OCCUPATIONAL THERAPISTS The Role of Occupational Therapy in Cardiac Rehabilitation | 1
THE ROLE OF OCCUPATIONAL THERAPY
IN CARDIAC REHABILITATION
PDH Academy Course #OT-1709 | 3 CE HOURS
CONTINUING
EDUCATION
for Occupational Therapists
This course is offered for 0.3 CEUs (Intermediate level; Category 2 – Occupational Therapy
Process: Evaluation; Category 2 – Occupational Therapy Process: Intervention; Category 2 –
Occupational Therapy Process: Outcomes).
The assignment of AOTA CEUs does not imply endorsement of specic course content, products,
or clinical procedures by AOTA.
Course Abstract
This course provides an overview of Occupational Therapy’s role in cardiac rehabilitation, with
attention to diagnoses, terminology and procedures, and process. It concludes with case studies.
Target audience: Occupational Therapists, Occupational Therapy Assistants (no prerequisites).
NOTE: Links provided within the course material are for informational purposes only. No endorsement of
processes or products is intended or implied.
Learning Objectives
At the end of this course, learners will be able to:
❏ Differentiate between primary cardiac diagnoses
❏ Identify terminology and procedures pertaining to cardiac rehabilitation
❏ Recognize roles of occupational therapy in cardiac rehabilitation
❏ Recall elements of three cardiac rehabilitation-focused case studies
| The Role of Occupational Therapy in Cardiac Rehabilitation OCCUPATIONAL THERAPISTS2
INTRODUCTION
Cardiovascular disease, known
popularly as heart disease, is
an umbrella term that includes
conditions affecting the blood
vessels such as coronary artery
disease; heart rhythm issues such
as arrhythmias; and congenital
defects. While hospitalizations
and deaths associated with heart
disease have declined in the
U.S.A. over the last decade – due
to an increase in evidence-based
practice and medications, as well as
initiatives to promote heart-healthy
lifestyles – it remains the number
one cause of death for both men
and women in the U.S.A., killing
more than 600,000 individuals
annually and spanning most racial/
ethnic groups.
1
Approximately
27.6 million American adults have
been diagnosed with some form of
heart disease, with coronary artery
disease (CAD) the most prevalent.
Although many forms of heart
disease are preventable or treatable
with healthy lifestyle choices, it
is estimated that approximately
49% of all Americans have at least
three risk factors for heart disease,
which include high blood pressure,
high LDL cholesterol, smoking,
diabetes, chronic stress, and obesity.
Additional lifestyle choices that
increase risk include poor diet,
physical inactivity, and excessive
alcohol consumption. The nancial
burden of heart disease, including
both health-related expenses and
lost revenue, is estimated to be more
than $200 billion per year.
2
Symptoms associated with heart
disease vary across conditions and
may also vary between genders.
Common symptoms associated
with coronary artery disease (CAD)
include fatigue and shortness of
breath, while changes in heart
rate, including the sensation of
uttering in the chest or a racing
heartbeat, may be indicative of an
arrhythmia. In cases of congestive
heart failure, individuals may also
experience lower extremity edema
or a persistent cough. Some adults
may even remain asymptomatic
until experiencing an acute cardiac
Timed Topic Outline
I. Primary Cardiac Diagnoses (60 minutes)
Hypertension (HTN), Coronary Artery Disease (CAD),
Atrial Fibrillation (AFib), Heart Failure / Congestive Heart Failure (CHF),
Myocardial Infarction (MI)
II. Common Cardiac Terminology and Procedures (15 minutes)
III. Role of Occupational Therapy in Cardiac Rehabilitation (45 minutes)
Overview, Settings, Process, Common Questions
IV. Case Studies (45 minutes)
V. Conclusion, Additional Resources, References, and Exam (15 minutes)
Delivery & Instructional Method
Distance Learning – Independent. Correspondence/internet text-based self-study,
including a provider-graded multiple choice nal exam. To earn continuing education
credit for this course, you must achieve a passing score of 80% on the nal exam.
Registration & Cancellation
Visit www.pdhtherapy.com to register for online courses and/or request
correspondence courses.
As PDH Academy offers self-study courses only, provider cancellations due to
inclement weather, instructor no-shows, and/or insufcient enrollment are not
concerns. In the unlikely event that a self-study course is temporarily unavailable,
already-enrolled participants will be notied by email. A notication will also be
posted on the relevant pages of our website.
Customers who cancel orders within ve business days of the order date receive
a full refund. Cancellations can be made by phone at (888)564-9098 or email at
support@pdhacademy.com.
Accessibility and/or Special Needs Concerns?
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Course Author Bio & Disclosure
Midge (Annamaria) Hobbs, OTR/L, originally from the UK, graduated with an MA
in Occupational Therapy from Tufts University, Boston MA in 2005. She spent
the following ten years working in long-term acute care gaining experience as a
clinician, educator, and manager. In 2010, Midge was selected for the inaugural
cohort of AOTA’s Emerging Leaders Development Program (ELDP). Since then she
has continued to amplify AOTA’s leadership initiatives by serving the Emerging
Leaders Development Committee (ELDC) as Chairperson and as a member of
AOTA’s Volunteer Leadership Development Committee (VLDC). She is currently
the Editor of AOTA’s A Mindful Path to Leadership, a new online self-paced
leadership development course, and she co-authored Module 3: Mentoring and
Leadership with current AOTA president, Amy Lamb.
Midge is currently employed as a consultant for internship development in the
adolescent residential psychiatric programs at Sheppard Pratt Hospital in Baltimore
MD, an adjunct professor at the MGH Institute of Health Professions in Boston,
and a clinician at local rehab and assisted living facilities. Midge is also enrolled
at Thomas Jefferson University for her post-professional OTD with a specialty in
teaching in the digital age. In her limited spare time she watches English soccer
and eats a lot of popcorn.
DISCLOSURES: Financial – Midge (Annamaria) Hobbs received a stipend as the
author of this course. Nonnancial – No relevant nonnancial relationship exists.
OCCUPATIONAL THERAPISTS The Role of Occupational Therapy in Cardiac Rehabilitation | 3
event, such as an episode of angina, a heart attack, or
a stroke.
3
Whether heart disease presents as an acute
health crisis or a chronic condition, symptoms can
often limit function leading to loss of independence
and a decline in condence.
4
Multidisciplinary
health care is designed to alleviate and/or manage
symptoms, increase strength and endurance in order
to optimize function, and maximize quality of life.
Occupational Therapy (OT) – with its distinct focus
on evaluating individual needs and developing
meaningful, client-centered interventions to maximize
individual functional capacity through education,
the improvement of strength and activity tolerance,
and psychosocial support – plays a key role within
the interdisciplinary team. While many occupational
therapists may not work primarily in cardiopulmonary
rehabilitation, many therapists working in physical
medicine settings will encounter adults with
limitations associated with heart disease, and it is
important to understand OT’s role and be prepared to
provide appropriate services.
5
PRIMARY CARDIAC DIAGNOSES
Hypertension (HTN)
Description:
Hypertension, or high blood pressure, is a common
condition determined by a resting systolic blood
pressure of 140 mm Hg or more, and/or a diastolic
pressure of 90 mm Hg or more, on repeated
examination. Approximately 95% of hypertension
develops without a known etiology (essential or
primary hypertension) and 5% of cases are attributed
to a comorbid condition such as chronic kidney
disease (secondary hypertension). Without appropriate
medical management, the persistent high force of
blood pumping through the blood vessels places
signicant stress on the heart, increasing the risk of
serious health problems.
6
Pathophysiology:
Approximately 75 million or one in three American
adults have high blood pressure yet only about half are
aware they even have the condition and in many cases
the disease is not adequately controlled.
7
Hypertension
signicantly increases the risk of heart disease and
stroke, which are two of the leading causes of death
in the United States. It is the most common chronic
disease managed by primary care physicians: annual
medical expenses associated with hypertension are
estimated to be around $47.5 billion each year. The
condition is either the primary or contributing cause of
almost 1000 deaths each day in the U.S.A. According
to the Centers for Disease Control (CDC), hypertension
affects men and women in equal numbers; however,
the condition is more prevalent in men if under the
age of 45, and is more likely to affect women than men
when over the age of 65. High blood pressure affects
all races and ethnicities, although it occurs more often
and at an earlier age in African Americans.
8
Blood pressure typically increases with age due to a
stiffening of the arteries or the development of small
vessel blockages, but genetics and environmental
factors, such as stress, sodium intake, and obesity,
are also major considerations in the development
of primary hypertension. Additionally, excessive
alcohol consumption, over-use of non-steroidal anti-
inammatory drugs (NSAIDS), corticosteroids, cocaine,
and oral contraceptives may also contribute to the
development of hypertension.
7
No specic pathologic changes occur in the early
stages of hypertension; however, a severe or chronic
disease prole will damage arteriole tissue over time
with further narrowing of vessels, thereby increasing
the risk of developing coronary artery disease (CAD),
myocardial infarction (MI), heart failure, stroke, or
renal failure.
6
Clinical picture:
Hypertension is commonly called the “silent killer”
because it is typically asymptomatic and individuals
are commonly unaware of the disease until a medical
professional conducts a blood pressure measurement
during a physical examination. In order to determine a
diagnosis, a doctor may require multiple readings over
the course of several days in order to assess whether
high blood pressure persists over time. High blood
pressure is classied by its degree of severity, which also
guides the treatment plan, but it is equally important
to consider the individual’s family history and any
additional risk factors that may require attention.
6
Classication
Systolic BP
(mmHg)
Diastolic BP (mmHg)
Normal <120 And <80
Pre-
hypertension
120-139 Or 80-89
Stage 1
hypertension
140-159 Or 90-99
Stage 2
hypertension
>160 Or >100
Classication of Blood Pressure
9
The primary goal in treating hypertension is to
decrease blood pressure to levels below those used
in determining a diagnosis. Prior to introducing
blood pressure medication, individuals who have
been classied as pre-hypertensive are typically
encouraged to make lifestyle changes to minimize
the risk of disease progression. With appropriate
healthcare guidance and support, a number of
nonpharmacological interventions have been shown
to help decrease blood pressure. Interventions include
| The Role of Occupational Therapy in Cardiac Rehabilitation OCCUPATIONAL THERAPISTS4
participation in a tailored weight loss program,
a reduction in sodium intake, a regular exercise
regimen, limiting alcohol consumption, and smoking
cessation.
10
While each individual case is unique, medication
treatment is typically initiated immediately for those
individuals who have been diagnosed with at least
stage 1 hypertension, in cases where lifestyle changes
have been shown to be ineffective, or when the
healthcare provider sees a need to expedite control
of blood pressure. Age, ethnicity, lifestyle factors, and
comorbidities are all considered in the drug treatment
plan.
10
Medication regimens may include diuretics
to eliminate excess sodium and water in order to
reduce blood volume, beta blockers such as atenolol
to minimize cardiac workload and dilate vessels to
optimize blood ow, angiotensin-converting enzyme
(ACE) inhibitors like Lisinopril to relax and open
vessels, and calcium channel blockers such as diltiazem
to relax vessels and decrease heart rate. Additional
medications that may be considered include alpha
blockers to minimize nerve impulses that narrow blood
vessels, vasodilators that directly impact artery walls
and decrease tightening and narrowing of vessels,
and aldosterone antagonists that reduce salt and uid
retention.
11
A comprehensive treatment plan may also include a
stress management program to minimize triggers and
help develop effective coping strategies, including
relaxation techniques. Regardless of whether
hypertension is treated with medication or lifestyle
changes or a combination, healthcare providers should
inform clients that treatment is invariably a life-
long commitment and any changes to the treatment
protocol should be rst discussed with a physician.
10
Coronary Artery Disease (CAD)
Description:
Coronary artery disease (CAD) is one of the most
common cardiac-related disorders that affects millions
of individuals worldwide. It is an ischemic disease,
most commonly attributed to atherosclerosis, a
buildup of fatty, brous plaque in the coronary arteries
that can progressively narrow the vessels over time and
occlude blood supply to the heart muscle, increasing
the risk of signicant health related issues.
12
Pathophysiology:
In the United States, approximately 370,000 deaths
are attributed to CAD annually.
13
The majority of
individuals who die as a result of the disease are over
65 years of age, and it typically affects more men than
women, although women typically develop heart
disease later than men and the death rate among
women continues to rise each year. The risk of heart
disease generally increases with age but a decline in
the hormone estrogen may play a role in increasing
the risk for post menopausal women. Research
suggests that estrogen helps to maintain the exibility
of blood vessels thereby improving blood ow and
as hormone level decline the risk of cardiovascular
disease increases.
14
While genetic predisposition or
a family history of heart disease may increase the
likelihood of developing CAD, there are also a number
of additional risk factors that can be modied or
controlled with appropriate medical care. For example,
controlling high blood pressure is key, as an increase
in cardiac output associated with hypertension
can place signicant stress on the heart muscle.
Other signicant factors that require appropriate
medical attention are managing cholesterol levels,
managing diabetes mellitus, monitoring weight,
staying physically active, and stopping smoking. More
recent research also implicates chronic inammation
associated with prolonged stress as a signicant
contributor to the development of atherogenesis and
the early development of plaque.
15
Approximately
68% of individuals over the age of 65 who have been
diagnosed with diabetes die as a result of some form
of heart disease. The correlation between high blood
cholesterol – in particular an increase in low-density
lipoprotein (LDL) cholesterol – and CAD is signicant,
with the risk escalating even further with the addition
of other risk factors such as tobacco use and obesity.
Other factors that contribute to the development of
CAD include excessive alcohol consumption, which
can raise blood pressure and contribute to high
cholesterol and weight gain. Individual exposure to
stress and the ability to manage stress may also be a
contributing factor to CAD: not only does it increase
the workload and strain on the heart muscle but it
may also lead to unhealthy behaviors such as poor
dietary choices or an increase in smoking or alcohol
consumption.
7
CAD is a complex chronic inammatory disease
notable for a narrowing of the coronary arteries that
supply oxygen to the heart by atherosclerotic plaque.
As blood ow is restricted over time, CAD can lead to
a weakening of the heart muscle increasing the risk for
major health concerns, including angina, myocardial
infarction, heart failure and arrhythmias. Restricted
blood ow or a blockage may also trigger a heart attack
and if blood supply is not restored promptly, cardiac
tissue will begin to die which may result in death.
