KNGF Guideline Diagnostic process for physical therapy

Cardiac Rehabilitation Royal Dutch Society for Physical Therapy History-taking

• presenting
Examination
• assessment of
Analysis
1. assessment of health
Designing treatment plan
Rehabilitation goals
problem / target impairments, status and current 1. exploring own limits
activity level (PSC) activity functional exercise 2. learning to cope with physical
• assessment of limitations, capacity limitations
Coronary heart disease activity level participation 2. physical impediments 3. optimizing exercise capacity
before current restrictions 3. other (internal or 4. diagnostic: evaluating changes
health problem and health external) factors in exercise capacity over
arose problems that impeding recovery time and relations between
(acute) cardiac event
• assessment of may influence 4. future target situation symptoms and objectifiable
health status the choice 5. can impediments be defects
(nature, course, of exercise reduced? 5. overcoming fear of physical
Clinical Phase: Phase I Preoperative phase (CABG / valve replacement) prognosis) activities in the 6. opportunities to exertion
• assessment of rehabilitation reduce health 6. developing / maintaining
current state program problem, i.e. improve physically active lifestyle
Screening for risk of developing PPC • other information • assessment functions, activities
- personal of functional and participation
details (social, exercise
environment) capacity (SWT
CCU ICU Surgery no increased risk - motivation or 6MWT)
- need for
information
Relative rest yes
pulmonary physical therapy if
necessary Therapeutic process

Medically stable • IMT Relevant information for physical therapist

• breathing exercises • medical diagnosis
• airway clearance techniques • relevant diagnostic and prognostic referral information on patient’s physical condition
• all individual rehabilitation goals, especially goals for physical exercise and possible impediments to physical exercise,
such as anxiety, dysfunctional coping style and comorbidity
• settings of ICD or pacemaker, if present (safe heart rate range for exercise)
Mobilization phase on ward Final outcome criteria
• results of maximum or symptom-limited exercise test
active mobilization • moderate intensity exercise (≥ 3–4 METs)
• risk profile
• some knowledge about heart disease
• all medications (type, dosage)
Beware of signs of excessive strain • coping with heart disease
• diagnosis for physical therapy
• information on occupational situation (so rehabilitation can be adapted to this) and prognosis
• any relevant further information about family
Rehabilitation phase: Phase II

Informing / advising Tailored exercise program Relaxation program

Medical referral information from patient’s Screening and intake Interventions • improving patient’s understanding • patient’s wishes / abilities • reducing tension
cardiologist by professional from MDT, usually • information program of heart disease and rehabilitation • patient’s exercise capacity • promoting body
• medical diagnosis the cardiac rehabilitation • exercise program* in relation to physical functioning • patient’s individual goals awareness
• relevant diagnostic details coordinator • relaxation program • encouraging compliance, active
• results of maximum or symptom-limited • behavior modification program lifestyle and work resumption
exercise test • lifestyle program • promoting suitable way to handle
• relevant comorbidity • psychological program symptoms (including anxiety
• prior history, cardiac & non-cardiac reduction)
• medication (type, dosage)

Selecting priorities for exercise • practicing skills and activities

1. Physical functioning affected / MDT program • training aerobic (general) exercise capacity
threatened? • rehabilitation coordinator • training local strength endurance
2. Psychological functioning • cardiac rehabilitation cardio- • training functions / activities to develop enjoyment of exercise
affected / threatened? logist • training to reduce risk factors (hypertension, diabetes mellitus,
3. Social functioning affected / • nurse overweight / obesity, inactivity)
threatened? • dietician
4. What is the cardiovascular risk • physical therapist
profile? • social worker Selecting exercise activities • practicing functional skills and activities for ADL, work or hobbies /
5. Any unhealthy behavior? • health psychologist field exercises / sports and games / fitness / aerobics / swimming /
• other disciplines if necessary ergometers / exercising in water / relaxation

Supplementary intake by Selecting exercise variables • aerobic exercise: intensity / frequency / duration / work/rest intervals
different disciplines / structure of exercise program
• strength training: external resistance / speed / number of repetitions
and sessions / recovery intervals
* The exercise program is part of the multidisciplinary cardiac rehabilitation.

Implementing program
6MWT = Six-minute walk test; CABG = coronary-artery bypass graft; CCU = coronary care unit; ICD = implantable cardioverter defibrillator; ICU =
intensive care unit; IMT = inspiratory muscle training; MDT = multidisciplinary cardiac rehabilitation team; MET = metabolic equivalent of task;
PPC = postoperative pulmonary complications; PSC = patient-specific complaints; SWT = shuttle walk test; VO 2max = maximum oxygen uptake
interim and final evaluation, adjusting program if necessary

Consultations with MDT and start of aftercare phase (Phase III)

