
Occupational therapists
Exercise physiologists
Nutritionist
Psychologists
Social worker
Vocational counsellors
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Coronary heart disease (CHD)
Risk factors : Modifiable CHD risk factors :
hypertension, cigarette smoking, obesity, habitually
sedentary lifestye, hypercholesterolemia, high levelLLD, low level HDL, hypertriglyceridemia,hyperinsulinemia, DM
Unmodifiable CHD risk factors:Advance age, gender, family history of premature CHD,
past history of CHD, cardiac event, abnormal ECG, past
history of occlusive peripheral vascular disease or CVD
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Cardiac Evaluation
A. History :
- Chief complaint
- Past history
- Medication history- Functional and occupational history
- Personal history
- Social history- Family history
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Cardiac Evaluation
B. Physical ExaminationGeneralVital signs Cardiovascular:
Inspection Palpation Auscultation :
Heart sounds Heart murmur Pericardial rub
Pulmonary Neurologic and musculoskeletal
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Cardiac EvaluationC. Diagnostic testsChest radiograph
Cardiac tests :
ECG
echocardiography
Laboratory tests
blood tests Cardiac stress tests
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Cardiac rehabilitation Consists of four distinct phase
Each phase of cardiac
rehabilitation has specific goals
with educational or lifestyle
modification component
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Phase I : In-patient cardiac
rehabilitation
In-patient acute phase
(generally lasting from 3- 6 days)
Started as soon as the patientscondition has stabilized
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Phase I : In-patient cardiac
rehabilitation - goals
To prevent the sequelae of immobilization and assist thepatient in tolerating self-care activities and householdambulation
To prepare the patient ( and family ) for a healthy lifestyle To reduce psychologic and emotional disorders that
accompany the cardiac diagnosis
To facilitate adjustment to the acute event and to the
hospital environment To motivate the patient to make a long-term commitment
to the cardiac rehabilitation program
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Phase I program :Education and risk-modification
program :
Hyperlipidemia control Hypertension control
Smoking cessation
DM control Stress management
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Exercise program Low-metabolic demand exercise and activities.
5-10 minute (progressed up to 20-30 minutes), 2-4 times daily,
Activity < 4 mets
Not raise HR above 20 bpm
Passive or active assistive ROM exerciseactive exercise insupine, sitting, upright position
Ankle pumping exercise
Exercise parameter : pulse, BP, ECG, activity-induce symptoms
Exercise testing At the end of phase I or prior to starting phase II
Exercise
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Stop Exercise ifSigns and symptoms:
angina, light-headedness, nausea, dyspnea, fatigue,
pallor, cyanosis, ataxia, hypoxia, altered mental status,peripheral circulatory insufisiency, bradicardia (dropin HR of more 10 bpm), activity-induce BP changes,SBP > 220 mmHg, DBP >110 mmHg, activity-induced
ECG change
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Phase II : Outpatient
Conducted in an outpatient setting or towards the endof hospitalization
if the patient is discharged from the hospitalphase
II start within 1 - 2 weeks and last for 8 -12 weeks By end of phase II, patient should be able to perform
the daily self-administered exercise program safely,have adequate knowledge of his or her disease and
symptoms to persue vocational , recreational, andsexual activities safely
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Phase II : Outpatient
Goals : To enhance cardiovascular function and physical work
capacity (strength,endurance,flexibility)
To detect ECG changes during exercise To teach the patient proper techniques of exercise and
provide him/her with guidelines for long-term exercise
To establish healthy lifestyle in patient and family
To enhance the patients psychologic function andprepare him or her for return to work and resumption ofnormal familial and social roles
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Phase II program :Education and risk-modification
program
Exercise : The patient is given individualized prescription of
intensity,duration, frequency, mode activity
Physical reconditioning, begin with dynamic-rhytmic or aerobic exercise at a level of 5 mets
Exercise involve upper and lower limb
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Phase II program :Exercise : Equipment : treadmills, bicycle ergometers, arm ergometers,
wall pulleys, steps, rowing machines
Exercise session lasting 1 hour (including warming-up andcooling-down), 3 times a week
Exercise goal : target HR for at least 20-30 min for training
adaptation
Intensity is increased on a weekly basis, progressing to 8
mets before starting phase III
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Phase II program :
Return to work program Patient are prepared to return to their
original job
7 Metswithout any abnormalresponses, generally patients should
be able to return to most jobs exceptheavy industrial work
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Phase III : Maintenance
Phase III usually last from 3 - 6month and generally includes
clinical supervision andintermittent ECG
Exercisein outpatient setting,
then progress to a community orhome setting
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Phase III The Goals of phase III are similar to those of phase II
Phase III is designed to provide a smooth transitionfrom structured, closely supervised to individually
suited program Program include :
- Education and risk modification
- Exercise : aerobic exercise, resistance
training, aquatic exercise program (water
temp. 26-33C)
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Phase IV : Long term cardiac
rehabilitation
Education and risk-modification program Exercise (at least 3 times per week for 30-60
min, target HR 80% max HR, progress
gradual until 85%)Aerobic exercise Resistance trainingAquatic exercisewater exercise
Goal : to continue in improving andmaintaining fitness and a healthy lifestyle
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Cardiovascular Prognosis
Regular physical activity of at least moderate intensityreduces the risks of coronary events ( physical
inactivity is a major CHD risk factor )
Endurance exercise program may improve aerobiccapacity
Strength training (at least 30 minutes / week) mayreduce the risk of an initial coronary event
Penilaian Kapasitas Fungsi
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Kapasitas Fungsi Physical Fitness
Aerobik =
O2maksimal
Nilai sesungguhnya Prediksi
SubmaksimalSteady state
Astrand
(1965)
Gosselink (1999) dan ATS (2002)
Uji Jalan Enam menit
Tabel Digital Jarak tempuh
Prediksi jarak tempuh Prediksi O2Maks
Rumus Cahalin
(1995)
Rumus Nury (2011)
Penilaian Kapasitas Fungsi
Rumus Paul Enright (1995)
Rumus Nury (2011)
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3
30 cm 30 cm
1
2
Metode Berputar 3 Langkah
Uji Jalan 6 Menit di Lintasan Biodex gait trainer
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Protokol Uji Jalan NuryLintasan Uji Jalan Metode Berputar 3
Langkah
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Keterangan : * 0= laki- laki; 1= perempuan
Jarak tempuh dalam satuan meterUmur dalam satuan tahun
Tinggi Badan dalam satuan sentimeter
Berat badan dalam satuan kilogram
Denyut jantung maksimal uji jalan dalam satuan kali/menit dengan menggunakan Polar RS300X
VEP1dan KVP dalam satuan liter
Rumus VO2= 0,053 (jarak tempuh) + 0,022 (umur) + 0,032 (TB) -
0,164 (BB) - 2,228 (jenis kelamin) -2,287
RumusTotal distance (m) = 586.254 + 0.622 BW (kg)0,265 BH (cm)63.343 gender*
+ 0.117 age
Rumus VO2max
Rumus Prediksi Jarak Tempuh
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