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Cardiopulmonary Physical Therapy: Cardiac Rehab Meets Pulmonary Rehab

Cardiopulmonary physical therapy is an excellent career path for physical therapists of all experience levels.

Cardiopulmonary physical therapy is devoted to helping patients improve cardiovascular health and/or lung health. Cardiopulmonary PTs work in all sorts of physical therapy settings, including hospitals (inpatient), outpatient clinics (hospital based and private), and possibly even home health environments.

Cardiopulmonary rehab can be separated into cardiovascular (cardiac) rehab and pulmonary rehab.

Cardiovascular rehabilitation (cardiac rehab)

The American Heart Association says it best: Cardiac rehab doesn’t change your past, but it can help improve your heart’s future.

Cardiovascular rehabilitation can help those who have heart disease, or those at risk, to reduce the risk of future cardiovascular episodes and improve overall health. For physical therapists, interprofessional collaboration is key for success. Cardiac rehab physical therapists work alongside family members and other professionals.

These professionals include, but are not limited to, the following:

  • Doctors
  • Nurses
  • Registered dietitians
  • Psychologists
  • Pharmacists
  • Social workers

As you can see, physical therapists play a small, but very important, role in the grand scheme of cardiac rehabilitation. Physical therapists must work collaboratively with other health team members to ensure optimal physical recovery.

Moreover – and often overlooked – cardiovascular rehabilitation also deals with a patient’s mental and emotional well-being after a traumatic cardiac event.

In a hospital/inpatient setting, cardiovascular rehabilitation should occur as soon as possible after a cardiac event.

For example, per the Journal of the Association of Physicians of India, after a myocardial infarction (MI), the goal is to mobilize the patient as soon as he or she is clinically stable, often within 24-48 hours of the episode.

Post-MI, a patient is considered stable if he or she displays the following:

  1. No new or recurrent chest pain in the past 8 hours
  2. Creatine kinase and/or troponin levels are not rising
  3. No new signs of uncompensated heart failure and no new significant, abnormal rhythm or ECG changes in the past 8 hours

Cardiac rehab is broken into different phases:

Phase I: Inpatient – This phase takes place at the hospital under a physician’s order. Early mobilization, patient education (e.g. sternal precautions), and emotional support are the prime components of this phase.

Examples of goals and activities include:

  • Supine-to-sit on the edge of the bed
  • Ambulation in the room
  • Ambulation for 2-5 minutes in the hospital hallways
  • Rate or Perceived Exertion (RPE) should be 13 or less on the 6-20 Borg scale.
  • Goal
  • Keep heart rate below 120 beats per minute (or no more than 20 beats above the resting heart rate if the patient has a high resting heart rate)
  • If safely able to do so, exercises and/or mobilization should be performed 2-4 times per day
Phase II: Initial Outpatient – Patients are monitored on telemetry monitors for this phase. Patients can begin this phase after clearance from his or her physician.

Phase II primarily consists of aerobic exercises; however, some programs may also include light strengthening and stretching. Although programs and timeframes can vary by individual patient, Phase II typically begins 2-4 weeks after the cardiac event and typically lasts 3-6 weeks.

Examples of goals and activities include:

  • Aerobic exercises (e.g. walking, running, swimming, cycling)
  • 3-5 days per week
  • 60-85% of maximal heart rate
  • 20-60 minutes per session
Contraindications – including, but not limited to:

  • Unstable angina
  • Resting systolic blood pressure greater than 200 mmHg
  • Resting diastolic blood pressure greater than 110 mmHg
  • 3rd degree atrioventricular block
  • Uncompensated congestive heart failure
  • Resting ST-segment depression greater than 2mm
  • Active pericarditis or myocarditis
  • Critical aortic stenosis
Phase III: Maintenance – The length of this program often lasts 3-4 weeks and can vary by individual patient. Transition from Phase II to III varies by individual case, but often occurs when vital signs remain relatively stable with increasing workloads.

Although patients are still supervised, vitals are no longer strictly monitored. Phase III will likely further incorporate strength training and stretching. Research has shown vast benefits from strength training – both in general and after a cardiac event – and stretching allows patients to build or maintain flexibility, which will help promote and maintain a long-term active lifestyle for years to come.

Examples of goals and activities include:

  • Moderate resistance exercises
  • 2-3 days per week
  • 3 sets of 10-15 repetitions
  • 8-10 different total exercises for the upper and lower body
(Phase IV: Some programs will even include a Phase IV, which is lifelong maintenance. Like any kind of rehabilitation, if a patient quits doing their home exercises and/or regresses back to their old self, then all gains previously made will eventually begin to fade. Cardiovascular rehabilitation is best utilized as a first step on a patient’s new positive lifestyle journey)

Pulmonary rehabilitation (Pulmonary rehab)

Pulmonary rehabilitation helps patients increase awareness of their lungs in regards to performing activity. Pulmonary rehab also helps patients improve overall pulmonary function. Pulmonary rehabilitation is beneficial for patients with a pulmonary disease, most commonly chronic obstructive pulmonary disease (COPD).

