4.2 Cardiac Rehabilitation Phases

Phase Overview

The NPTE-PTA expects you to match a patient description to the correct phase and to know what activity is appropriate there. A Metabolic Equivalent of Task (MET) is the energy cost relative to quiet sitting (1 MET = about 3.5 mL O2/kg/min), and phases progress along a MET ladder.

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'). Downgrade immediately if RPE jumps to 15 or above, or if HR rises more than 20-30 bpm above resting in a strict post-MI prescription.

Typical Phase I progression after an uncomplicated MI or CABG:

1. Day 1: supine and seated active range of motion (AROM), dangle at edge of bed, check orthostatic BP.
2. Days 2-3: stand, march in place, short hallway walks with telemetry.
3. Days 4-5: longer hallway walks, single flight of stairs with supervision.
4. Days 6-7: stair training, basic Activities of Daily Living (ADL) clearance, discharge planning.

Sternal Precautions After CABG

A CABG patient has a wired sternum that takes roughly 6-12 weeks to heal. Standard precautions (always verify the individual 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 held against the chest.
• Get out of bed with the log-roll technique - knees bent, roll to the side, push up with the lower elbow rather than pulling on side rails.

A common test trap: do not let a fresh CABG patient bear down on a standard walker with both arms, because that loads the sternum like a push-up.

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. Light resistance training is typically added once the patient tolerates about 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 or skilled-nursing follow-up, focusing on functional progression, fall prevention, and recognition of warning signs the patient can self-report.

Absolute Contraindications to Exercise (Memorize)

Do not start or continue training when any of these 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 plan-of-care parameter (commonly less than 88-90%)

These mirror the textbook PTA stop lists in Goodman and Snyder, Pierson and Fairchild, and the APTA Guide to Physical Therapist Practice.

Reading the Scenario for the Right Phase

NPTE-PTA cardiac items rarely say 'this is Phase II' outright. Instead they hand you clues: the setting (hospital bed vs outpatient clinic vs home), the timing relative to the event, and the monitoring described. A patient three days after a CABG who is doing supine ankle pumps and edge-of-bed dangling is Phase I; a patient six weeks out attending a clinic three times a week on continuous telemetry is Phase II; a patient walking a neighborhood loop with a home heart-rate strap is Phase III/IV. Match the activity intensity to the phase - prescribing a 5-MET resisted circuit in a Phase I scenario is a classic wrong answer.

Relative vs Absolute Contraindications

The list above is absolute - exercise stops, full stop. A separate set of relative contraindications means proceed only with caution and close monitoring after the supervising PT and physician weigh risk versus benefit. Examples include resting tachycardia, moderate stenotic valvular disease, electrolyte abnormalities, an uncontrolled metabolic disease such as diabetes, and a left bundle branch block that obscures the EKG. On the exam, an absolute contraindication points to 'hold and notify,' while a relative one may allow modified, low-intensity activity with the PT's blessing.

Orthostatic Screening in Phase I

Deconditioned inpatients and post-cardiac-event patients are prone to orthostatic hypotension. Before the first standing trial, the PTA checks supine BP, then sitting, then standing BP and HR, watching for a drop of 20 mmHg systolic or 10 mmHg diastolic within three minutes of standing, often paired with dizziness or a compensatory HR jump. If it occurs, sit the patient down, recheck, and progress position changes slowly. Documenting orthostatic vitals is a routine Phase I PTA task and a frequent NPTE-PTA detail.