4.2 Cardiac Rehabilitation Phases
Key Takeaways
- Phase I (inpatient) is low-level activity within 1-7 days of a Myocardial Infarction (MI), Coronary Artery Bypass Graft (CABG), or other acute cardiac event; target Borg Rating of Perceived Exertion (RPE) is below 13 on the 6-20 scale.
- Sternal precautions after CABG generally include no upper extremity lifting over about 5-10 pounds, no pushing or pulling, and no driving for 4-6 weeks (some surgeons extend to 12 weeks).
- Phase II is outpatient, EKG-monitored exercise that typically runs 2-12 weeks; Phase III/IV are community-based maintenance programs without continuous monitoring.
- Absolute contraindications to exercise testing or training include a resting Systolic Blood Pressure (SBP) above 200 mmHg or Diastolic Blood Pressure (DBP) above 110 mmHg, unstable angina, and symptomatic uncontrolled arrhythmia.
- PTAs must memorize the stop-exercise list and report any new sign or symptom to the supervising Physical Therapist (PT) before progressing the plan of care.
Phase Overview
| Phase | Setting | Typical Timing | Monitoring | PTA Focus |
|---|---|---|---|---|
| I | Inpatient | Day 1 to about day 7 post-event | Continuous EKG telemetry, SpO2, BP, RPE | Bed mobility, low-MET (Metabolic Equivalent of Task) self-care, short walks |
| II | Outpatient hospital or clinic | Week 1-12 after discharge | EKG, BP, RPE each visit | Progressive aerobic and light resistive exercise per plan of care |
| III | Community or home with periodic check-ins | Months 3-6 | Spot checks of HR, BP, symptoms | Independent program; PTA may reinforce technique |
| IV | Lifelong maintenance | Indefinite | Self-monitored | Lifestyle, return to work and recreation |
Phase I - Inpatient Cardiac Rehabilitation
Goals: prevent deconditioning, screen for orthostasis, educate, and discharge safely. Sessions are short (5-10 minutes a few times a day) and low MET (1.0-3.5 METs). Use the Borg RPE 6-20 scale and keep the target below 13 ('somewhat hard'). Stop or downgrade immediately if RPE jumps to 15 or above.
Typical Phase I progression after an uncomplicated MI or CABG:
- Day 1: supine and seated active range of motion (AROM), dangle at edge of bed.
- Day 2-3: stand, march in place, short hallway walks with telemetry.
- Day 4-5: longer hallway walks, single flight of stairs with supervision.
- Day 6-7: stair training, basic Activities of Daily Living (ADL) clearance, discharge planning.
Sternal Precautions After CABG
CABG patients have a wired sternum that takes about 6-12 weeks to heal. Standard precautions (verify each surgeon's protocol):
- No lifting, pushing, or pulling more than about 5-10 pounds with the upper extremities for 6-12 weeks.
- No driving for 4-6 weeks (post-op pain, narcotics, and steering force can stress the sternum).
- No reaching both arms behind the back simultaneously.
- Cough or sneeze with a pillow splint to the chest.
- Get out of bed using the log roll technique - knees bent, roll to side, push up with the lower elbow rather than pulling on side rails.
Phase II - Outpatient Cardiac Rehabilitation
Usually 2-12 weeks, three sessions per week, with continuous EKG monitoring. The PTA progresses intensity using the plan of care, the Karvonen target HR, RPE, and symptom response. Resistance training is typically added once the patient tolerates 5 METs of aerobic exercise without warning signs.
Phase III and IV - Community and Maintenance
Monitoring shifts to the patient. The PTA may still contribute during home health visits or skilled nursing follow-up, focusing on functional progression, fall prevention, and recognition of warning signs.
Absolute Contraindications to Exercise (Memorize)
Do not start or continue training when any of the following are present:
- Resting SBP above 200 mmHg or DBP above 110 mmHg
- Unstable angina or new chest pain at rest
- Symptomatic uncontrolled arrhythmia
- Active or suspected myocarditis, pericarditis, or endocarditis
- Acute systemic infection, fever, or acute Deep Vein Thrombosis (DVT)
- Symptomatic severe aortic stenosis
- Decompensated heart failure (resting dyspnea, new third heart sound)
- Resting SpO2 below the parameter set in the plan of care (commonly less than 88-90%)
These are textbook PTA stop signs (Goodman and Snyder; Pierson and Fairchild; APTA Guide to Physical Therapist Practice).
On post-op day 3 following CABG, a PTA is about to start morning treatment. The patient says, 'My nurse said I can use my walker now - can you let me push it with both arms to feel sturdy?' The best PTA response is:
A PTA arrives for an outpatient Phase II session. The patient's pre-exercise BP is 212/96 mmHg and they report a 'pressure' in the chest at rest. The PTA should: