Principles of Physical Therapy Management

Patients may be referred to physical therapy with a history of angina as a primary or secondary problem. Regardless, angina is managed with the same care and vigilance because it can be a life-threatening condition either way. A patient for whom antianginal medication is prescribed must have the medication present. The medication must not have expired and must be within visible access during treatment. The physical therapist should examine the medication before treatment to ensure that the expiratory date has not passed and to take responsibility for positioning the medication near the patient for access to it should the patient develop angina during treatment.

The goals of long-term management of the patient with angina include the following:

Patient monitoring includes hemodynamic monitoring (i.e., heart rate, blood pressure, rate-pressure product, and dyspnea). Subjective responses to treatment, particularly exercise, should also be recorded (e.g., Borg’s rating of perceived exertion). Signs of chest pain, dyspnea, anxiety, lightheadedness, dizziness, disorientation, discoordination, cyanosis, coughing, and chest sound changes (i.e., a gallop) must be monitored. Angina is not an acceptable symptom under any circumstance. Should it occur, treatment is immediately discontinued and emergency measures instituted as indicated. Treatments will be safer and more precisely prescribed with continuous ECG monitoring. Without ECG monitoring, treatments must be conservative. If there is any doubt at any time concerning the hemodynamic stability of a patient and his or her ability to tolerate treatment safely, the patient should be referred to a general practitioner or cardiologist for clearance before being treated.

Medication that is necessary to maximize treatment response is administered before treatment. Knowledge of the type of medication, its administration route, and time to as well as duration of peak efficacy is essential if treatment is to be maximally effective.

For the long-term management of patients with angina, interventions include some combination of education, aerobic exercises, strengthening exercises, chest wall mobility exercises, relaxation, activity pacing, and energy conservation. Education includes information about heart disease and risk factors (i.e., smoking, diet, stress, weight, alcohol, coffee, and being physically active in hot environments) and appropriate preventative strategies (i.e., smoking reduction and cessation, low-fat diet, reduced alcohol consumption, exercise, relaxation, activity pacing, and stress management).

Patients with angina are at risk of having an infarction; therefore vigilance and stringent monitoring are necessary to detect angina or frank myocardial infarction. These patients are potentially hemodynamically unstable; thus their hemodynamic responses before, during, and after treatment, particularly aerobic and strengthening exercises, should be monitored and recorded. Minimally, heart rate, blood pressure, and rate-pressure product should be recorded, along with the patient’s subjective responses to treatment. Heavy lifting, static exercise, straining, the Valsalva maneuver, and heavy, repetitive upper-extremity work are avoided during physical activity and exercise. These activities are associated with a disproportionate hemodynamic response. Physical activity and aerobic exercise are prescribed at a target heart rate or perceived exertion ranges that are below the anginal threshold based on a graded exercise tolerance test (see Chapters 19 and 24). Peak exercise tests in patients with cardiac dysfunction that may elicit angina or ST-segment changes are performed in a cardiac stress testing laboratory, usually under the supervision of a cardiologist unless in a specialized facility where physical therapists perform such testing.

The body position in which aerobic exercise is performed is important in patients with heart disease. Positions of recumbency increase the volume of fluid shifted from the periphery to the central circulation. This increases venous return and the work of the heart. Therefore upright body positions have long been known to minimize cardiac work during exercise in these patients and during rest after exercise.5,6

Sexual dysfunction is common in individuals with systemic atherosclerosis owing in part to underlying pathology (dyslipidemia, vascular insufficiency, and diabetes), medication, and the psychological impact of heart disease.⁷ In terms of energy demands, those of sexual activity are comparable to those of other daily activities (e.g., walking 1 mile on the level). Optimizing health in general with diet and exercise can contribute to regression of atherosclerosis and improved peripheral circulation. Breathing control, body positioning, and energy conservation strategies such as exercising at a high energy time of day may also help minimize symptoms. Also, patients should be advised to avoid sexual activity within an hour of eating, and even then not to consume a heavy meal.

