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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.com
http://rehab-med-research.blogspot.com
http://tanpa-pita-suara.blogspot.com
http://laryngectomees.blogspot.com

Citizen journalism : wikimu.com

Nury Nusdwinuringtyas
Angela BM Tulaar
Deddy Tedjasukmana

Definition
The sum of activities required to influence
favourably the underlying cause of the disease, as
well as the best possible physical, mental and sosial
condition, so that they may by their own efforts
preserve or resume as normal a place as possible in
the community. ( WHO 1993 )

AHA Scientific Statement 1994


Cardiac rehabilitation:
Not limited to an exercise training program
Include multifaceted strategies aimed at reducing
modifiable risk factors

AHA Scientific Statement 2005


Cardiac rehabilitation / secondary prevention programs
include:
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]

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

Cardiac Rehabilitation services


Involves:
- Medical evaluation
- Exercise prescription
- Modification of risk factors
- Education
- Counselling
- Vocational programs

Goals of cardiac rehabilitation


General goals:
- to optimize the patients physiologic, phychosocial, and
vocational function;
- to reduce the morbidity and mortality of cardiac
disease

Educational program:
- lifestyle modification such as low-cholesterol diet,
stress-reduction, and smoking cessation to reduce
the risk factor for heart disease;
- reconditioning exercises to improve safety and
tolerance of daily activities (vocational, recreational,
and sexual activity)

Cardiac rehabilitation team:


Physicians

Nurses
Physical therapists
Occupational therapists
Exercise physiologists
Nutritionist
Psychologists
Social worker
Vocational counsellors

Coronary heart disease (CHD)


Risk factors :
Modifiable CHD risk factors :

hypertension, cigarette smoking, obesity, habitually


sedentary lifestye, hypercholesterolemia, high level
LLD, 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

Cardiac Evaluation
A. History :
- Chief complaint
- Past history
- Medication history
- Functional and occupational history
- Personal history
- Social history
- Family history

Cardiac Evaluation
B. Physical Examination
General
Vital signs
Cardiovascular:
Inspection
Palpation
Auscultation :

Heart sounds
Heart murmur
Pericardial rub

Pulmonary
Neurologic and musculoskeletal

Cardiac Evaluation
C. Diagnostic tests
Chest radiograph
Cardiac tests :
ECG
echocardiography
Laboratory tests
blood tests
Cardiac stress tests

Cardiac rehabilitation
Consists of four distinct phase
Each phase of cardiac

rehabilitation has specific goals


with educational or lifestyle
modification component

Phase I : In-patient cardiac


rehabilitation
In-patient acute phase

(generally lasting from 3- 6 days)


Started as soon as the patients

condition has stabilized

Phase I : In-patient cardiac


rehabilitation - goals
To prevent the sequelae of immobilization and assist the

patient in tolerating self-care activities and household


ambulation
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

Phase I program :
Education and risk-modification

program :

Hyperlipidemia control
Hypertension control
Smoking cessation
DM control
Stress management

Exercise
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 exercise active exercise in
supine, 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

Stop Exercise if
Signs and symptoms :
angina, light-headedness, nausea, dyspnea, fatigue,
pallor, cyanosis, ataxia, hypoxia, altered mental status,
peripheral circulatory insufisiency, bradicardia (drop
in HR of more 10 bpm), activity-induce BP changes,
SBP > 220 mmHg, DBP >110 mmHg, activity-induced
ECG change

Phase II : Outpatient
Conducted in an outpatient setting or towards the end

of hospitalization
if the patient is discharged from the hospital phase
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, and
sexual activities safely

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 and
prepare him or her for return to work and resumption of
normal familial and social roles

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 dynamicrhytmic or aerobic exercise at a level of 5 mets
Exercise involve upper and lower limb

Phase II program :
Exercise :

Equipment : treadmills, bicycle ergometers, arm ergometers,


wall pulleys, steps, rowing machines
Exercise session lasting 1 hour (including warming-up and
cooling-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

Phase II program :
Return

to work program

Patient are prepared to return to their


original job
7 Metswithout any abnormal
responses, generally patients should
be able to return to most jobs except
heavy industrial work

Phase III : Maintenance


Phase III usually last from 3 - 6

month and generally includes


clinical supervision and
intermittent ECG
Exercise in outpatient setting,

then progress to a community or


home setting

Phase III
The Goals of phase III are similar to those of phase II

Phase III is designed to provide a smooth transition

from structured, closely supervised to individually


suited program
Program include :
- Education and risk modification
- Exercise : aerobic exercise, resistance
training, aquatic exercise program (water
temp. 26-33 C)

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 training
Aquatic exercisewater exercise

Goal : to continue in improving and


maintaining fitness and a healthy lifestyle

Cardiovascular Prognosis
Regular physical activity of at least moderate intensity

reduces the risks of coronary events ( physical


inactivity is a major CHD risk factor )

Endurance exercise program may improve aerobic

capacity
Strength training (at least 30 minutes / week) may

reduce the risk of an initial coronary event

Penilaian Kapasitas Fungsi


Physical Fitness

Kapasitas Fungsi
Aerobik =
O2 maksimal
Nilai sesungguhnya

Prediksi

Submaksimal
Steady state

Astrand
(1965)
Tabel

Gosselink (1999) dan ATS (2002)


Uji Jalan Enam menit
Digital

Jarak tempuh

Rumus Nury (2011)


Prediksi jarak tempuh
Rumus Paul Enright (1995)

Prediksi

Rumus Cahalin
(1995)

O2 Maks
Rumus Nury (2011)

Uji Jalan 6 Menit di Lintasan


30 cm

30 cm

Metode Berputar 3 Langkah

Biodex gait trainer

Protokol Uji Jalan Nury


Lintasan Uji Jalan

Metode Berputar 3
Langkah

Rumus VO2max
Rumus VO2 =

0,053 (jarak tempuh) + 0,022 (umur) + 0,032 (TB) 0,164 (BB) - 2,228 (jenis kelamin) -2,287

Rumus Prediksi Jarak Tempuh


Rumus Total distance (m) = 586.254 + 0.622 BW (kg) 0,265 BH (cm) 63.343 gender*
+ 0.117 age

Keterangan : * 0= laki- laki; 1= perempuan


Jarak tempuh dalam satuan meter
Umur 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 RS 300X
VEP1 dan KVP dalam satuan liter