16
Research suggests that 70% of sudden deaths associated
with CAD can be attributed to plaque rupture or
plaque erosion.
17
Clinical picture:
CAD is commonly diagnosed through a detailed
medical history, physical exam, and diagnostic tests
that may include an echocardiogram to assess the
heart’s effectiveness, a stress test to determine the
heart’s response to increased activity demand, and/or
cardiac catheterization or angiogram to determine
potential blockages.
18
Individuals may not experience
OCCUPATIONAL THERAPISTS The Role of Occupational Therapy in Cardiac Rehabilitation | 5
any symptoms during the early stages of the disease,
which is commonly treated by controlling risk factors,
such as managing high blood pressure, cholesterol
levels, and diabetes, as well as other preventative
actions designed to address diet and weight, activity,
stress, and smoking cessation.
Angina is a complication of CAD that may develop as
the arteries continue to narrow over time and blood
supply is reduced. This causes the heart muscle to
constrict with increased activity demand, such as
exercise, eating, or stress, causing chest discomfort
or pain. It may also be experienced as pressure,
aching, or a squeezing sensation in the left shoulder,
the arms, neck, back, or jaw. Other symptoms
associated with angina include shortness of breath,
nausea or vomiting, a rapid or irregular heartbeat,
diaphoresis, or a feeling of fullness or heartburn
similar to indigestion.
19
Typically, women’s angina
symptoms are less easily identied as cardiac related
and consequently women are often less likely to seek
medical help for the onset of a heart attack. While
women can also experience chest pain or pressure
that extends to the arm or jaw during an episode of
angina, many often report additional symptoms prior
to having a heart attack, including signicant fatigue,
sleep disturbance and anxiety.
20
Angina is commonly classied as either stable or
unstable. The stable kind occurs more predictably
during periods of exertion or stress with episodes
lasting approximately 2-15 minutes and resolving
with rest or medication. Unstable angina typically
occurs when more than 70% of the arteries are
occluded, and symptoms can occur at rest without
any notable cardiac demand. Treatment for angina
includes nitrates, such as nitroglycerin tablets, or
beta-adrenergic blockers that dilate vessels. Symptoms
of angina are very similar to those of a heart attack and
immediate medical attention is imperative if symptoms
persist and last longer than 15 minutes or there is no
response to prescribed medication.
21
With signicantly narrowed or blocked vessels a more
invasive treatment may be indicated to alleviate angina
and minimize the risk of myocardial infarction (MI).
This includes coronary artery bypass graft (CABG)
surgery to circumvent blocked vessels by using another
vessel harvested from the body, most commonly the
saphenous vein in the leg.
22
Alternately, percutaneous
coronary intervention (PCI), also known as coronary
angioplasty, with or without stent placement may be
indicated to open the artery. The procedure involves a
deated balloon being passed through a catheter that
has been inserted into the narrow artery. Once in place,
the balloon is inated to open the vessel and a stent is
commonly left in place to maintain the changes.
23
Atrial Fibrillation (AFib)
Description:
A cardiac arrhythmia is a disturbance in the normal
rhythm of the heart that can be benign or immediately
life-threatening. Changes in the heart’s electrical
impulse sequence can cause the heart to beat too fast,
too slowly, or irregularly, which may impact the heart’s
ability to pump effectively. Atrial brillation (AFib) is
the most common sustained arrhythmia condition,
notable for cardiac irregularity and sometimes referred
to as rapid heartbeat.
24 25
Pathophysiology:
AFib affects an estimated 2.7-6.1 million individuals
in the United States and occurs when the atria and
ventricles beat out of sync. It may develop as a result
of another disorder such as high blood pressure,
CAD, heart failure, or heart valve issues. It may also
occur as a result of pneumonia (PNA), a thyroid
problem, or sleep apnea. Each year more than 750,000
hospitalizations are attributed to the condition
with healthcare related costs estimated to be about
$6 billion. Of note, the condition can increase an
individual’s risk for developing an ischemic stroke by
15-20% and each year approximately 130,000 deaths
in the U.S. are associated with AFib as either the
primary cause or a contributing factor. Risk factors for
developing AFib include advancing age, high blood
pressure, obesity, diabetes, ischemic heart disease, and
heavy alcohol consumption.
26
A normal heartbeat begins with an electrical signal
from the sinus node, a single point within the right
atrium of the heart. During AFib, electrical signals
re rapidly from multiple sites in both atria thereby
overwhelming the ventricles, which are unable
to ll and pump in a normal rhythm. As a result,
an individual will experience a rapid and irregular
heartbeat. With ongoing cardiac inefciency, the risk
of a blood clot developing increases as blood pools in
the upper chambers. In turn, this leads to greater risk
of stroke.
23 27
Clinical picture:
For many, AFib does not cause obvious symptoms but
may include an uneven pulse, a racing or pounding
heart, a sensation that the heart is uttering, chest
pain, feeling short of breath, dizziness and/or fatigue.
Signs and symptoms of an acute medical event include
severe chest pain, feeling weak or faint, as well as the
typical signs associated with stroke.
25
In addition to a full physical evaluation, a diagnosis
of AFib is conrmed via electrocardiogram (ECG),
which detects and records the heart’s electrical activity
and rhythm. Doctors may also suggest a portable
ECG device, such as a Holter Monitor, to record an
individual’s heart rhythm over a set period of time,
or an Event Monitor that may be used for longer
| The Role of Occupational Therapy in Cardiac Rehabilitation OCCUPATIONAL THERAPISTS6
periods of time but is only triggered by abnormal
heart rhythm. If an ECG is consistent with AFib,
additional tests such as an ultrasound may be used to
also determine if valve damage or heart failure are also
present.
23
25
If AFib is the result of a treatable medical condition
such as PNA, the arrhythmia may resolve as the
infection resolves. However, typical treatment of
AFib varies according to symptoms. Antiarrhythmic
medication may include those designed to slow
the heart rate or control rhythm. Additionally,
anticoagulants are often prescribed to also
minimize the risk of stroke. Treatment options also
include catheter ablation to destroy the cardiac
cells producing the errant electrical signals, or
cardioversion whereby the heart is shocked into
rhythm under controlled circumstances. While the
cardioversion procedure is considered effective in
reestablishing normal sinus rhythm it does not
necessarily prevent a future recurrence. For others, a
pacemaker may be indicated to correct the heart’s
rhythm.
25
Despite the increased risk for stroke, individuals with a
diagnosis of AFib can continue to lead healthy, active
lives with careful medical management and lifestyle
modications. Managing triggers, such as excessive
caffeine and alcohol intake, poor sleep, and increased
stress, is considered an essential component of long
term care.
28
Heart Failure / Congestive Heart Failure (CHF)
Description:
Heart failure, or congestive heart failure (CHF), is a
complex diagnosis that results from impaired structure
and/or function of the ventricles. It is a chronic
progressive condition that affects the heart’s ability
to pump blood to the body and provide organs and
tissues with necessary oxygen and nutrients. Heart
failure often affects both sides of the heart; however,
one side may be more affected than the other. While
both left or right sided dysfunction share similar
clinical traits, left ventricular dysfunction typically
presents with increased fatigue, shortness of breath,
and pulmonary edema, while right sided dysfunction
is notable for peripheral edema. The decrease in cardiac
efciency and output impacts the body’s ability to
circulate blood, hence the term “congestive” heart
failure. Left or right sided heart failure may be the
result of either systolic dysfunction, whereby the
heart is unable to contract efciently, or diastolic
dysfunction when cardiac muscle is unable to relax.
29
Pathophysiology:
Approximately 5.7 million American adults have a
diagnosis of CHF, with an additional 500,000 new cases
each year. Globally, about 23 million are affected by
CHF with about half dying from the disease within
5 years of diagnosis. Each year in the United States,
one million hospitalizations are attributed to CHF
with costs estimated in the region of $30.7 billion,
which includes medical care and treatment costs,
medications, and missed work.
27
30
Any disorder that directly impacts the heart may
contribute to the development of heart failure. The
most common etiology for systolic dysfunction
is coronary artery disease, typically caused by a
combination of factors; as vessels narrow over time
limiting the ow of oxygenated blood to the heart,
cardiac muscle weakens impacting its ability to
contract. Chronic HTN is the most common disorder
that leads to diastolic dysfunction; s the heart pumps
more forcibly at a higher pressure the cardiac walls
thicken leading to ventricle hypertrophy, which makes
oxygenating the heart muscle even more difcult and
may lead to ischemic damage. Additionally, an acute
ischemic event such as a myocardial infarction (MI)
may destroy tissue contributing to cardiac inefciency.
Unhealthy lifestyle factors may also increase the risk
for developing heart failure. These include smoking,
having a diet high in fat and/or sodium, alcohol or
drug abuse, limited physical activity and/or obesity.
27
Under stress, the body responds by releasing
epinephrine and norepinephrine, two hormones
designed to increase cardiac output. However, with a
sustained response to the stress of chronic conditions
such as CAD or HTN, the heart ultimately becomes
weaker with a notable impact on stroke volume
and a further decrease in cardiac output. The body
responds by triggering compensatory mechanisms that
include an inammatory response as well as structural
changes to the wall of the heart muscle. As the heart
works harder its walls thicken and enlarge in order
to contract more forcefully. While this measure may
increase stroke volume in the short term, the tissue
ultimately stiffens with effort thereby decreasing its
effectiveness over time. Additionally, decreased renal
perfusion causes a release of the renin-angiotensin-
aldosterone-vasopressin system (antidiuretic hormone
ADH), which promotes sodium and water retention
ultimately leading to volume overload. Initially,
retaining salt and water instead of excreting it into
urine helps to increase heart function and regulate
blood pressure and organ perfusion, but chronic
activation is detrimental to cardiac efciency. Over
time the effort weakens the cardiac muscle worsening
the heart failure.
27
Clinical picture:
Heart failure may begin with an acute onset or progress
slowly and become a chronic condition, although in
many cases individuals are initially asymptomatic.
Heart failure symptoms are classied in stages from
mild to severe.
OCCUPATIONAL THERAPISTS The Role of Occupational Therapy in Cardiac Rehabilitation | 7
Class Description
I
No limitations with normal activity. For example,
no undue fatigue or dyspnea with exertion.
II
Mild limitations with ordinary physical activity.
For example, dyspnea when ambulating long-
distances, climbing two ights of stairs.
III
Moderate limitations with increased activity
demand. For example, fatigue and dyspnea while
ambulating short distances, climbing one ight
of stairs.
IV
Severe limitations. For example, dyspnea occurs
at rest or with minimal exertion.
New York Heart Association (NYHA) Heart Failure Symptom
Classication
31
Even when both types of heart failure are present,
one side will likely dominate. In the majority of
cases, left-sided heart failure will lead to right-sided
dysfunction.
32
Although right and left-sided heart
failure produce different symptoms, the most common
symptom associated with the disease is shortness of
breath.
Initially, in left-sided heart failure, shortness of breath
may only be evident with increased activity demand.
However, as the disease progresses and with increasing
uid accumulation in the lungs, dyspnea may also
occur at rest or with minimal exertion. Additionally,
individuals may also experience orthopnea as gravity
causes the increase in uid to move to the lungs,
which is exacerbated in supine. Breathing is often
improved by sitting up. In addition to shortness of
breath, individuals may also experience wheezing and
bronchospasms, as well as an increase in fatigue and
muscle weakness.
30
Right-sided heart failure is characterized by peripheral
edema that includes the lower extremities, the liver,
and abdomen. With signicant uid accumulation
in the abdomen or liver, individuals may experience
a decline in appetite and/or nausea. When food is
not being absorbed efciently, cardiac cachexia is
common.
30
Depression, decreased alertness, and a decline in
cognition are also characteristics of CHF. Cognitive
decits are particularly indicated in the elderly with
research showing that heart failure has an impact on
memory and recall, attention, and the capacity for
new learning. The effects on function may include an
inability to manage the disease appropriately, problem-
solve daily routines or challenges, and adequately
perform self-care tasks. A decline in cognition
alongside a decline in function may lead to decreased
condence and depression.
33
In severe cases individuals may also experience a rapid
or irregular heart rate or Cheyne-Stokes respiration.
Any sudden changes in dyspnea or heart rate with
chest pain should be considered a medical emergency
requiring immediate help. Individuals are also at
greater risk of developing emboli, which in turn
increases the risk for stroke.
34
Diagnosis is typically determined through a complete
medical history with a thorough assessment of
symptoms and physical examination. Additional
procedures are used to support the diagnosis, which
typically includes an electrocardiogram (ECG) to
determine heart rhythm irregularities, whether there
are structural changes in the ventricles or to assess
valve function. An ECG may also help to determine
if the heart failure is the result of systolic or diastolic
dysfunction by assessing the thickness and stiffness of
the heart wall and the ejection fraction (EF). A normal
ventricle ejects approximately 60% of its blood. An EF
below this percentage conrms systolic heart failure.
A normal EF suggests diastolic dysfunction. Additional
procedures used to conrm diagnosis include blood
tests, chest X-rays to assess uid build up in the
lungs, a stress test to determine the cardiovascular
system’s response to exertion, a cardiac computerized
tomography (CT) scan, magnetic resonance imaging
(MRI), or a coronary angiogram to assess arterial
health.
30
While CHF is considered a chronic condition, it can
be managed long-term with appropriate medical care
and lifestyle changes. However, CHF may worsen
rapidly requiring immediate emergency care and
hospitalization. While a good number of individuals
manage the disease for many years and life expectancy
can improve with treatment, much depends upon
the severity of the condition and which treatments
options are applicable. Approximately 70% of
individuals with mild heart failure die within 10 years
of being diagnosed, while those who are classied as
severe cases often die within 2 years. In older adults,
treatment options may be limited and quality of
life takes priority versus attempting to implement
heroic measures. In such cases, hospice is the main
consideration whereby the individual is offered
symptom relief and compassionate care to ensure
comfort and dignity at end of life.
27
Treatment options vary but typically include a
combination of measures. Medications and lifestyle
changes are often the cornerstone of treatment plans
while oxygen and/or surgical interventions may also
be indicated. For example, if the known etiology is
valve dysfunction or vessel blockage, surgery may be
appropriate. A heart transplant may also be an option
for eligible candidates with worsening symptoms but
no other comorbidities.
