Even debilitated patients can improve conditioning

When patients are stable, get them active

A 75-year-old man was admitted to the hospital with fatigue, shortness of breath, and a history of myocardial infarction. He has had cardiac bypass surgery and is obese. As far as chronic illness, he has CHF, hypertension, diabetes, renal insufficiency, and osteoarthritis in one knee. His ejection faction is less than 30%.

This patient may be presenting you with more red flags than a construction crew working on a 60-mile stretch of highway. But experts say it’s important not to give up on helping patients become more functional, even when they have extensive comorbidities.

"What everything may look like on paper doesn’t equate to rehab potential," says Chris Wells, PT, a doctoral candidate in physical therapy at the University of Pittsburgh. "Given the right prescription, you can take a patient who is very disabled and help him into something he wants to do."

This case is one Wells has handled and presented to the American Physical Therapy Association’s Combined Sections Meeting in Seattle in February, during one of the pre-conference programs.

When this patient was released from the hospital, he could walk only about 40 feet at a time and used a walker. He could not take stairs and kept a toilet at his bedside. But through an activity program that began with supervised physical therapy at home, he now walks on a treadmill for 30 to 40 minutes. Wells says after she assessed his condition, she returned to his doctor for a suggested schedule of activity. "In this case, we set up for a home care setting."

Therapy began with a lower-extremity routine. While the man sat at his kitchen table, Wells brought over stationary bike pedals the patient could use from his chair. As he gained mobility, he could progress to aerobic ambulation and eventually upper-extremity exercise. Combining the lower and upper exercises is less stressful to the patient, Wells notes. Arms and legs were worked to 20% or 30% of their maximum capacity, which allowed the heart to work on a better preload and afterload. (For more information on determining maximum exercise capacity, see related story, p. 34.) Today, the patient may now be able to work up to lifting light weights and doing other routines.

Wells says that just like any other aspect of the patient’s treatment, exercise has to be tailored to the individual.

"He was too dysfunctional to go to a cardiorehab program," she says. "Just getting that guy out and into the car would have been all the exercise he could do for that day." Now that he can tolerate more exercise, he has more options open to him.

Wells says right from the start, the patient has to set goals for what he or she wants to do. And these preparations are key in getting insurers to pay for the care. Because physical therapists identify deficits in what the patient can do, set goals, show progress, assess potential, and reassess every 30 days, most payers are willing to cover the costs.

"Insurance may have to pay for an ambulance to get patients back and forth to see the doctor," she says. "It’s costing the insurance company less to go this route. If you can make these kinds of arguments, insurers usually will agree to pay."

Other patients may look great at rest, but when they become active, their status changes. Assess-ment here could mean discussing with the physician if activities should be broken up into more manageable parts or even if patients need to be pretreated with a nitroglycerine tablet before physical therapy. The key is to establish goals with the doctor and patient, then find out what will help patients achieve these goals, such as:

    - improve the way they get around the house;
    - condition themselves to be able to shop at the mall;
    - reduce their shortness of breath.

"It’s a misconception that people with heart failure shouldn’t be exercising," says Ross Zimmer, MD, a cardiologist with the joint heart failure program of Presbyterian Medical Center and the Hospital of the University of Pennsylvania in Philadelphia. If a patient remains inactive, it can lead to decompensation and detriment to the lungs and muscles.

Zimmer says an activity routine can begin after these important steps happen with the patient:

    - evaluation by the physician, where the CHF etiology can be established;
    - education about his or her particular condition;
    - recovery from procedures or operations;
    - administration of the right medication (and patient is stable on them);
    - other factors (such as blood pressure) addressed and under control.

"Exercise may be some stretching or may be a combination of activities that can help them around the house," Wells says. It’s important to look at the physical status and the medical status and try to set goals.

Whether patients get their exercise in their homes, can get out to walk, or go to a gym or cardiorehab program, it’s important to stay active. Stop exercising, and those gains will decline. Even an extensive cardiorehab program, complete with supervision, education, and equipment, lasts about 12 weeks. What happens after that is up to the patient.

"Make a contract with your patients," urges Scot Irwin, DPT, professor of physical therapy at North Georgia College in Dahlonega. "Tell them if they are coming into a program, they are going to do it for life."

Irwin notes the heart itself is not getting better from exercise. "You are targeting peripheral muscles so they become better adept at using what the heart can pump to them." If those muscles don’t continue to stay busy, they lose their ability to extract oxygen. "What rehab does is spiral them up. But if they are not going to stay there if they don’t keep it up," he says.

Irwin says only 10% of the patients who leave formal cardiorehab are still exercising on their own in a year. Part of the problem may be that patients may find it too difficult to keep things going on their own. They may not have access to the same equipment or lack the motivation when they are not being supervised anymore.

What’s the follow-through?

Right from the start, Irwin says it’s important to answer the question of what comes next. "Patients have to be taught how to exercise and how to monitor symptoms," he says. That makes patients able to continue on their own after formal programs end.

Wells helped to organize walking routines on the boardwalk at the Jersey shore so patients would have something to go to after their insurance benefit ran out for formal physical therapy. During the events, volunteers were available to take blood pressure as they made their way down the boards.

"I tell everyone they should be walking," Zimmer says, noting that people should take a common sense approach. Competitive sports and heavy exertion may be out, but if the patient can tolerate it, using the stairs may be appropriate. He notes that after his patients have been optimized, he will suggest they head out to the mall or some other public place. Having other people around may be reassuring to the patient and the numerous benches provide places to rest when they are needed.

Irwin says patients can learn to keep their exercise practical. That way, activity remains accessible and patients are more likely to stay motivated to do it.

"Patients have to be taught how to exercise and how to monitor symptoms, or else they’ll just revert back again in about the same time it took to build them up," Irwin says. He says his patients often begin with monitored sessions of aerobic exercise and functional activities like step-ups. He also teaches his patients about walking and other aerobic activity and then, perhaps, working on muscle strength.