Angina frequently precedes frank myocardial ischemia and infarction. Myocardial ischemia is reversible, whereas infarction denotes myocardial injury and cell death (i.e., necrosis). Injured myocardial cells either recover or die during the healing period. Thus minimizing further damage and maximizing the healing during this 6-week period is critical. Myocardial infarctions can range from being silent and unnoticed by the patient to being life-threatening. They can occur anywhere in the myocardium but occur primarily in the ventricles (in the left more frequently than in the right ventricle). The greater the severity, the greater the risk of ventricular insufficiency, acute pulmonary edema, and left ventricular failure. Because myocardial ischemia and infarction impair the pumping action of the heart and thus cardiac output, patients tend to be hypoxemic and in need of oxygen. Even after the oxygen has been discontinued and the myocardium has healed, the patient may continue to be vulnerable hemodynamically. The myocardium will have some scarring that will affect both the electrical excitability (producing dysrhythmias) and the mechanical function of the heart. In addition, the patient may continue to have low-normal arterial blood gases. Hypoxemia is lethal in that it triggers dysrhythmias and predisposes tissues to hypoxia. Thus hypoxemia must be avoided. After myocardial infarction, patients are usually discharged home on several medications (e.g., nitroglycerin, calcium antagonists, beta blockers, and diuretics). Depending on the severity of involvement, patients usually continue to require one or more of these medications over the long term. The need for oxygen is usually short term and restricted to the patient’s hospital stay.

The patient’s ECG will be important for determining the parameters of exercise, the level of monitoring required, and education. Dysrhythmias are described in Chapter 4, and basic ECG reading is presented in Chapter 12. Ventricular dysrhythmias can be lethal. Occasional premature ventricular contractions must be monitored to ensure that their frequency remains low and that coupling does not occur. Atrial fibrillation is considered a relatively serious dysrhythmia. It is associated with a high incidence of coronary disease, stroke, and overall mortality.⁸ Medication or a pacemaker may be necessary.

Central sleep-disordered breathing is highly prevalent in individuals with left ventricular dysfunction and is associated with abnormal cardiac autonomic control and increased dysrhythmias.⁹ Although sleep-disordered breathing may not be related to the severity of hemodynamic dysfunction, loss of recuperative sleep will affect functional capacity as well as capacity and motivation to participate in an exercise program and be physically active.

Health-related quality of life reported by individuals with chronic heart failure is associated with function and exercise capacity, not with ejection fraction.¹⁰ Health-related quality of life should be an outcome measure for all individuals managed for heart failure because it provides important supplemental information that is independent of physiological indices of cardiac function and the NYHA classification of function (see Table 31-2).

Nonpharmacological approaches to the management of individuals with heart failure are an essential component to the overall management of the condition.¹¹ These measures are incorporated into an individualized program of health behavior change, and include the following:

All patients with cardiovascular risk factors can benefit from cardiac rehabilitation. After a cardiac event, patients are typically discharged with drugs, the prospect of surgery, and rather infrequently with referral to an individual physical therapist or one who is a member of the cardiac rehabilitation team. There is a high incidence of recurrence and repeated surgery with further associated mortality and burden of disease. The physical therapist as a noninvasive practitioner has a primary responsibility to help avoid recurrence of symptoms and repeated surgeries. This is consistent with the physical therapist’s overriding objective of reducing the need for invasive care (i.e., drugs and surgery) and developing a sustainable, lifelong health plan with the patient.

Risk factor modification is a major goal. A marker of inflammation such as C-reactive protein along with appropriate lipid testing findings may be a more discriminating risk factor than lipid profiling alone.¹² Refining the risk factor definition on the basis of C-reactive protein level will help target management (e.g., indicate necessity for intensified exercise programs, weight loss, and smoking cessation).