27 30
There are a number of medications used to treat
heart failure. These include angiotensin-converting
enzyme (ACE) inhibitors, a type of vasodilator,
which are often the core of treatment and work to
reduce the levels of the hormones angiotensin II and
aldosterone in the blood. In doing so, ACE inhibitors
dilate vessels, help the kidneys eliminate excess water,
and lower blood pressure thereby decreasing cardiac
| The Role of Occupational Therapy in Cardiac Rehabilitation OCCUPATIONAL THERAPISTS8
workload. Common alternatives to ACE inhibitors
are angiotensin II receptor blockers that have similar
benets. Beta blockers are also frequently used with
ACE inhibitors to treat heart failure. In cases of
diastolic heart failure, beta blockers reduce heart rate
and relax thickened cardiac muscle that has stiffened.
Consequently, the heart can ll more readily and work
more efciently.
30
Diuretics are also commonly use to manage uid
retention, particularly when dietary sodium restriction
is inadequate. Most often, diuretics are taken orally
as part of a long-term regimen; however, they are also
used intravenously in acute situations. Aldosterone
antagonists directly obstruct the effects of aldosterone
and are potassium-sparing diuretics.
30
In acute heart failure, such as the development of
pulmonary edema, individuals commonly require
supplemental oxygen alongside diuretics to decrease
edema and morphine to manage the signicant
anxiety associated with respiratory distress. By
slowing respiration rate and dilating blood vessels,
the morphine can decrease cardiac effort and improve
breathing.
27, 30
Lifestyle changes are also important considerations
in heart failure management and can help minimize
symptoms and slow the progression of the disease.
Doctors may recommend smoking cessation, daily
weight monitoring including checking for edema,
dietary changes with sodium and high fat restrictions,
limiting alcohol and uid consumption, reducing
stress, and increasing physical activity as tolerated.
27
Despite managing chronic disease symptoms, heart
failure can cause sudden death even without a period
of worsening symptoms. Healthcare providers are
encouraged to discuss end of life issues and advance
directives with individuals who have been diagnosed
with CHF and include family members and signicant
others in the dialogue.
27
Myocardial Infarction (MI)
Description:
Commonly referred to as a heart attack, acute
myocardial infarction (MI) is the irreversible damage to
heart muscle as a result of coronary artery obstruction
or prolonged lack of oxygen to cardiac tissue. If blood
ow is not restored quickly, cardiac muscle begins to
die and the infarction may be fatal.
35 36
Pathophysiology:
In the United States, someone has a heart attack
every 43 seconds with approximately 735,000
events occurring annually. One in ve infarctions
is asymptomatic and around 50% of individuals
experiencing an MI die within an hour after onset
before they reach the hospital.
37
Men are more likely
to experience an MI than premenopausal women,
although the number of women who are at risk for
heart attack increases post menopause. Myocardial
infarction affects all ethnicities and about half of all
Americans have at least one of the three risk factors
that may contribute to heart disease and increase the
possibility of an MI. These include hypertension, high
cholesterol, and smoking. In addition, several lifestyle
factors and medical conditions may also increase
risk of triggering a MI, including diabetes, obesity,
poor diet, physical inactivity, and excessive alcohol
consumption.
38
Infarction is tissue death that occurs in response to
one or more coronary occlusions. It may occur as
a result of an atherosclerotic rupture that leads to
thrombus formation that in turn plugs the artery and
obstructs blood ow to the heart. In many cases, the
vessels may already be narrower if there is underlying
atherosclerosis, a build-up of fatty, brous plaque in
the coronary arteries. Less common is an MI stemming
from a coronary artery spasm that inhibits blood ow,
which may be triggered by amphetamine or cocaine
use.
39
An acute MI typically affects the left ventricle but
ischemia may also impact the right ventricle or the
atria. Anterior infarcts are more commonly associated
with a poor prognosis than inferoposterior events.
Prolonged ischemia to the myocardium can cause
irreversible tissue damage or death. In terms of
function, an MI may cause reduced contractility
with unstable cardiac wall movement, altered left
ventricular compliance, reduced stroke volume,
decreased ejection fraction, and elevated left
ventricular end-diastolic pressure.
34
Classication of an acute MI is designed to assist
rapid decision-making and is based on the presence of
serum markers in the blood, symptoms of ischemia,
and imaging results. The three classications include
unstable angina and two types of MI: Non-ST-segment
elevation MI (NSTEMI) and ST-segment elevation
MI (STEMI), which are determined by the presence
or absence of ST-segment elevation or Q waves on
an Electrocardiogram (ECG). In cases of NSTEMI,
there may be ST-segment depression and/or T-wave
inversion, and blood tests will show cardiac markers,
troponin I or troponin T and CK-MB, to be elevated.
In cases of STEMI, ECG changes will show ST-segment
elevation as well as elevated cardiac markers.
34
OCCUPATIONAL THERAPISTS The Role of Occupational Therapy in Cardiac Rehabilitation | 9
Acute MI may be classied further according to
etiology and context.
34
Type Etiology/context
I
MI caused by ischemia due to primary coronary
event such as atherosclerotic rupture or
coronary dissection
II
MI caused by ischemia due to coronary artery
spasm decreasing O2 supply or increased O2
demand due to hypertension
III MI related to sudden cardiac death
IVa
MI linked with percutaneous coronary
intervention
IVb MI linked with stent thrombosis
V
MI associated with coronary artery bypass graft
(CABG)
The severity of an infraction depends upon several
key factors: the extent of the arterial occlusion,
the duration of the blockage, and whether there is
collateral circulation. Typically, the more proximal
the blockage, the more likely there will be extensive
myocardium tissue necrosis.
33
Clinical picture:
While some individuals are asymptomatic during a
heart attack, there are several characteristic warning
signs associated with an infarction, although
these often differ between men and women. Most
commonly, symptoms include signicant chest pain
that is often described as pressure, aching, fullness, or
a squeezing sensation that may radiate into the jaw,
shoulders, left arm, and/or upper back. Symptoms may
also include dyspnea, diaphoresis, epigastric discomfort
with nausea or vomiting, syncope or near syncope
episodes, and impaired cognition. Skin is often pale
and peripheral cyanosis may be visible.
33 34
In women,
a heart attack is often precluded by extreme weakness
akin to u-like symptoms with a sense of restlessness
or apprehension, and they may not experience any
notable chest pain. The milder, less characteristic heart
attack symptoms may be why so many women fail to
seek or do not receive appropriate emergency medical
attention.
40
Evaluation begins with serial electrocardiography
(ECG) and should be carried out immediately upon
presentation of chest pain. These measurements will
show the electrical activity of the heart, the location
of damaged cardiac muscle, and help determine
whether an individual is having a heart attack or not.
An ECG will also help doctors differentiate between
unstable angina, NSTEMI, or STEMI in order to provide
appropriate medical care. A blood test is also a key
diagnostic tool, measuring the presence of cardiac
markers or cardiac enzymes in the blood indicating
myocardial cell injury. Heart muscle proteins, troponin
I and troponin T, and an enzyme called CK-MB are
normally only found in heart muscle unless tissue is
damaged or dead, upon which they are released into
the bloodstream. Levels of these cardiac markers are
high within 6 hours of infarction and remain elevated
for several days after an event. Additionally, a coronary
angiography (diagnostic imaging) may be considered
after an acute MI if there is evidence of ongoing
ischemia, the individual remains hemodynamically
unstable, or there is recurrent ventricular
tachyarrhythmias.
34
Delay in medical attention caused by failure to
recognize MI symptoms may signicantly limit
options for care, and reduce the potential for successful
intervention. Trained pre-hospital personnel are often
the key to improving survival rates.
33 41
Pre-hospital
intervention, including collecting early diagnostic
data, may signicantly increase diagnosis conrmation
and reduce mortality rates associated with heart attack.
Early interventions include administering potent
antiplatelet medication, like aspirin, immediately upon
recognition of MI symptoms, providing supplemental
oxygen if O2 sats are below 90%, and if available,
administering nitroglycerin for active chest pain.
Paramedics may also initiate intravenous (IV) access,
provide appropriate analgesics, and initiate telemetry
or ECG, if available.
42
Treatment focuses primarily on restoring coronary
blood ow and recovering functional myocardium.
Once diagnosis is conrmed, intervention is
determined by the clinical picture and prognosis.
Medication is most often the mainstay of therapy.
Typical drugs include thrombolytic agents to
revascularize tissue, antiplatelet drugs to prevent new
clots forming or existing clots from growing larger,
and beta blockers to relax cardiac muscle, decrease
blood pressure and myocardial demand, and minimize
heart muscle damage. Additional medications include
ACE inhibitors to lower blood pressure and minimize
the stress on the heart, antiarrhythmics to manage
ventricular arrhythmias, and pain medication such as
morphine to ease discomfort. Surgical interventions
include percutaneous coronary intervention (PCI),
also known as angioplasty, and stenting, a reperfusion
procedure that uses a catheter to place a stent to open
an occluded vessel. PCI is the preferred reperfusion
intervention for individuals with STEMI provided it
can be performed within 90 minutes of admission
to the hospital. For others, coronary artery bypass
grafting (CABG) may be indicated when arterial disease
is severe and an individual cannot undergo PCI, or in
cases where thrombolytic drugs are contraindicated
due to a recent surgery or stroke.
39 40
Even if blood ow is successfully restored, individuals
who have experienced MI may remain in the hospital
until considered medically stable. Additional treatment
focuses on minimizing complications, restoring normal
function, and the exploration of lifestyle modications
to reduce risk factors. Once discharged from the
hospital, treatment may include cardioprotective
| The Role of Occupational Therapy in Cardiac Rehabilitation OCCUPATIONAL THERAPISTS10
medications, cardiac rehabilitation, and ongoing
dietary/lifestyle education.
40
Unless complications are
present, progressive mobility and activity participation
is encouraged while hospitalized to minimize physical
deconditioning and depression.
37
Upon discharge, several key lifestyle modications
have been shown to strongly decrease risk for recurrent
MI and minimize the progression of cardiac disease,
including adoption of a low fat and low sodium diet,
smoking cessation, and increased physical activity.
Regular exercise based on an individual’s age and
cardiac picture, as well as the resumption of normal
daily routines, will be guided by healthcare providers.
37
Individuals who survive an acute heart attack
are at greater risk of additional infarcts, as well
developing other cardiac conditions, such as heart
failure, arrhythmias, angina, or stroke. However,
prognosis may vary according to age and clinical
picture, including the presence of absence of risk
factors. Many individuals continue to live full active
lives with appropriate lifestyle changes and medical
management.
43
COMMON CARDIAC
TERMINOLOGY AND PROCEDURES
Angina pectoris: Acute chest pain due to inadequate
oxygen to the heart muscle. Angina is symptomatic
of heart disease and may preclude a heart attack. It
is often characterized by a feeling of localized pain,
pressure, or tightness behind the sternum.
44
Angiogram: An imaging technique used to diagnose
heart conditions. It is the primary procedure used to
evaluate arterial blockages and is typically conducted
under sedation. The procedure is conducted using
X-rays and contrast dye to identify blockages and
determine the most appropriate treatment. The most
common interventions provided during an angiogram
are stent placement and balloon angioplasty.
45
Anticoagulant: A blood clot is the body’s way of
sealing and containing bleeding wounds. While
typically useful, the clotting process can also block
vessels and restrict blood ow thereby increasing
the risk of myocardial infarction or stroke. An
anticoagulant is a medication that is used to prevent
blood clots by inhibiting the process of clot formation.
They are also referred to as “blood-thinners” although
this is somewhat of a misnomer. They are commonly
recommended by physicians in conditions such as
heart disease, arrhythmias, congenital heart defects,
vascular issues, or after surgery. Common side effects
associated with anticoagulants include increased risk
of bruising, nosebleeds, bleeding gums, heavy periods
for women, and changes in temperature or pain in the
extremities.
46
Arrhythmia: An abnormal heart rhythm that is
considered too fast, too slow, or irregular, and that
most commonly occurs as a result of a heart disorder,
such as coronary artery disease (CAD) or heart failure.
The heart is normally regulated by the autonomic
nervous system via an electrical sequence and is
designed to maintain efciency and reliability over
a lifetime. Some individuals are asymptomatic while
others experience palpitations, although these vary
considerably between people. If an arrhythmia is
limiting the heart’s ability to contract and pump blood,
some individuals may experience decreased activity
tolerance, dyspnea, hypotension and dizziness with
an increased risk for syncope, or death. Diagnosis is
conducted via an electrocardiogram (ECG). Treatment
includes antiarrhythmic medication, lifestyle changes,
or surgically implanting a pacemaker.
47
Atherosclerosis: Arteriosclerosis is slow progressive
disease that is typied by a thickening and
hardening of the arteries. Atherosclerosis is a form of
arteriosclerosis that specically refers to an increase
in lipids, cholesterol, or other substances that
restrict arterial blood ow.
48
When mild it is usually
asymptomatic but as arteries deteriorate over time and
decrease in elasticity, the condition may gradually
limit blood ow to the heart muscle increasing the
risk of complications such as arrhythmias, angina,
peripheral artery disease, or stroke.
49
Arteriosclerosis
/ atherosclerosis is most commonly caused by
hypertension, high cholesterol, tobacco use, diabetes,
obesity, or inammation associated with conditions
such as arthritis or lupus. Additional risk factors
include aging, diabetes, a family history, poor diet,
and a sedentary lifestyle. Diagnosis is via a complete
physical and may include blood tests, a doppler
ultrasound, electrocardiogram (ECG), and/or a
stress test. Treatment includes medication, surgical
interventions, and lifestyle changes.
50
Atria: One of two upper heart chambers separated by
the septum. The right atrium receives deoxygenated
blood returning to the heart from the superior and
inferior venae cavae. The left atrium receives blood
returning from the pulmonary veins.
Bibasal consolidation: A radiological term that refers
to dense material, such as uid accumulation, in the
alveolar within the base of both lungs. It is commonly
associated with pneumonia and congestive heart
failure.