• monitoring lifestyle after 6 and 12 months
• maintaining physically active lifestyle
• inactive lifestyle? see KNGF guidelines for exercise intervention for coronary heart disease (KNGF-standaard
V-08/2011 © KNGF Beweeginterventie Coronaire Hartziekte; in Dutch)
Consult the full Guideline on www.kngfrichtlijnen.nl
KNGF Guideline
Cardiac Rehabilitation Royal Dutch Society for Physical Therapy

Chronic heart failure Therapeutic process

Relevant information for physical therapist

Diagnostic process
• (medical) diagnosis
• relevant diagnostic (e.g. > 3 weeks hemodynamically stable) and prognostic referral information on patient’s physical
Medical referral Screening and intake Interventions MDT condition
information from • all individual rehabilitation goals, especially goals for physical training and possible impediments to physical training,
patient’s cardiologist • by professional from • information program • cardiac rehabilitation such as anxiety, dysfunctional coping style, decompensation risk and comorbidity
MDT, usually the • training program* coordinator • results of maximum or symptom-limited exercise test with gas analysis
• medical diagnosis cardiac rehabilitation • relaxation program • cardiac rehabilitation • settings of ICD or pacemaker, if present (safe heart rate range for training)
• relevant diagnostic coordinator • behavior modification cardiologist • all medications (type, dosage)
details program • nurse • information relevant to work resumption (mostly for younger patients), prognosis and familiy information (social support)
• results of maximum • lifestyle program • dietician • diagnosis for physical therapy
or symptom-limited • psychological program • physical therapist
exercise test • social worker
• relevant comorbidity • health psychologist Informing / advising Tailored training program Relaxation program
• prior history, cardiac & • other disciplines if
non-cardiac necessary • improving patient’s understanding • patient’s wishes / abilities • reducing tension
• medication (type, of heart disease and rehabilitation • patient’s exercise capacity • regulating breathing
dosage) regarding physical functioning • patient’s individual goals • promoting body awareness
1. Physical functioning • lifestyle information / education • physical improvements to be expected
Supplementary intake by
affected / threatened? • recognizing signs of deterioration
different disciplines
2. Psychological of heart failure (decompensation)
functioning affected / • encouraging compliance, active
threatened? lifestyle and work resumption
3. Social functioning • promoting suitable way to handle
affected / threatened? symptoms and exertion in daily life
4. What is the (dyspnea and fatigue)
cardiovascular risk
profile?
5. Any unhealthy Selecting priorities for exercise • practicing skills and activities
behavior? program • training aerobic (general) exercise capacity
and encouraging physical activity
• training (local) strength endurance
of peripheral muscle groups and / or
Diagnostic process for physical therapy
inspiratory muscles
• training functions / activities to develop
enjoyment of exercise, reduce physical
History-taking Examination Analysis Designing treatment plan inactivity and reduce risk factors

• presenting problem • assessment of 1. assessment of health Rehabilitation goals

/ target activity level impairments, activity status and current Selecting training activities • practicing functional skills and activities
(PSC) limitations and health functional exercise specific goals for ADL, work and/or hobbies / field
• assessment of activity problems that may capacity 1. optimizing exercise training / sports and games / fitness
level before current influence the choice of 2. physical impediments capacity / aerobics / swimming / ergometers /
health problem arose exercise activities in the 3. other (internal or 2. balancing exertion with exercising in water / relaxation
• assessment of health rehabilitation program external) factors physical abilities
status (nature, course, • assessment of functional impeding recovery 3. reducing dyspnea,
prognosis) exercise capacity (SWT) 4. future target situation fatigue and inactivity
• assessment of current 5. is target situation Selecting exercise variables • aerobic training: intensity / frequency /
state feasible within the duration / work/rest intervals / structure of
• other information: limits of patient’s general goals training program
- personal details abilities? 1. exploring own physical • strength training: external resistance
(social, environment) 6. opportunities to reduce limits / speed / number of repetitions and
- motivation health problem, i.e. 2. learning to cope with sessions / recovery intervals
- need for information improve functions, physical limitations
activities and 3. overcoming fear of
participation physical exertion Implementation of program
4. developing /
maintaining a physically
active lifestyle
interim and final evaluation, adjusting
program if necessary
* The training program is part of the multidisciplinary cardiac rehabilitation. For locations of cardiac rehabilitation see the Preface and the
introduction to the Verantwoording & Toelichting (review of the evidence) document.
Consultations with MDT and start of aftercare phase (Phase III)

ICD = implantable cardioverter defibrillator; MDT = multidisciplinary cardiac rehabilitation team; PSC = patient-specific complaints; • monitoring lifestyle after 6 and 12 months
SWT = shuttle walk test; VO 2max = maximum oxygen uptake • maintenance training ≥ 60% VO 2max
- primary care physical therapy practice / certified exercise facility
• maintenance training < 60% VO 2max
- independently
- primary care physical therapist / certified exercise facility
• network including primary care practice and hospital or rehabilitation center where cardiac rehabilitation took place
V-08/2011 Consult the full Guideline on www.kngfrichtlijnen.nl © KNGF