Examples of pulmonary rehabilitation exercises include pursed-lip breathing, diaphragmatic breathing, and ambulation.

Like cardiovascular rehabilitation, pulmonary rehab is administered by a vast team of healthcare professionals. While sometimes begun in an inpatient setting, pulmonary rehab is often utilized in an outpatient program that is conducted at a clinic, hospital, or sometimes at the patient’s home.

Pulmonary rehabilitation may include:

  • Nutritional counseling
  • Patient education about the disease
  • Breathing strategies
  • Energy-conservation techniques
  • Relaxation techniques
  • Group support
  • Psychological counseling
  • Exercise training

As with cardiac rehab, pulmonary rehabilitation is broken into separate phases:

Phase I: Individualized Rehabilitation – Phase I may include basic inpatient introductory exercises to pulmonary rehab. This phase is characterized by patient and/or family education on the specific pulmonary pathology. Patients may also be introduced to the outpatient pulmonary rehabilitation program.
Phase II: Outpatient rehabilitation – This phase is characterized by patient education and exercises to increase lung capacity, as tolerated. A physician’s referral is required, but this phase of pulmonary rehab is often covered by most insurances.
Phase III: Maintenance – This is an unsupervised continuation of Phase II. Patients are encouraged to continue exercises to maintain the benefits made in Phase II. This phase is often fueled by self-motivation and is seldom covered by insurance. 

Virtually all patients enrolled in pulmonary rehab report benefits to at least some degree. Patients often report less shortness of breath and more energy.

Pros and Cons to working as a cardiac rehab PT or pulmonary rehab PT

Pros of cardiopulmonary rehab include collaboration with multidisciplinary teams, working with patients after traumatic illnesses and surgeries to ensure they safely return to activity, feeling like you truly make a difference in patients’ lives, it’s relatively easy on your body compared to other types of practice, and you can become highly specialized with your care. Plus, you can teach online or at a local university!
Cons include the fact that you’re unlikely to go the cash pay route, unless you really want to market yourself heavily. Also, if you don’t enjoy working with an older, less healthy population, this might not be the right setting for you. Patients aren’t always willing to make the recommended life changes to improve their health.

Want to explore cardiopulmonary physical therapy in more depth?

These are just the bare basics of cardiac and pulmonary rehab. If either of these settings sound like your calling within the realm of PT, a great website to visit next is the
Cardiovascular & Pulmonary Section of the American Physical Therapy Association.

Another great way to start is by looking for physical therapy jobs where you can float into the cardiopulmonary physical therapy departments to be trained. If you can work at a large hospital system, you might be able to do some working or shadowing in both the inpatient and outpatient departments.

Make sure you state your intentions in your cover letter and during your interview, so that your hiring manager is aware that you are very interested in this area of practice.

If you’re unable to leave your current job to take a chance on a new role, consider shadowing or volunteering on your days off. And if you’re feeling super ambitious, you could pick up a per diem home health job on your off days, or shadow a home health PT who performs cardiac rehab.

Taking these steps will enable you to get your feet wet in the field and see if you wish to pursue a specialization.

Ready to specialize as a Cardiovascular and Pulmonary Certified Specialist (CCS)?

If you’re enjoying your role as a cardiopulmonary physical therapist, that’s fantastic! You can take it further by pursuing a residency in cardiopulmonary physical therapy, or you can gain hours on the job. At the end of either path to specialization, you’d need to pass an examination to get those letters after your name.

Not sure if you are eligible to apply for specialization? Take a look at the minimum criteria for CCS. If you’ve met the minimum criteria, go on and apply to be a CCS specialist! Your job options will multiply! Plus, you can teach at local and online physical therapy schools to spread your passion for the specialty to the next generation of physical therapists!

Hey CCS folks and cardiac rehab/pulmonary rehab PTs…did we miss anything? Hit us up on FB or in the comments and we’ll expand the article accordingly!

References:
http://www.heart.org/HEARTORG/Conditions/More/CardiacRehab/What-is-Cardiac-Rehabilitation_UCM_307049_Article.jsp#.WLs7mvkrI2x
http://japi.org/december_special_issue_2011/10_cardiac_rehabilitation_after.pdf
https://www.stmaryhealthcare.org/PhasesofCardiacRehab
https://www.nhlbi.nih.gov/health/health-topics/topics/pulreh
http://www.uhhospitals.org/geauga/services/rehabilitation-services/pulmonary-rehabilitation/phases-of-pulmonary-rehabilitation
http://www.upcra.org/phasedefinitions.html
https://www.verywell.com/phase-3-cardiac-rehabilitation-2696079
http://www.abpts.org/Certification/CardiovascularPulmonary/

About Clinton Boone

Clinton Boone
I am a physical therapist currently practicing for Athletico Physical Therapy in Bloomington, IL. I graduated with my Doctorate in Physical Therapy from the University of New England in Portland, ME and completed my undergraduate studies at Bradley University in Peoria, IL. I like to lift weights, travel, golf (badly), cycle, make new memories with my wife, and learn more about the profession of physical therapy. I chose to become a PT to help others and leave a positive impact in the world.

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