51
Blood pressure measurement: A diagnostic measure
used to determine the strength of the blood pushing
against blood vessels. Typically measured via the radial
artery by means of a gauge called sphygmomanometer,
which comprises of an inatable cuff, a measuring
unit, a bulb mechanism for ination, and a
stethoscope, or a digital version that uses electronic
calculations versus manual ination and reading. The
procedure measures two numbers. The higher number,
or systolic blood pressure, indicates the pressure in
OCCUPATIONAL THERAPISTS The Role of Occupational Therapy in Cardiac Rehabilitation | 11
the heart when it beats, while the lower number, or
diastolic reading, denotes the pressure in the heart at
rest in between beats.
52
Bradycardia: Abnormally slow heart rate. In adults,
it is typically under 60 beats per minute. Symptoms
may include fatigue, dizziness or light headedness,
confusion, or syncope.
53
Bronchospasm: An involuntary contraction of the
walls of the bronchi and bronchioles resulting in a
narrowing of the airway. It is most commonly the
result of an infection, allergen, or irritation or injury to
the mucosa. It is a key characteristic of asthma and is
often associated with a cough or wheezing.
54
Cardiac arrest: The abrupt loss of heart function
caused by a malfunction in the electrical system often
resulting from underlying abnormal or irregular heart
rhythms. More than 350,000 out of hospital cardiac
arrests occur each year in the United States. In many
cases, underlying heart disease is undiagnosed and
deaths can be unexpected and instant.
55
Cardiac cachexia: Often described as “body wasting,”
cardiac cachexia is a common complication of chronic
disease such as congestive heart failure. Weight loss is
unintentional and typically associated with decreased
appetite, nausea, poor absorption, and an increased
respiration rate that causes the body to burn additional
calories. Individuals often experience a generalized
loss of muscle mass that leads to signicant weakness
and fatigue and impacts activity tolerance and daily
function.
56
Cardiac catheterization: A 30-minute procedure used
to diagnose and treat cardiovascular conditions by
means of inserting a catheter into an artery or vein
in the groin, neck, or arm, which is then threaded
through the blood vessels to the heart. Contrast
material and imaging help to identify narrow
arteries or blockages, and if indicated, a non-surgical
intervention such as an angioplasty may also be
performed during the diagnostic procedure.
57
Cardioversion: A common procedure to restore
normal heart rhythm. In non-emergency situations,
chemical or pharmacological cardioversion may be
used via an IV. During electrical cardioversion shocks
are provided via electrodes to try and regulate the
heartbeat.
58
Catheter ablation: A low risk procedure commonly
used to treat cardiac arrhythmias, in particular
supraventricular tachycardia (SVT), when medication
has been unsuccessful. The procedure takes
approximately 2-4 hours and is conducted in a cath
lab. Catheter ablation selectively destroys the abnormal
tissue responsible for the rhythm problem without
damaging the rest of the heart.
59
Cheyne-Stokes respiration (CSR): Dened as a
periodic breathing pattern whereby episodes of apnea
alternate with hyperventilation. It is a common
characteristic of congestive heart failure, particularly
during sleep. The pattern typically occurs every
45 seconds to 3 minutes, and is considered a poor
prognostic sign.
60
Coronary angioplasty: See percutaneous coronary
intervention (PCI)
Coronary artery bypass graft (CABG): An established
cardiothoracic surgical procedure used to improve
blood ow to the heart by diverting blood around
narrowed or restricted arteries. It is typically used in
cases of severe heart disease, such as CAD, where a
build of plaque has narrowed arteries and is restricting
blood ow to the heart. During the procedure a heathy
artery or vein is harvested from the body and used as a
graft to bypass any blockages in the coronary arteries.
Surgery can be performed for multiple vessel disease
and typically requires a stay in the hospital with close
post-operative care. Mortality rate is low and many
individuals continue to live full, active lives although
physical, psychological, and social variables must be
considered and addressed.
61 62
Coronary occlusion: Refers to a complete obstruction
within a coronary artery interrupting the blood ow to
the heart and often resulting in a heart attack.
63
Debrillation: Delivery of a controlled electric shock
via an automated external debrillator (AED) in
order to restore normal cardiac rhythm during life-
threatening ventricular brillation. Early debrillation
is vital to increasing an individual’s survival rate after
sudden cardiac arrest.
57
Diuretics: Medication used to increase urine output
and excrete excess water and sodium from the body
thereby decreasing the amount of uid and pressure
in the blood vessels. They are commonly used to treat
high blood pressure and edema in heart failure. There
are three types of diuretics, each addressing different
needs with different side effects and precautions,
although they are considered generally safe.
64
Dyspnea: Shortness of breath or difculty breathing,
commonly an indicator of airway, lung, or heart
dysfunction. The most common respiratory diseases
associated with dyspnea include asthma, pneumonia,
and chronic obstructive pulmonary disease (COPD).
Red ags of particular concern include dyspnea at
rest, chest pain, wheezing, palpitations, and crackles
(suggestive of left sided heart failure or interstitial
lung disease). An appropriate history and physical is
required to determine severity, cause, and treatment.
65
Echocardiogram (echo): A non-invasive test that
uses sound waves to produce images of the heart and
determine the cause of heart disease. It is often used
to assess overall cardiac performance as well as more
specic concerns such as unexplained chest pain,
arrhythmias, or heart valve function.
66
| The Role of Occupational Therapy in Cardiac Rehabilitation OCCUPATIONAL THERAPISTS12
Ejection fraction (EF): A measurement of the
percentage of blood leaving the ventricles during
each contraction, often used to diagnose and track
heart failure. A normal EF reading is typically between
50-70%. An EF under 40% may be evidence of
heart failure. It is most commonly measured via an
echocardiogram.
67
Electrocardiogram (ECG or EKG): A painless
diagnostic test used to measure the heart’s electrical
activity via electrodes attached to specied areas
of your body. It is commonly performed to assess
unexplained chest pain, check the condition of the
heart in the context of disease such as hypertension,
high cholesterol, smoking, diabetes, and to diagnose
heart disease. Normal test results include a heart rate
of 60-100 beats per minute with a consistent, even
rhythm.
68
Hypercholesterolemia: More commonly referred to
as high cholesterol, hypercholesterolemia is an excess
of low-density lipoprotein (LDL) cholesterol in the
blood, which is linked to atherosclerosis and coronary
artery disease. Most individuals with high cholesterol
are asymptomatic, although over time the condition
may lead to signicant narrowing of arteries that may
trigger chest pain associated with angina. The most
common medical interventions are lifestyle changes,
including diet and exercise, and medications such
as statins, which are used to reduce the risk of heart
attack or stroke.
69
Implantable Cardioverter Debrilator (ICD): A small
battery powered device implanted under the skin in
the chest or abdomen to monitor heart rhythm, that
will also deliver a shock to restore normal rhythm if it
detects an individual going into sudden cardiac arrest.
The generator is the size of a pocket watch with ne
wires connecting it to the heart. If the ICD determines
that an individual is experiencing bradycardia it will
work as a pacemaker and send signals to the heart. If
the heart beat detected is too rapid or irregular, the ICD
will give debrillation shocks to stop the abnormal
rhythm. It is typically recommended if someone has
had a heart attack, survived a sudden cardiac arrest, has
ventricular arrhythmia, has congenital heart disease, or
any other condition that increases the risk for cardiac
arrest.
70
Infarct: An area of tissue that has been damaged or
has died as a result of inadequate blood supply to
the affected area. It may be the result of an arterial
blockage, rupture, or trauma.
54
Ischemia: Restriction of blood supply to tissue,
particularly the heart, preventing it from receiving
adequate oxygen.
54
METs (metabolic equivalents): A simple, practical
measure used to determine the amount of energy
expressed during physical activities. It can be measured
on a continuum from static to dynamic. For example,
one MET is roughly the equivalent of sitting quietly
while ten METs is typical of playing a game of
basketball. Despite its simplicity, it is considered a
convenient means of describing functional capacity
or activity tolerance for dened tasks so that an
individual may continue to participate in his or her
daily routine within prescribed intensity parameters.
71
Myocardium: The middle and thickest layer of
contractile cardiac muscle.
53
Nitroglycerin (nitro): A prescription medication
commonly used to treat angina as a result of coronary
artery disease. It works by relaxing blood vessels and
increasing blood ow to the heart while reducing
cardiac workload.
72
Orthopnea: Shortness of breath that occurs while an
individual is lying down but is relieved by assuming
an upright position. It is often caused by pulmonary
congestion as blood volume is redistributed from the
lower extremities to the lungs while in a recumbent
position, and is commonly associated with the early
stages of heart failure.
73
Pacemaker: A small device implanted in the chest
or abdomen to control abnormal heart rhythms. It
uses electrical pulses to prompt the heart to beat at a
normal rate if it detects irregularities.
74
Palpitations: The sensation of having a rapid,
uttering, or pounding heart, commonly associated
with stress, medication, or exercise. While typically
harmless, palpitations can also be associated with
arrhythmias that may require medical attention.
75
Percutaneous coronary intervention (PCI): A non-
surgical reperfusion procedure, also known as coronary
angioplasty, that uses a catheter to open an occluded
vessel or place a stent in order to improve blood ow to
the heart. PCI may be used to open coronary arteries if
there is narrowing of vessels or a blockage, and is also
the preferred reperfusion intervention for individuals
who have experienced a heart attack. It is most
commonly used with a ST-segment elevation myocardial
infarction (STEMI) provided it can be performed within
90 minutes of admission to the hospital.
76
Plaque: A fatty deposit made up of cholesterol, fat,
calcium, and other cellular waste substances in the
blood that may slowly build up and line the arterial
walls thereby restricting blood ow. If plaque breaks
off and blocks the artery risk of heart attack or stroke
increases.
77
Pleural effusions: An increase in uid accumulation
in the space between the pleura, the thin membrane
that lines the surface of the lungs. A pleural effusion
may be indicative of a number of conditions, including
congestive heart failure. Symptoms may include
shortness of breath, chest pain, and/or a cough. A
pleural effusion is typically detected via imaging, such
as a chest X-ray.
78
OCCUPATIONAL THERAPISTS The Role of Occupational Therapy in Cardiac Rehabilitation | 13
Rales: An abnormal respiratory sound, sometimes also
referred to as a crackle, heard during inhalation. It is
synonymous with a number of conditions, including
heart failure and pulmonary edema.
53
Saphenous vein: A large subcutaneous and supercial
vein in the leg, commonly harvested as a venous graft
in coronary bypass surgery.
53
Sinus rhythm: Normal heart rhythm established by
the sinus node, the heart’s natural pacemaker, found in
the right atrium.
79
Stent: A small wire mesh tube that is fed through a
catheter via a surgical procedure (angioplasty) in order
to open a blocked coronary artery and increase blood
ow.
80
Stress test: An assessment of cardiovascular tness in
a controlled clinical setting. The procedure typically
involves walking on a treadmill or riding a stationary
bike while heart rate, blood pressure, and respiration
rate are monitored. It is commonly used to diagnose
heart diseases such as coronary artery disease and
arrhythmias. It may also be used to monitor cardiac
treatment for effectiveness, particularly following
surgery such as valve replacement or the introduction
of medication.
81
Stroke volume (SV): The amount of blood pumped
from the left ventricle with each beat.
73
Syncope: A temporary loss of consciousness, often
called fainting, as a result of insufcient blood supply
to the brain. It is a characteristic of low blood pressure
and can also be symptomatic of stress, dehydration,
pain, exhaustion, and sudden changes in body
position. The risk of cardiovascular syncope increases
with age and may be a symptom of coronary artery
disease, myocardial infarction, cardiomyopathy,
arrhythmias, or angina. Additional symptoms
associated with cardiovascular syncope include
dyspnea, palpitations, and/or chest pressure or pain.
82
Tachyarrhythmia: A disturbance in the heart’s normal
rhythm resulting in a heart rate over 100 beats per
minute.
53
Telemetry: A means of electronically measuring
cardiac rhythms and heart rate via electrodes placed
on the patient’s chest. Blood pressure, respiration rate,
and oxygen may also be monitored if necessary using
a cuff and probe placed on a nger. The data is sent to
a central area where it is displayed on monitors and
read by staff. It is particularly indicated for patients
who require a higher level of care, including those with
arrhythmias or have undergone an ICD or pacemaker
procedure.
83
Thrombosis: The development or presence of a blood
clot in a vessel that has the potential to restrict or
block blood ow to the affected part of the body. It
is commonly dened by the type of vessel affected,
arterial or venous) and the location.
54
Ventricle: One of two lower heart chambers that
receives blood from the atriums, the upper chambers,
and pumps blood to the body. The right ventricle
supplies the lungs via the pulmonary artery, while the
left supplies the rest of the body via the aorta.
73
ROLE OF OCCUPATIONAL THERAPY
IN CARDIAC REHABILITATION
Overview of Occupational Therapy Philosophy
Occupational Therapy practice, education, research,
and advocacy is founded on the premise that
individuals, communities, and populations of all
age groups have the right to engage in meaningful
occupations throughout the lifespan. It is understood
that participation in occupation can be a conduit to
change and a means to foster health and well-being.
“Health enables people to pursue the tasks of everyday
living that provide them with life meaning that is
necessary for their well-being.”
84
Occupation is dened as any purposeful and
meaningful activity that enables participation in
society and supports the ability to live life to its fullest.
Occupational Therapists (OT) and Occupational
Therapy Assistants (OTA) consider both intrinsic
and extrinsic factors in determining interventions,
including psychosocial, cultural, physical, and
environmental issues, and use occupation as a means
to promote health and wellness.
85
OT/OTAs are trained in the areas of prevention,
life-style modication, and physical and
psychosocial rehabilitation.
86
Therapists work from
the understanding that many factors inuence
participation and performance, and that clients have
values, life experience, and skills that are invaluable
in developing meaningful short and long-term
goals. OT/OTAs understand that including the client
and caregivers in the decision-making process care
is empowering and that client-centered practice
fosters greater collaboration and participation in the
therapeutic process.
87
Additionally, interprofessional collaborative practice
is integral to providing safe, quality, accessible, and
client-centered care. Successful interprofessional
practice includes four competencies: understanding
one’s role and those of other professions to assess
and address the needs of clients and populations
served; maintaining a climate of mutual respect based
on shared values and ethical principles; providing
responsible and timely communication with clients,
caregivers, communities, and other healthcare
providers; and applying relationship-building values
to maintain healthy team roles in order to plan and
deliver effective client-centered health care.
