Phase 2 Cardiac Rehabilitation: Loading Protocol

This protocol outlines the progression for Phase 2 cardiac rehabilitation, specifically focusing on the loading phase. It is designed to improve cardiovascular endurance, strength, and functional capacity in patients following a cardiac event (e.g., myocardial infarction, heart surgery). Individualization of the program is paramount, considering patient history, comorbidities, and response to exercise. Close monitoring of vital signs and patient reported outcomes (PROs) is essential throughout the process.

I. Clinical Presentation

Patients entering Phase 2 generally present with improved stability compared to Phase 1. They should be able to perform basic activities of daily living (ADLs) with minimal assistance. Common characteristics include:

• Stable angina or well-controlled heart failure (NYHA Class I or II).
• Adequate wound healing (if post-surgical).
• Controlled blood pressure and heart rate.
• Absence of unstable arrhythmias.
• Ability to understand and follow instructions.
• Improved functional capacity demonstrated in Phase 1 (e.g., MET level > 3).

II. Rehabilitation Phases within Phase 2 (Loading)

Progression should be gradual and based on the patient's response to exercise. We use the Borg Rate of Perceived Exertion (RPE) scale (6-20) and monitor vital signs to guide progression.

1. Phase 2A (Early Loading): Focus on light to moderate intensity aerobic exercise and low-resistance strength training. RPE target of 11-13 ("fairly light" to "somewhat hard").
2. Phase 2B (Progressive Loading): Gradually increase the intensity and duration of aerobic exercise and the resistance in strength training. RPE target of 13-15 ("somewhat hard" to "hard").
3. Phase 2C (Maintenance Loading): Maintain achieved fitness levels and focus on incorporating exercise into daily life. RPE target may vary based on the activity, aiming for sustainable levels. Emphasis on patient education for long-term adherence.

III. Specific Exercise Examples

These exercises are examples and should be modified based on the individual patient's needs and abilities. Always begin with a 5-10 minute warm-up and end with a 5-10 minute cool-down.

A. Aerobic Exercises:

• Treadmill Walking: Start with a comfortable pace and gradually increase speed and incline.
• Stationary Cycling: Adjust resistance to maintain target heart rate and RPE.
• Elliptical Training: Provides a low-impact option for cardiovascular training.
• Rowing Machine: Works multiple muscle groups while providing cardiovascular benefits.
• Stair Climbing (modified): Monitor for shortness of breath and fatigue. Ensure stable handrails.
• Arm Ergometer: Useful for patients with lower extremity limitations.

B. Strength Training Exercises:

• Wall Push-ups: Modified version for upper body strength.
• Bicep Curls (light weights or resistance band): Focus on proper form and controlled movements.
• Triceps Extensions (light weights or resistance band): Emphasize full range of motion.
• Seated Rows (resistance band): Improves posture and back strength.
• Squats (modified): Partial squats or chair squats for lower body strength.
• Heel Raises: Strengthens calf muscles.
• Plank (modified): Hold for short durations, gradually increasing time as tolerated.
• Bird Dog: Improves core stability and balance.

IV. Evidence-Based Return to Function Criteria

Return to function is determined by a combination of objective measures and subjective patient reports. These criteria should be met before progressing to the next phase or independent exercise.

• Achievement of Target MET Level: Demonstrates ability to perform functional tasks (e.g., climbing stairs, carrying groceries) without significant symptoms. MET level requirements will vary depending on the patient’s pre-cardiac event activity level.
• Stable Vital Signs during Exercise: Heart rate, blood pressure, and respiratory rate should return to near baseline levels within a reasonable timeframe after exercise cessation.
• Adequate Exercise Tolerance: Able to complete prescribed exercise duration and intensity without significant fatigue, shortness of breath, or chest pain.
• Borg RPE within Target Range: Patient's perception of exertion aligns with the prescribed intensity level.
• Successful Completion of Exercise Stress Test (if indicated): Shows adequate cardiovascular response to maximal exercise.
• Patient Education and Self-Management: Demonstrates understanding of risk factors, medication management, and exercise guidelines. Can self-monitor heart rate and blood pressure.
• Absence of Adverse Events: No episodes of angina, arrhythmias, or significant hemodynamic instability during exercise.

V. Monitoring and Documentation

Detailed documentation of each session is critical. This includes:

• Vital signs (heart rate, blood pressure, respiratory rate) before, during, and after exercise.
• Borg RPE at regular intervals during exercise.
• Exercise parameters (duration, intensity, resistance).
• Patient symptoms (angina, dyspnea, fatigue).
• Progression or regression of exercise based on patient response.
• Patient education and adherence to program.

This protocol serves as a guideline and should be adapted based on the individual patient's needs and progress. Regular communication with the patient's physician is essential.