Valve dysfunction is either congenital or acquired and may require treatment as a primary condition or be present as a secondary condition. Any of the heart and pulmonary valves may be affected. Rheumatic fever was a common cause of rheumatic heart disease and in particular mitral valve insufficiency. Interconnecting lymphatic vessels between the tonsils and the heart are thought to be responsible. Calcification of valves that impairs opening and closing is another example of an acquired valve dysfunction.

Clinically, patients with valve disease may demonstrate exertional dyspnea, excessive fatigue, palpitations, fluid retention, and orthopnea. These signs and symptoms are often relieved when exertion is discontinued. Aerobic exercise, however, has been shown to reduce the symptoms of prolapsed valve.¹⁶ Anxiety has been reported to decrease general well-being. If effectively managed, however, reduced anxiety can improve or reduce chest pain, fatigue, and dizziness.

Prophylactic antibiotics against endocarditis are administered to most patients with significant valvular involvement and in mild disease before procedures such as dental work.

Peripheral vascular disease refers to diseases of the arteries and the veins. Peripheral arterial disease results primarily from atherosclerosis and occlusion of the peripheral arteries (e.g., thoracic aorta, femoral artery, and popliteal artery).¹⁷ The diagnosis may be overlooked until serious limb ischemia is evident.¹⁸ Diabetes mellitus, which can result in microangiopathy and autonomic polyneuropathy, is another important cause of PVD in the lower extremities. Venous disease results in phlebitis, venous stasis, and thromboembolus and leads to valvular incompetence of the veins of the legs.

Arterial occlusion results in reduced blood flow to the extremities and hence reduced segmental blood pressure distal to the occlusion (i.e., lower ankle-brachial index). In mild cases of arterial stenosis the patient may be asymptomatic because considerable stenosis has to occur before there is significant reduction in peripheral blood flow. If atherosclerosis develops gradually, collateral circulation may develop sufficiently to offset progressive vessel narrowing. Clinically the patient reports limb pain on exercise, coldness in the affected leg, and possibly numbness. The characteristic limb pain results from ischemia and is referred to as intermittent claudication. Mild to moderately severe cases are managed conservatively. Pain at rest is suggestive of severe stenosis and significant reduction of blood flow to the limb. Significantly reduced blood flow leads to ischemic color changes, skin breakdown, ulceration, and eventually gangrene. Bypass surgery is performed to revascularize a threatened limb. In severe cases in which gangrene has developed, amputation of the limb is indicated. The severity of PVD is a significant predictor of cardiovascular mortality. Individuals with PVD show a systemic endothelial dysfunction and an increase in the serum concentration of white blood cells, endothelin, and C-reactive protein that may trigger acute coronary syndromes.

Individuals with intermittent claudication can have a marked decrease in exercise tolerance and thus can benefit from aerobic exercise, which may stimulate the development of collateral blood vessels around the stenosed vessel. This condition can severely restrict mobility, which reduces function in addition to aerobic capacity and efficient oxygen transport overall.

Individuals with PVD from diffuse systemic atherosclerosis can be expected to have stenosis of the coronary arteries even though they may be asymptomatic. These individuals are monitored as stringently as if they had overt ischemic heart disease.

Venous insufficiency can lead to thromboemboli, skin lesions, and poorly healing ulcers of the lower extremities. Furthermore, the risk of infection and slow healing is increased.

Individuals with PVD secondary to diabetes mellitus have accelerated atherosclerosis compared with age-matched individuals without diabetes. Diabetes affects the macrocirculation and microcirculation; thus wounds must be prevented, particularly in the lower legs and feet, and managed aggressively should they occur. These individuals may be at risk for lower extremity lesions because of autonomic neuropathy and angiopathy. To restore insulin sensitivity and promote weight loss, activity levels must be significantly increased, and a formal exercise program instituted. Weight-bearing activities are safe for individuals with poor sensation in the feet and do not increase the risk of reulceration.¹⁹