88
Occupational Therapy plays a distinct role in
interprofessional practice and in the provision of
| The Role of Occupational Therapy in Cardiac Rehabilitation OCCUPATIONAL THERAPISTS14
client-centered care while addressing cardiac disease
across the continuum of care from acute care to
inpatient rehab to home care.
Typical Settings Associated with Occupational
Therapy and Cardiac Rehabilitation
Acute Care Hospitals:
Individuals are typically admitted to acute care
hospitals with signicant or life-threatening health
concerns requiring immediate medical diagnosis and/
or intervention, as well as 24-hour physician and
nursing care. An intensive care unit (ICU) is indicated
for those individuals who require advanced medical
care, which may include support after a myocardial
infarction (MI) or survival of sudden cardiac arrest.
Life-saving surgical interventions include percutaneous
coronary intervention (PCI) or angioplasty and
coronary artery bypass grafting (CABG), as well as
providing supportive measures for arrhythmias and
congestive heart failure (CHF) exacerbations.
OT/OTAs are increasingly assuming a more active
role in acute care settings with an emphasis on early
mobilization, monitoring of vitals with activity,
client and caregiver education, restoring function,
and performing evaluations to assist with the
coordination of care and to determine appropriate
discharge recommendations. OT/OTAs work within
an interprofessional team that may include members
from medicine, nursing, respiratory therapy, case
management, physical therapy, speech and language
pathology, social work, and spiritual care.
Long-term Acute Care (LTAC):
In some cases, individuals require ongoing medical
care while beginning rehabilitation. In these instances,
individuals may have experienced a prolonged and/or
complex hospital course or may remain signicantly
impaired requiring 24-hour care. In these cases, a long-
term acute care facility may be indicated as a bridge
between acute care and rehabilitation or home.
As successful critical care intervention increases and
mortality rates decline, the number of individuals
surviving but experiencing long-lasting complications
is on the rise. These include chronically impaired
cardiopulmonary function, neuromuscular weakness,
and cognitive impairments, as well as anxiety and
depression. It is important for all members of the
interprofessional team to understand these additional
complications while addressing the more common
impairments associated with cardiac disorders.
89
Common cardiac conditions encountered in long-
term acute care include complications from CABG
surgery, including non-healing incision, and end stage
congestive heart failure (CHF) including failure to
thrive. Occupational therapy provides evaluations and
develops client-centered short- and long-term goals
that may address ADL and IADL re-training, as well as
education that includes safety, energy-conservation
strategies, and cognitive impairments. Therapists
are also involved in caregiver training and discharge
planning. OT/OTAs work within an interprofessional
team that may include members from medicine,
nursing, respiratory and/or pulmonary therapy, case
management, physical therapy, speech and language
pathology, social work, and spiritual care.
Inpatient Rehab and Skilled Nursing Facilities (SNF):
Given the number of admissions to acute care facilities
that are associated with chronic cardiac conditions,
such as CAD and arrhythmia, as well as health crises
that are acute in nature, such as CHF exacerbations and
myocardial infarctions, individuals are often referred
to inpatient rehabilitation facilities. The primary focus
of OT in short-term rehab is to promote strength,
endurance, and mobility within the context of ADL
and IADL re-training, and provide client/caregiver
education, including energy conservation strategies,
in order to manage conditions at home and in the
community upon discharge.
OT/OTAs work within an interprofessional team that
may include members from medicine, nursing, case
management, physical therapy, speech-language
pathology, social work, and spiritual care.
Home Care, Including Independent and Assisted
Living Facilities (ILF and ALF):
Upon discharge from either acute care, inpatient rehab,
or long-term acute care settings, clients may benet
from continued OT services to maximize functional
independence within the context of their own homes.
Therapists often continue to provide ADL and IADL
re-training, as well as safety and energy-conservation
education while supporting caregivers during this
transitional period.
The most common cardiac conditions addressed in
home care or independent/assisted living facilities
are related to CHF exacerbations and post surgical
interventions, such as CABG. However, OT/OTAs
may also assist clients who have experienced a
prolonged hospitalization with failure to thrive, or
more signicant cardiac events, such as myocardial
infarction.
Occupational therapy works within an
interprofessional team that may include members from
medicine, nursing, physical therapy, speech-language
pathology, as well as independent/assisted living staff.
Outpatient Cardiac Rehab:
OTs have a distinct role in outpatient cardiac
rehab programs with clinicians working within
an interdisciplinary team to address the needs of
clients with chronic cardiac conditions or with those
recovering from acute events such as CABG surgery
or myocardial infarction. OT/OTAs typically assess an
OCCUPATIONAL THERAPISTS The Role of Occupational Therapy in Cardiac Rehabilitation | 15
individual’s ability to perform meaningful ADLs and
IADLs in a satisfactory manner, develop individualized
treatment plans, and collaborate with the client and
caregivers to establish goals and provide education to
manage conditions at home and in the community.
OT Process –
From Evaluation to Discharge
OT Evaluations and Screening Tools that May
be used in Cardiac Rehabilitation
Evaluation Process:
An OT evaluation is indicated when there are concerns
regarding an individual’s functional ability to perform
the activities that are meaningful and necessary
to live life to its fullest. In order to understand an
individual’s performance strengths and limitations,
an OT will use his/her clinical reasoning skills to
perform an evaluation that may include a synthesis of
formal standardized assessment tools, medical data,
informal observation and interview techniques, as
well as interprofessional communication. In addition
to performance skills impacting motor, cognitive
processing, and/or social interaction, client factors
and performance patterns, such as values and beliefs
and roles and routines, as well as environmental and
contextual factors are also considered in OT’s holistic
approach to care.
By synthesizing all pertinent data, the OT is able to
develop an occupational prole that will guide the
plan of care. This includes collaborating with the client
and/or caregiver to determine his or her priorities
regarding outcomes in order to develop objective
and measurable goals that are meaningful and client-
centered. Once the goals have been established,
interventions may be determined to execute the plan
of care.
90
ADLs:
Functional Independence Measure (FIM
): A system of
measuring dysfunction appropriate for varied settings
including sub-acute and rehabilitation facilities, long-
term care hospitals, and skilled nursing facilities. It
determines the degree of assistance required for an
individual to perform his or her ADLs and is typically
completed upon admission and discharge. The
tool assesses 18 areas of ADLs, including 13 motor
and 5 cognitive items. Performance areas are rated
on a 7-point scale ranging from total assistance to
independence. Every facility has its own processes in
place for administering the FIM; however, OTs will
most commonly address the performance areas of
eating, grooming, bathing, upper body dressing, lower
body dressing, toileting, toilet transfer, shower transfer,
problem-solving and memory.
91
FIM levels:
7 = Independence (timely, safely)
6 = Modied independence (device, increased
time)
5 = Supervision (cuing, prompting)
4 = Minimal assistance (performs 75% or more of
task)
3 = Moderate assistance (performs approximately
50-74% of task)
2 = Maximal assistance (performs approximately
25-49% of task)
1 = Total assistance (performs less than 25% of
task)
0 = Activity does not occur (only used upon
admission)
91
Barthel Index (BI): A 10 item ordinal scale used to
measure ADL performance that is most commonly
used in inpatient rehabilitation, skilled nursing
facilities, and home care. Each of the 10 items
describes performance in feeding, bathing, grooming,
dressing, bowel control, bladder control, toileting,
chair transfer, ambulation, and stair climbing. Each
performance item has a designated score. A higher
total score is associated with the increased likelihood
of an individual successfully and safely living at home
independently.
92
BI sample performance items and rating scale:
Grooming
0 = needs help with personal care
5 = independent face/hair/teeth/shaving
(implements provided)
Dressing
0 = dependent
5 = needs help but can do about half unaided
10 = independent (including buttons, zips, laces,
etc.)
Transfers (bed to/from chair)
0 = unable, no sitting balance
5 = major help (one of two people, physical)
10 = minor help (verbal or physical)
15 = independent
92
ADLs/IADLs:
Canadian Occupational Performance Measure (COPM): An
evidence-based, client-centered outcome tool designed
to reect an individual’s satisfaction with ADL and/
or IADL performance. It is primarily administered by
OTs and can be used across the lifespan with all clients,
| The Role of Occupational Therapy in Cardiac Rehabilitation OCCUPATIONAL THERAPISTS16
regardless of diagnosis or setting. The COPM enables
individuals to self-assess performance, prioritize areas
to address, and collaborate with their therapist to
identify goals. Administration is conducted via a semi-
structured interview format and is recommended at
the beginning of services and periodically thereafter to
monitor progress towards outcomes. The tool has ve
key steps: The client is asked to identify performance
areas that are challenging, rate the importance of each
identied area using a 10-point scale, and then select
up to 5 of the most important problems to address
through therapy. The client is then asked to self-assess
their own level of performance and satisfaction with
each of the identied problem areas. The therapist
then calculates an average score, typically between
1-10. A low score indicates poor performance and
lower satisfaction with a higher score indicative of
good performance and a higher level of satisfaction.
93
Satisfaction with Performance Scaled Questionnaire (SPSQ):
An instrument developed to measure an individual’s
performance satisfaction with their independent
living skills. The tool is a self-report questionnaire and
consists of two subscales. Subscale I identies 24 items
associated with home management, such as using a
stove, handling a milk carton, and cleaning the tub
or shower stall. Subscale II contains 22 items related
to social and community activities, including paying
bills and participating in vocational, educational, and
leisure tasks. Each item is scored on a 5-point scale
using the percentage of time over the past six months
to report performance satisfaction.
94
Stress Management:
Stress Management Questionnaire (SMQ): A valid and
reliable tool designed to help individuals determine
their personal stressors before exploring appropriate
coping strategies to minimize the symptoms associated
with stress. The questionnaire is a self-scoring tool
that takes approximately 20 minutes to complete and
consists of 87 psychometrically designed questions that
uses a 5 point Likert scale.
95
Resilience Scale for Adults (RSA): A 25-item, self-report,
7-point Likert scale tool used to assess resilience in
adults, including their ability to adjust successfully
after a major life event. The Likert scale is based on
ve characteristics of resiliency that include the ability
to accept self/life, personal competence, self-reliance,
meaning, equanimity, perseverance, and existential
aloneness.
96
Interest Checklist: A simple measure used to glean
information on a client’s strength of interest and
engagement in 68 varied activities in order to help
them select meaningful activities as a leisure pursuit or
manage stress.
97
Exercise/Activity Intensity:
Borg Rating of Perceived Exertion Scale (RPE): A self-
assessment tool used by individuals to measure
their perceived intensity of an exercise or activity.
Individuals are asked to estimate the degree of exertion
required during an activity using a 0-10 scale where 0
equals no perceived exertion and 10 indicates maximal
exertion.
98
Cognition:
The Mini Mental State Examination (MMSE): A 30-point
questionnaire designed to measure cognitive
impairment, most commonly used as a screen for
dementia but can be used to estimate cognitive
impairment associated with illness or injury. The
tool typically takes approximately 5-10 minutes
to administer and assesses cognitive areas such as
attention, recall, language, repetition, orientation,
calculation, and ability to follow directions. One point
is given to each correct response with a score equaling
or greater than 24 points out of 30 indicating normal
cognition. A score of 19-23 indicates mild cognitive
impairment, a score of 10-18 suggests moderate
impairment, with a score equal or below 9 points
indicative of severe cognitive decits.
99
MMSE sample questions:
• What is the year? Season? Date? Day? Month?
(Maximum score = 5)
• The examiner names three unrelated objects
clearly and slowly, then asks the patient to
name all three of them. The patient’s response
is used for scoring. The examiner repeats them
until the patient learns all of them, if possible.
(Maximum score = 3)
• “I would like you to count backward from 100
by sevens.” (93, 86, 79, 72, 65…) Alternative:
“Spell WORLD backwards.” (D-L-R-O-W).
(Maximum score = 5)
• “Repeat the the phrase: “No ifs, ands, or buts.”
(Maximum score = 1)
• “Make up and write a sentence about
anything.” (This sentence must contain a noun
and a verb.) (Maximum score = 1)
99
Short Portable Mental Status Questionnaire test (SPMSQ):
A short 10-item standardized assessment tool designed
to detect intellectual impairment, particularly in the
elderly. Incorrect responses are tallied to provide an
indication of cognitive impairment. For example,
0-2 errors indicate normal mental functioning, 3-4
errors indicate mild cognitive impairment, 5-7 errors
suggest moderate impairment, and 8 or more errors are
associated with severe decits.
100
SPMSQ sample questions:
• What is the date, month, and year?
• What is the name of this place?
• How old are you?
• What year were you born?
OCCUPATIONAL THERAPISTS The Role of Occupational Therapy in Cardiac Rehabilitation | 17
• Who is the current president?
• Who was the president before that?
100
OT Interventions and Education that
May be used in Cardiac Rehabilitation
Intervention process:
Cardiac rehabilitation typically involves an
interdisciplinary approach and refers to a structured
program of therapeutic exercise, functional
participation, and client education to manage recovery
and optimize function. Following a cardiac event, there
are typically four phases of recovery. Phase I is the
acute phase where an individual may receive care in an
ICU or step down cardiac unit following a signicant
cardiac event such as a myocardial infarction or open
heart surgery. Phases II and III typically occur in a sub-
acute setting, rehab facility, or outpatient unit where
an individual can receive more intensive therapy
and education. Phase IV focuses on empowering
individuals to apply their knowledge and assume
responsibility for maintaining optimal health and
functional independence.
Once the initial evaluation process is complete, and
objective, measurable goals have been determined,
OTs develop an individualized treatment plan tailored
to meet individual needs that also incorporates
anticipated outcomes and methods. Discharge and
long-term needs are also considered, along with
recommendations to other professionals if needed. The
plan of care typically includes meaningful occupation-
based interventions such as skill training and
education, but may also include preparatory methods
to facilitate performance. The client’s response to
therapy is monitored throughout the process and
modied as needed.
84
85
Early mobilization: A process of passive, active, and
progressive movement during critical illness to
counter the effects of sedation and immobility that
may lead to neurocognitive decits and physical
debilitation. It may be performed by any member
of the interdisciplinary team, including OTs. Early
mobilization typically occurs in acute care settings,
particularly in the ICU with critically ill patients,
but may also be relevant in long-term acute care or
sub-acute settings when the client has experienced
a prolonged or complex hospital course after critical
illness and remains signicantly debilitated. Evidence
indicates that limited mobility is a signicant
contributor to long-term health issues including
muscle weakness, delirium and cognitive impairments,
and joint shortening. Research suggests that safe and
appropriate early mobility can signicantly improve
functional outcomes.
101
Activities of daily living (ADL) re-training: Clients
experiencing cardiac events or chronic conditions
commonly nd their ability to perform basic ADLs
compromised by fatigue, dyspnea and decreased
activity tolerance. OT/OTAs provide interventions to
address tasks that are typically performed on a daily
basis and are considered essential to an individual’s
ability to live life to its fullest. ADLs include bathing/
showering, grooming, dressing/undressing, toileting
including hygiene, eating, sexual activity, and the
ability to perform functional mobility.
86
In caring
for clients with cardiac-related disorders, energy
conservation techniques are commonly embedded
into ADL re-training. For example, the OT/OTA may
provide recommendations to modify tasks, such
as adjusting body mechanics to minimize fatigue
and work of breathing, or may suggest altering the
environment to reduce extraneous effort and decrease
activity demand. Therapists will also educate the client
or caregiver regarding the use of adaptive equipment
(AE) to maximize functional independence, such a
long-handled shoe or sock aide, or the use of durable
medical equipment (DME), such as a tub seat for seated
showers. The ability to complete ADL tasks safely
is also a consideration and appropriate education is
provided to both client and caregiver.
Instrumental activities of daily living (IADL) re-training:
IADLs include activities that support daily life and
enable an individual to successfully live life to its
fullest and interact with his/her environment and
community. Examples of IADLs include home
management, shopping, meal preparation, driving
and community mobility, pet care, nancial
management, medication management, care of
others, leisure tasks, employment, education, rest/
sleep, and social participation.
86
The OT/OTA may
provide recommendations to modify tasks or alter the
environment to reduce extraneous effort and decrease
activity demand. Energy conservation techniques are
commonly embedded into IADL re-training. Examples
of recommendations include making larger meals
to freeze, letting dishes air dry, grouping task items
together to minimize unnecessary searches, sliding
rather than carrying items, shopping with someone
who can carry grocery bags, or using grocery home
delivery services.
Activity tolerance and energy conservation techniques:
Fatigue, shortness of breath, and limited endurance
are common factors that may limit performance and
participation. OT/OTAs address strategies to modify
tasks, and make recommendations regarding the use of
assisted devices (AD) and/or adaptive equipment (AE)
to reduce effort associated with the performance of
daily routines in order to minimize fatigue, shortness
of breath, and work of breathing. Energy conservation
education emphasizes prioritizing, planning, and
organizing tasks. This may include simple strategies
such as eliminating unnecessary steps, sitting versus
standing if possible, setting up task equipment in
advance to minimize extraneous effort, and using
lightweight tools or utensils. Additionally, clients are
encouraged to self-assess symptoms, pace themselves
| The Role of Occupational Therapy in Cardiac Rehabilitation OCCUPATIONAL THERAPISTS18
through activities, and take rest breaks prior to
experiencing fatigue.
Cardiac/sternal precautions: Sternal precautions are
typically recommended after open heart surgery,
such as a coronary artery bypass graft (CABG), where
a median sternotomy is performed. During this
procedure, the sternum is cut in two before being
repaired after the intervention has been completed.
While there are some inconsistencies between facilities
with regard to post-operative restrictions, the most
common sternal precautions include the following,
recommended for 6-8 weeks following surgery or until
cleared by the health care team:
102
• No lifting anything over 5lbs
• No excessive twisting or turning of the body
• No pushing or pulling (this includes using
upper extremities to push/pull up in bed. Log-
rolling technique is recommended)
• Avoid simultaneous bilateral upper extremity
shoulder exion or abduction above 90
degrees. Okay to perform unilateral active
range of motion (ROM) as tolerated to perform
functional tasks
• Minimize upper extremity weight-bearing
when using adaptive equipment like canes and
walkers
• Encourage chest splinting using a pillow when
coughing
• No driving until cleared by surgeon
103
Permanent pacemakers and implantable cardiac
debrillators (ICD) are surgically implanted to
maintain a normal heart rate and prevent life-
threatening arrhythmias, and require 4-6 weeks of
post surgical precautions to ensure incision healing.
Recommendations include:
104
• No exercise to the involved shoulder, although
it may be used functionally as tolerated but
limited to exion and abduction to 90 degrees
/ shoulder level
• Minimize upper extremity weight-bearing
when using adaptive equipment like canes and
walkers. Crutches are not recommended
• No lifting anything over 5lbs with affected
extremity
• No driving until cleared by surgeon
105
While it is the responsibility of every member of
the interdisciplinary team to ensure precautions are
adhered to, the restrictions are particularly relevant in
OT where ADLs and IADLs are addressed and use of the
upper extremities and full body movement are integral
to task performance.
Edema/weight management: Edema is a common
complication of congestive heart failure (CHF) and
occurs as a result of sodium and water reabsorption by
the kidneys and expansion of the extracellular uid.
Edema in the lower extremities, or peripheral edema,
is more noticeable, but edema can also impact the
abdominal cavity, known as ascites. It is important for
individuals to know their dry weight, which is their
baseline weight without edema, and to perform daily
weight checks to monitor uid retention, which may
be reected by an increase in weight as well as fatigue
and shortness of breath.
105
It is the responsibility of
all members of the interdisciplinary team to monitor
edema and provide client education regarding disease
management. Empowering individuals to manage
their own chronic conditions can reduce hospital
readmissions. OTs are able to identify barriers to
weight/edema management and recommend strategies
to increase responsibility and maximize independence.
Additionally, the prevalence of lower extremity edema
and the risk of developing a deep vein thrombosis
(DVT) increases among those in rehabilitation
following cardiac surgery such as coronary artery
bypass graft (CABG).
106
OTs are able to measure and
educate clients on appropriate compression garments
as well as provide strategies to don stockings using
compensatory strategies and/or adaptive equipment.
Stress management / relaxation strategies: Stress,
anxiety, and depression are common by-products of
cardiac disorders and life-threatening events, such
as myocardial infarction or coronary artery bypass
surgery. Providing education to help individuals
manage their symptoms in the context of daily
routines is an important step in lessening anxiety and
promoting participation in the treatment program.
Interventions include strategies to help clients
prioritize activities and create a balanced lifestyle,
increase awareness of body and mind interaction to
manage stressors and perform daily activities with
more condence, and provide education on a variety
of relaxation methods. These include guided imagery,
progressive muscle relaxation, and diaphragmatic
breathing.
107 108
Therapeutic exercise programs / upper extremity function:
Prolonged hospitalization and chronic cardiac
conditions frequently impact muscle strength, and
in turn, may limit participation and/or performance
in functional activities. For example, individuals who
have experienced critical illness may present with
signicant muscle weakness. Providing education
for body mechanics, stretching, and an appropriate
exercise program can be invaluable to the process of
improving aerobic capacity, reducing O2 requirements
if applicable, minimizing pain, and increasing
performance in functional tasks.
109
OCCUPATIONAL THERAPISTS The Role of Occupational Therapy in Cardiac Rehabilitation | 19
OT Considerations for Safe Discharge Planning
While each discipline involved in an individual’s care
will contribute specic information according to their
professional expertise, discharge planning is typically
an interdisciplinary effort ensure safe transitions.
OT provides a distinct perspective on the client’s
functional status, including the individual’s ability
to safely perform ADLs, IADLs, and mobility, with
recommendations for the continuum of care including
the potential need for equipment, home modications,
or further services.
83
Safety / home O2 management: OT/OTAs address home
safety training that may include recommendations
for environmental modications, such as grab bar
installation, the removal of scatter rugs, and the
improvement of lighting. Education also focuses on
fall prevention training and emergency responses,
safe O2 tank use and O2 cord management training if
applicable, as well as caregiver education to support a
safe transition.
Health / wellness at home and in the community:
Education includes medication management training,
exploration of healthy leisure pursuits for the home
and/or the community to promote lifestyle balance,
information regarding community resources, such
as tness groups, diet, nutritional, and weight loss
education, and smoking cessation, as well as caregiver
education to support a safe transition. Community
resources and support may also be indicated in cases
of depression, commonly associated with a decline in
cardiac health or when signicant lifestyle changes are
necessary, or post-operatively, such as coronary artery
bypass graft (CABG).
110
Common Client / Caregiver Questions
Q. Are there any restrictions to lifting weights after heart
surgery?
A. Typically, no lifting over 5lbs is recommended for
approximately 2 months. A gallon of milk weighs
8lbs.
Q. Will I be depressed after heart surgery?
A. Cardiac surgery, such as a coronary artery bypass
graft (CABG), is considered major surgery and
requires a period of recovery where participation
in regular, meaningful activities is limited. It
is common to experience varying degrees of
frustration, anxiety, and depression and it’s
important to discuss supportive measures with the
healthcare team.
Q. When can I drive my car again after heart surgery?
A. This will depend on the surgeon’s recommendations,
but is typically 3-4 weeks after surgery.
Q. When can I go back to work after heart surgery?
A. It depends on the type of work. Some individuals
may be able to return to a desk job approximately
2-3 weeks after a MI or 4 weeks after a CABG
without any post-operative complications. For
others who have a more physically demanding job,
it may take 8-12 weeks. It is essential to discuss
returning to work with the medical team.
Q. When can I travel again after heart surgery?
A. Airline travel is often permitted within 1-2 months
after discharge from the hospital. It is important to
consider the activity demand required to travel and
discuss plans with a physician. For example, it is
important to be aware of the impact associated with
stressful business trips, long distance walking, and
stair climbing.
Q. Can I travel with CHF?
A. Generally, individuals whose symptoms are poorly
controlled should avoid locations with high altitude
as they are more likely to experience an increase
in shortness of breath and fatigue. The stress and
activity demand of travel should also be considered,
as well as the need for prolonged sitting during long
haul ights to minimize the development of blood
clots. It is important to discuss all travel plans with a
physician.
Q. What are the red ags I should look out for with CHF?
A. The three key symptoms to look out for include
uid build-up/edema, arrhythmias, and increased
shortness of breath.
Q. I have cardiac problems, is it really necessary for me to
quit smoking?
A. Smoking has been strongly associated with heart
disease and death. It signicantly increases blood
pressure, damages blood vessels and restricts blood
ow to the heart, as well as increasing the risk of
blood clots.
CASE STUDY #1
Hypertension (HTN) / Myocardial infarction
(MI) (Acute care setting)
History of presenting information (HPI):
Mr. S. is a 70-year old active male with a past medical
history signicant for hypertension (HTN), coronary
artery disease (CAD) and hypercholesterolemia with
a remote history of tobacco use who presented to
the Emergency Room following 35 minutes of chest
pain that was not relieved by nitroglycerin. Upon
admission, Mr. S. appeared restless and diaphoretic
and reported ongoing chest pressure with a rapid,
irregular heart rate. His blood pressure was 170/94
with a pulse of 112 at rest, a respiration rate of 24,
and an oxygen saturation of 97%. An ECG and blood
draws to measure cardiac markers in the bloodstream
| The Role of Occupational Therapy in Cardiac Rehabilitation OCCUPATIONAL THERAPISTS20
indicated that Mr. S. had experienced a ST-segment
elevation myocardial infarction (STEMI) and he was
also experiencing tachyarrythmias. He underwent a
percutaneous coronary intervention (PCI) to open
the occluded vessels with stent placement, and an
implantable cardioverter debrillator (ICD) procedure
to manage his arrhythmia and minimize the risk of
further cardiac events. There were no post-operative
complications and after 2 days in intensive care, Mr. S.
was transferred to a cardiac step down unit.
Reason for OT Referral:
Mr. S. tolerated both the PCI and ICD procedures well.
While still being monitored, he is considered medically
stable to begin phase one of his cardiac rehabilitation,
including education from the interprofessional team.
He is being referred to occupational therapy services to
assess his current functional status, develop a plan of
care, and help him return to his baseline independent
level of function. Mr. S. informs his team that his goals
are to return home to his wife who requires care and to
return to work.
OT Initial Assessment:
The initial evaluation is conducted in Mr. S.’s room
on the step down unit. His pulse and cardiac rhythms
are being monitored via telemetry and he is receiving
2L oxygen via a nasal cannula. He appears relaxed
and is resting in a bedside chair wearing a hospital
gown and pants. When asked, he reports mild fatigue
and 3/10 pain at his incision site but is agreeable to
participate in the OT evaluation. His prior level of
function, current status, and personal goals for therapy
are assessed via an informal interview, observation,
and the Functional Independence Measure (FIM) to
determine a baseline for ADLs.
Mr. S. was diagnosed with HTN 20 years ago and
CAD approximately 5 years ago. He has attempted
to manage both conditions by actively participating
in lifestyle changes that included modifying his diet,
stopping smoking, and incorporating an exercise
regimen into his daily routine. He reports feeling
disappointed that he still had a heart attack and is
now motivated to participate in cardiac education to
decrease the risk of future events. He lives with his wife
in a 2 level home with the laundry in the basement.
He has two steps to enter the house with bilateral rails.
His bedroom and bathroom is on the second oor,
and he typically uses a tub/shower combo for standing
level showers. Mr. S. reports that his wife has COPD
and in the past year underwent a hip replacement,
so grab rails were installed and a tub seat is available.
Otherwise, he has no other equipment. Prior to this
hospitalization he was independent with all ADLs, he
ambulated without an assistive device (AD), and was
still driving. He works for H&R Block approximately
32 hours a week but often works more than that. He
shares grocery shopping, meal prep, and the laundry
with his wife, and they have a housekeeper 1 x pw. Mr.
S. likes to go to the gym at least 3 x pw and play tennis
during the summer. He has a golden retriever dog and
is responsible for walking her.
During the evaluation, Mr. S. participated in ADL tasks
to assess his response to increased activity demand,
his functional status, and to begin his cardiac rehab
education. He was encouraged to participate in
physical activity as tolerated to maintain strength
and endurance as well as increase his functional
independence in preparation for a safe discharge
home. He was educated about pacemaker precautions
and how to apply the restrictions, particularly while
bathing and dressing. He was able to complete all ADLs
with close supervision (CLS) while being monitored
for vitals, safety, precautions, and fatigue. He tolerated
4 minutes standing sink-side to perform grooming
tasks but benetted from sitting for approximately
75% of the time while performing a sponge-bathing
routine. He required a 10 minute seated rest break
before dressing into a hospital robe, pants, and socks.
He was able to ambulate to/from the bathroom and
perform toileting tasks with CLS and without an
assisted device (AD) but benetted from verbal cues for
pacing and O2 cord management. The Mini Mental
State Examination (MMSE) was used to assess cognition
and provide a baseline for learning potential. Mr. S.
was alert and oriented x 3, able to follow multi-step
directions, and both short- and long-term memory
was intact. Throughout the evaluation process, Mr. S.
demonstrated good problem-solving and capacity for
new learning.
OT Problem List:
• Limited activity tolerance impacting mobility
and participation in ADLs/IADLs
• Limited knowledge of energy-conservation
education, and effective pacing strategies
• Limited knowledge of pacemaker precautions
with ADLs and IADLs
• Limited knowledge of recommended lifestyle
modications required to minimize further
cardiac events
• Limited knowledge of community-based
resources
OT Plan of Care (POC):
Anticipated length of stay: 4-7 days
Duration and frequency of OT sessions: 3-4 x 20-40
minute visits.
OT Goals: Anticipated timeframe to meet goals - 3-5
days (STGs = LTGs)
• Patient will independently (I) recall pacemaker
precautions
• Patient will Independently (I) complete shower
routine sitting/standing as tolerated with good
OCCUPATIONAL THERAPISTS The Role of Occupational Therapy in Cardiac Rehabilitation | 21
application of energy conservation strategies
and pacemaker precautions
• Patient will Independently (I) complete
dressing routine sitting/standing as tolerated
with good application of energy conservation
strategies and pacemaker precautions
• Patient will independently (I) complete safe
tub transfer with appropriate use of durable
medical equipment as needed and application
of pacemaker precautions
• Patient will independently (I) complete all
steps of toileting routine with good application
of energy conservation strategies and
pacemaker precautions
• Patient will tolerate 20 minutes continuous
standing while independently (I) performing
grooming routine
• Patient will participate in disease management
and lifestyle modication education
Interprofessional Communication:
Physical Therapy (PT): Discussed Mr. S.’s OT plan of
care including functional goals and education in order
to develop a coordinated, collaborative effort with PT
to build strength, activity tolerance, and functional
mobility. Participated in daily communication to
provide updates, reinforce consistent educational
material, and coordinate efforts to minimize schedule
conicts.
Nursing: Discussed Mr. S.’s ADL goals and provided
rationale for application of energy conservation
skills to improve his functional status and perform
his bathing, dressing, and toileting tasks at an
independent level by discharge. Participated in daily
communication to determine current clinical status.
Cardiologist: Discussed evaluation results and discharge
goals, including lifestyle changes. Provided ongoing
updates throughout Mr. S.’s stay regarding his
functional status and vitals, as well as his progress
towards discharge goals.
Care Coordinator: Ongoing communication throughout
Mr. S.’s hospitalization regarding his OT plan of care,
goals, and recommendations for a safe discharge home
and cardiac rehab.
Interventions:
Mr. S.’s plan of care focused on increasing activity
tolerance and cardiac education via ADLs and mobility
in order to maximize his functional independence
and minimize the potential for future cardiac events.
Education included disease management, energy
conservation skills, and application of pacemaker
precautions.
Mr. S. was educated regarding the importance of
early mobilization after surgery but encouraged
to pace himself throughout the day and prioritize
activities. In order to perform his tasks more efciently
and with less fatigue while continuing to build
endurance he was instructed in energy conservation
strategies. He was also educated regarding appropriate
body mechanics to complete his ADL tasks while
maintaining his pacemaker precautions. Once he had
mastered his daily ADL routine more efciently, safely,
and independently, he was educated in the application
of energy conservation strategies and pacemaker
precautions via his typical IADLs. Mr. S. was introduced
to metabolic equivalents (METs), a measure used to
describe activity tolerance for dened tasks so that he
could continue to participate in his meaningful daily
tasks while maintaining intensity parameters set by his
cardiology team.
Disease management education included identifying
risk factors, stress management strategies, dietary
modications, and good sleep hygiene. The benets
of cardiac rehab were explained to Mr. S. who was
encouraged to participate in a program after discharge.
The value of ongoing education, psychological support,
as well as a tailored and monitored physical exercise
regimen was stressed and Mr. S. seemed motivated to
participate.
Discharge:
Mr. S. was discharged home after 5 days having been
deemed medically stable by his cardiology team and
having met all of his discharge goals for therapy. While
still experiencing limited endurance, he returned home
at an independent level for mobility, ADLs, and simple
IADLs. He agreed to cardiac rehab upon discharge to
continue his education and build activity tolerance in a
supportive environment. His long-term goals included
participation in higher level IADLs and ultimately
return to work.
CASE STUDY #2
Coronary artery disease (CAD) / Coronary
artery bypass graft (CABG) - Short-term Rehab
Setting
History of presenting information (HPI):
Mr. P. is a 58-year old male with a past medical history
signicant for hypertension (HTN), coronary artery
disease (CAD), hypercholesterolemia, obesity, R total
knee replacement, with a 40-year tobacco history
(1 pack per day) who developed chest pain due to
angina while at work. He was treated on site with
nitroglycerin and oxygen before being transported by
EMTs to the local emergency room. Upon admission
his blood pressure was 162/102 with a heart rate
of 96 at rest, a respiration rate of 22, and an O2
saturation of 92%. He underwent an ECG and cardiac
catheterization to identify arterial blockages, and
subsequently underwent surgery for a coronary artery
| The Role of Occupational Therapy in Cardiac Rehabilitation OCCUPATIONAL THERAPISTS22
bypass graft (CABG) x 4. The great long saphenous
vein (GSV) was harvested for grafting during the
procedure. Mr. P. initially tolerated the surgery well but
then experienced an episode of ab, as well as lower
extremity edema and signicant pain that impacted
his early mobilization and recovery. Once medically
stable, Mr. P.’s interdisciplinary team determined that
he would benet from additional medical management
and rehab at a skilled nursing facility prior to discharge
home.
Reason for OT Referral:
In addition to decreased strength, endurance, and
reduced functional mobility, Mr. P. has ongoing
discomfort at both sternal and graft sites and he
is functioning signicantly below his baseline. He
is in the process of a divorce and lives alone, and
must be independent with all ADLs and many IADLs
before returning home. He is being referred to OT for
evaluation in order to assess his current status, develop
a plan of care, and provide appropriate interventions
and education to support a safe discharge home. His
long-term plan is to return to work.
OT Initial Assessment:
The evaluation to ascertain Mr. P.’s background and
current functional status is conducted in his room via
informal interview, observation, and the Functional
Independence Measure (FIM). Mr. P. is an overweight
male wearing a hospital gown and socks and is greeted
sitting in a bedside chair with his lower extremities
elevated. He is reading through some paperwork but
appears comfortable. He reports fatigue and 4/10 pain
at his graft site but agrees to participate as tolerated.
His sternum is covered with a protective dressing while
his lower extremity incision is open to the air with
staples visible.
Mr. P. states that he is in the process of “a messy and
expensive divorce” which has added to his stress
lately. He has two adult children who live and work
out of state. He is determined to return home at an
independent level rather than ask for help from his
ex-wife or family. He works approximately 60 hours
a week in the retail industry, which he reports is also
highly stressful. He lives in a second oor single level
condo with one ight of stairs to enter and bilateral
rails. His bathroom has a tub/shower combo but he has
no equipment or grab rails installed. Prior to surgery,
he was independent (I) with all mobility without an
assistive device, and all ADLs and IADLs, including
laundry, housekeeping tasks, grocery shopping, and
meal prep. However, Mr. P. admits to eating a lot
of take-out food lately because of his workload and
divorce. He also reports that he is generally very
sedentary even though he knows he should be making
healthier decisions due to his heart condition. He has
not taken a vacation in 6 years and cites watching
sports on TV as his only leisure interest.
During the initial OT evaluation, Mr. P. appeared
fatigued with any moderate increase in activity
demand although his vitals were stable and he only
reported a mild increase in pain at his graft site with
movement. He was able to perform bed mobility and
a sit-stand transfers to a rolling walker (RW) with
supervision and benetted from several verbal cues
not to push with his upper extremities when sitting
up in bed or when using the RW in order to protect
his sternum. He ambulated 15 feet to the bathroom
and performed a toilet transfer with supervision but
reported the sternal precautions limited his ability
to perform hygiene thoroughness. He completed
oral hygiene and a sponge-bathing routine while
sitting sink-side but was able to stand as tolerated
for 1-2 minutes when necessary. He subsequently
dressed using his personal clothes. He benetted from
moderate assistance (Mod A) for both bathing and
dressing tasks due to the sternal precautions impacting
his ability to reach his lower extremities, or bend and
twist his torso. He reported signicant fatigue with the
increased workload of an ADL and deferred shaving at
this time. Using the Borg Rating of Perceived Exertion
Scale (RPE), he described the ADL as very hard. A
basic cognitive screen using the Mini Mental State
Examination (MMSE) indicated that Mr. P. was alert
and oriented x 3, able to follow multi-step directions,
and both short- and long-term memory were intact. At
the end of the evaluation, Mr. P. expressed his concerns
regarding returning to work and how he would
manage the lifestyle changes being recommended by
his cardiologist.
OT Problem List:
• Limited activity tolerance impacting mobility
and participation in ADLs/IADLs
• Limited knowledge of available adaptive
equipment (AE) to assist with ADLs
• Limited knowledge of energy-conservation
education, and effective pacing strategies
• Inconsistent application of sternal precautions
with ADLs/IADLs and mobility
• Limited knowledge of lifestyle modications
consistent with cardiologist’s heart healthy
recommendations, including smoking
cessation
• Increased signs of stress associated with life
events and decline in function with limited
knowledge of stress management strategies
• Limited knowledge of community-based
resources
OT Plan of Care (POC):
Anticipated length of stay: 10-14 days
Duration and frequency of OT sessions: Approximately
60 minutes per day, 5-6 x per week.
OCCUPATIONAL THERAPISTS The Role of Occupational Therapy in Cardiac Rehabilitation | 23
OT Goals: Anticipated timeframe to meet goals –
approximately 2 weeks
• Patient will independently (I) complete all
steps of toileting routine with appropriate
body mechanics and application of sternal
precautions
• Patient will complete shower routine with
modied independence (Mod I) sitting/
standing as tolerated with appropriate use of
adaptive equipment (AE) and application of
sternal precautions
• Patient will complete dressing routine sitting/
standing as tolerated with Mod I, appropriate
use of AE, and application of sternal
precautions
• Patient will independently (I) complete safe
tub transfer with appropriate use of durable
medical equipment as needed
• Patient will tolerate 15 minutes continuous
standing while independently (I) performing
full grooming routine, including shaving tasks
• Patient will independently (I) complete simple
meal prep or laundry task with appropriate
energy conservation strategies and application
of sternal precautions
• Patient will purchase adaptive equipment to
maximize functional independence with ADLs
upon discharge home
• Patient will independently (I) don compression
garments to minimize LE edema using
appropriate compensatory strategies and AE as
needed
• Patient will explore stress management
strategies, including healthy leisure pursuits,
and plan to implement them into daily routine
• Patient will participate in disease management
and lifestyle modication education
• Patient will explore community resources
regarding smoking cessation
Interprofessional Communication:
Physical Therapy (PT): Discussed Mr. P.’s OT plan of
care and goals in order to develop a coordinated,
collaborative effort with PT to build strength, activity
tolerance, and functional mobility. Participated in
daily communication to provide updates, reinforce
consistent educational material, and coordinate efforts
to minimize schedule conicts.
Nursing: Discussed Mr. P.s ADL goals and provided
rationale for allowing him to practice energy
conservation skills and use of adaptive equipment
during all tasks so that he could improve his functional
status and perform his bathing, dressing, and toileting
tasks at an independent level by discharge. Reinforced
importance of cuing Mr. P. to apply appropriate sternal
precautions throughout ADLs.
Social Work: With Mr. P.’s permission, a referral was
made to Social Work services. Discussed the need for
smoking cessation material and community resources.
MD: Discussed evaluation results and discharge
goals, including Mr. P’s concerns regarding stress
management and lifestyle changes. Provided ongoing
updates throughout Mr. P.’s stay regarding his
functional status and vitals, as well as his progress
towards long-term goals.
Spiritual Care: With permission from Mr. P. a referral
was made to Spiritual Care services with particular
concern regarding his divorce and possible grief around
his family breakdown.
Case Manager: Ongoing communication throughout
Mr. P.’s stay regarding his OT plan of care, goals, and
recommendations for a safe discharge home with
continued OT services.
Interventions:
Mr. P.’s treatment plan consisted of increasing his
functional mobility and activity tolerance through
both ADLs and IADLs in order to maximize his
functional independence. It was of primary importance
to include education for disease/stress management,
energy conservation skills, and adaptive equipment
use via all tasks so that he could better manage his
condition and prepare for a safe discharge home.
Mr. P. was encouraged to pace himself throughout
the day but gradually increase his tolerance for more
demanding tasks in order to manage all necessary
ADLs and IADLs upon discharge. He was instructed
in energy conservation strategies to perform his
tasks more efciently and with less fatigue while
continuing to build endurance. Discussion about the
benets of adaptive equipment (AE) was embedded
into his ADL routine and he was encouraged to trial
recommendations for a reacher, a long-handled
shoe-horn, a sock aide, and a long-handled sponge.
After practicing, Mr. P. decided to purchase all
recommended items as they enabled him to reach his
lower extremities when bathing and dressing without
breaking his sternal precautions. He was also educated
regarding appropriate body mechanics to complete his
hygiene tasks after toileting. Once he had mastered his
daily ADL routine more efciently and independently,
he more condently participated in meaningful IADL
activities. Energy conservation, work simplication
strategies, and application of sternal precautions were
included in beverage and meal prep activities, as well
as light housekeeping allowing Mr. P. to perform tasks
more efciently and condently.
Addressing disease management education to help
implement lifestyle changes was an important step
| The Role of Occupational Therapy in Cardiac Rehabilitation OCCUPATIONAL THERAPISTS24
in empowering Mr. P. to take responsibility for his
health and minimizing the risk of future cardiac
events. Mr. P. committed to smoking cessation and
agreed to review the literature provided as well as
follow up with community resources if required. He
also agreed to explore stress management strategies
and healthier leisure options. He completed both the
Stress Management Questionnaire (SMQ) and Interest
Checklist to better understand his high risk stressors
and potential areas of interest. Mr. P. identied the
warning signs associated with burnout and anger, and
was educated about the physical effects of high level
and prolonged stress, including the implications for
cardiac health. He identied several healthier leisure
tasks to explore in the future, including hiking, visiting
museums, and sketching. Mr. P. also expressed an
interest in exploring relaxation strategies and was
introduced to progressive muscle relaxation and guided
imagery as additional means of managing stress.
Discharge:
Mr. P. met all his long-term goals by the anticipated
date and was discharged home at an independent level
for mobility, at a Mod I level of function for all his
ADLs and simple IADLs. He agreed to OT services upon
discharge to ensure a safe transition home, apply his
new strategies in his own environment, and continue
to build activity tolerance via higher level IADLs so
that he could perform these meaningful tasks to a
satisfactory level and ultimately return to work. As a
short-term measure and while he was still unable to
drive, he also agreed to a home delivery service for his
groceries and a home health aide to assist with the
heavier household tasks.
CASE STUDY #3
Congestive heart failure (CHF) -
Home Care Setting
History of presenting information (HPI):
Mrs. L. is an 81-year-old female with a past medical
history signicant for hypertension (HTN), diabetes
mellitus, osteoporosis, chronic obstructive pulmonary
disease (COPD), and pneumonia (PNA) who lives alone
in an assisted living facility (ALF). She also has a 50-
year history of tobacco use but quit approximately 13
years ago. Three weeks ago, the ALF staff noticed Mrs.
L. was experiencing increased fatigue and shortness of
breath with a persistent cough, and she was transferred
to the hospital for assessment. Upon admission, she
had difculty breathing with a respiration rate of 26
and signicant dyspnea in supine or with exertion.
Her BP was 178/112, she had a pulse of 110 and an
O2 saturation of 86% on room air. Mrs. L. had rales
on auscultation, an elevated white blood count
(WBC), and a chest X-ray revealed right middle and
lower lobe pleural effusions consistent with PNA
and bibasal consolidation consistent with CHF. Due
to her advanced age and weakened condition, Mrs.
R. was admitted and treated with antibiotics and
supplemental oxygen. Once stable she was transferred
to a short-term facility for continued medical
management and rehab efforts where she received
OT services 5 x per week for 10 days until ready for
discharge home. It was recommended that she use O2
at home as needed.
Reason for OT Referral:
Mrs. L made steady progress in rehab and was
considered both medically stable and functionally
able to return home to the assisted living facility
(ALF). While not at her prior level of function, Mrs.
L.’s family is willing to pay for short term additional
AL staff services to assist her with showering and
housekeeping tasks while she continues to get therapy.
The primary goal of occupational therapy services is to
help Mrs. L. return to her baseline independent level
of function by addressing strength, endurance, safety,
education, and compensatory strategies.
OT Initial Assessment:
The initial evaluation to determine Mrs. L.’s functional
status, her potential barriers, and goals for therapy is
conducted in her apartment via informal interview,
observation, mobility assessment, the Barthel Index
(BI) to assess ADL ability, the Short Portable Mental
Status Questionnaire (SPMSQ) to assess cognition, and
the Missouri Alliance for Home Care test (MAHC-10)
to assess fall risk. Mrs. L’s studio apartment includes
a living room with kitchenette area, and a separate
bathroom with a walk-in shower stall and ip-down
seat. Both the shower and standard toilet have grab
rails in place. She is greeted fully dressed sitting in
her recliner reading the newspaper. She appears
comfortable and is not using O2, although both a
concentrator and portable tank are present. She is
pleasant and cooperative throughout the evaluation
and highly motivated to participate in therapy in order
to continue living as independently as possible.
Mrs. L. informs her therapist that she has recently
lost her husband of 60 years. He had multiple co-
morbidities, including dementia and lung cancer, and
she had been his primary caregiver in recent years.
However, a year ago the couple was transferred to the
memory care unit in the facility so that her husband
could get additional care as his health and cognition
deteriorated. Mrs. L. was hospitalized for CHF
exacerbation at the time of her husband’s passing and
she reports still feeling sad that she was unable to be
with him at the end. Upon discharge from rehab, Mrs.
L. was transferred back to an assisted living apartment
within the facility and feels that she is still acclimating
to her new environment.
Prior to her recent hospitalization, Mrs. L. was able to
ambulate independently without an assistive device
in her apartment and within the ALF, although she
OCCUPATIONAL THERAPISTS The Role of Occupational Therapy in Cardiac Rehabilitation | 25
used a rollator in the community due to decreased
activity tolerance and mild dyspnea with increased
activity demand. She was independent with all her
ADLs, performing standing level showers, and she
was able to complete routine homemaking tasks like
making the bed and doing the laundry, although she
also utilized the ALF housekeeping services for heavier
household chores. She was able to make snacks and
beverages, but ambulated to the dining room for all
meals. She has always been very sociable and enjoys
visiting with other residents and participating in many
of the community leisure groups. She loves politics
and reading the newspapers. Her daughter lives locally,
visits regularly, and is able to provide transportation as
needed.
During the initial evaluation, Mrs. L. was able to
independently ambulate approximately 20 feet to
the bathroom using her rollator. She completed her
toileting routine independently with mild dyspnea
during hygiene and clothes management tasks. She
performed a shower transfer and completed a full
bathing routine mostly sitting but standing as tolerated
with supervision. She used a hand held shower and
long-handled sponge to reach her lower extremities.
She dressed with moderate assistance (Mod A), needing
help to reach her feet to don both socks, as well as
feed her feet through her left pant leg. She was able to
stand to hike her pants and donned both shoes with
Velcro straps unassisted. She reported moderate fatigue
and shortness of breath with the sustained increase in
activity demand as well as bending to perform lower
body dressing. She also presented with 2+ edema in
both lower extremities. Using the Barthel Index in
addition to observation, it was apparent that Mrs. L.’s
main decits with regard to her ADLs was performing
lower body dressing (LBD) tasks, with both endurance
and edema as limiting factors. The results of the
MAHC test suggested that Mrs. L. is at risk for falling
although she has no prior history of falls. Throughout
the evaluation, she was capable of sustained attention
with an ability to follow multi-step directions. On
the SPMSQ test, Mrs. L. scored two errors indicating
normal mental functioning with capacity for new
learning. She reported feeling frustrated with her
decreased activity tolerance and shortness of breath.
She did not use oxygen at any time during the
evaluation and maintained O2 saturations between
90-93%. Mrs. L. reported that while the oxygen makes
her feel better if she gets winded, she is fearful of using
it without someone present as the cord makes her
feel anxious and she worries about falling. She reports
feeling particularly short of breath when she ambulates
approximately 300 feet to the dining room area or
activity room.
OT Problem List:
• Limited activity tolerance impacting
participation in ADLs/IADLs and community
mobility
• Limited knowledge of energy-conservation
education, effective pacing strategies, and
ventilation techniques impacting performance
in ADLs and participation in IADLs
• Limited knowledge of available adaptive
equipment to assist with ADLs
• Limited knowledge of O2 use, including
O2 cord management and fall prevention
techniques
• Limited knowledge of edema management
OT Plan of Care (POC):
Anticipated length of OT services: 6 weeks
Duration and frequency of OT sessions: Approximately
30-40 minutes, 2 x per week.
OT short-term goals: Anticipated timeframe – 3 weeks
• Patient will independently complete safe
shower stall transfer with appropriate use of
durable medical equipment (DME)
• Patient will complete shower routine with
Supervision (S) sitting/standing as tolerated
with appropriate use of adaptive equipment
(AE) and verbal cues for energy conservation
strategies including ventilation techniques as
needed
• Patient will complete dressing routine sitting/
standing as tolerated with Supervision (S) and
verbal cues for appropriate energy conservation
strategies, ventilation techniques, and use of
AE as needed
• Patient will participate in edema management
education in order to monitor signs and
symptoms of CHF exacerbation that may
require immediate medical attention
• Patient will participate in O2 cord
management and fall prevention education in
order to maximize safety
OT long-term goals: Anticipated timeframe – 6 weeks
• Patient will independently (I) complete shower
routine sitting/standing as tolerated with
appropriate use of adaptive equipment (AE)
and energy conservation strategies including
ventilation techniques as needed
• Patient will independently (I) complete
dressing routine sitting/standing as tolerated
with appropriate application of energy
conservation strategies, ventilation techniques,
and use of AE as needed
• Patient will independently (I) complete a
simple beverage/snack prep with appropriate
energy conservation strategies including
ventilation techniques as needed
| The Role of Occupational Therapy in Cardiac Rehabilitation OCCUPATIONAL THERAPISTS26
Patient will participate in disease management
education, including edema management, and
be able to verbalize strategies to monitor signs
and symptoms of CHF exacerbation requiring
immediate medical attention
•
Patient will independently (I) demonstrate
appropriate O2 cord management and fall
prevention techniques in order to maximize safety
Interprofessional Communication:
Primary Care Physician (PCP): Discussed evaluation
results and rationale with request for continued OT
services 2 x pw for 6 weeks. PCP agreed with plan of
care and provided verbal order.
Physical Therapy (PT): Discussed Mrs. L.’s OT plan
of care and goals in order to develop a coordinated,
collaborative effort with PT to build strength, activity
tolerance, and maximize functional mobility and
safety. Participated in frequent communication to
provide updates, reinforce consistent educational
material, and coordinate efforts to minimize schedule
conicts.
Nursing: Discussed Mrs. L.’s evaluation results
including decits, goals, and rationale for OT services.
Discussed potential risk for falls and depression due
to the client grieving her husband’s death, loss of
caregiver role, and social isolation. Participated in
frequent communication to provide updates, reinforce
consistent educational materials, and monitor for signs
and symptoms of depression or caregiver burden.
Independent Living Facility Staff: Discussed evaluation
results including Mrs. L.’s goals to return to baseline
level of function for ADLs. Discussed OT plan of
care and recommendations to maximize functional
independence with use of adaptive equipment and
energy conservation strategies.
Independent Living Facility Resident Programs Coordinator:
Discussed evaluation results and decits impacting
participation in social/community activities, including
options to incorporate energy conservation strategies
and encourage participation.
Interventions:
Mrs. L.’s treatment plan consisted of increasing her
activity tolerance and functional mobility through
both ADLs and IADLs in order to maximize her
functional independence and minimize the potential
for depression associated with grief and loss of her
caregiver role. Given Mrs. L.’s goal to return to her
baseline level of function and her capacity for new
learning, disease management education including
daily weight/edema checks, energy conservation
skills, and adaptive equipment use were considered of
primary importance in her plan of care.
Given Mrs. L.’s recent bereavement, hospitalization,
and apartment change, The Resilience Scale for Adults
(RSA) was completed early in her plan of care in
order to assess her strengths and ability to adapt after
adversity. It was clear that Mrs. L. thrived in social
contexts and her level of conscientiousness suggested
she had a preference for routine and planning.
Mrs. L. was issued a daily planner and encouraged
to prioritize her activities according to importance
and level of fatigue. She was educated about the need
to decrease extraneous tasks if necessary while still
building up her activity tolerance. She was encouraged
to include ADLs and social participation through
community leisure activities in her daily schedule in
order to plan for tasks, include adequate rest breaks,
and create a balance of necessary and meaningful
occupations. She was also encouraged to pace herself
through all tasks and sit when possible.
Mrs. L. was instructed on using energy conservation
strategies to perform tasks more efciently and with
less fatigue. She was highly motivated to use adaptive
equipment to improve her dressing routine and she
was encouraged to trial a reacher, a long-handled shoe-
horn, and a sock aide. Mrs. L. practiced with each item
and was excited to notice less shortness of breath when
minimizing the need to bend frequently to reach her
feet. She decided to purchase all recommended items.
Once Mrs. L. had mastered her daily ADL routine
more efciently and independently she was more
condently able to participate in meaningful IADL
activities, including retrieving drinks or snacks from
the apartment’s kitchenette, selecting clothes from
the closet or dresser, and straightening the bed. She
was also able to slowly increase her time participating
in social activities within the ALF community. Energy
conservation and work simplication strategies were
included allowing Mrs. L. to perform IADL tasks more
efciently and condently without signicant fatigue
or shortness of breath.
Providing Mrs. L. with education to self-monitor signs
and symptoms of a CHF exacerbation was important
in minimizing the risk of future hospitalizations. Mrs.
L. was provided with an easy to follow visual self-
check plan from the American Heart Association
168
to help her monitor typical signs and symptoms and
know when to seek medical assistance or call 911.
She was also provided with several blank weight-
monitoring logs and was encouraged to check and
record her daily weights. She understood that sudden
weight gain of several pounds over a 24-hour period
would require at least a check in with her Primary
Care Physician. Additionally, she was encouraged to
perform daily checks for increased lower extremity
edema and monitor for abdominal discomfort. She was
also encouraged to be aware of worsening shortness
of breath, the development of a dry cough, or if her
quality of sleep deteriorated and she was no longer able
to tolerate lying at in bed. Mrs. L. was also educated
regarding use of oxygen if needed, including safe O2
cord management, and fall prevention strategies.
OCCUPATIONAL THERAPISTS The Role of Occupational Therapy in Cardiac Rehabilitation | 27
Mrs. L. was encouraged to participate in regular
functional activities and ambulate as tolerated. She
verbalized her understanding of the importance of
physical activity in maintaining general endurance
that would also enable her to continue participating in
meaningful social activities within the ALF and local
community.
Discharge:
For the rst two weeks, Mrs. L. used her rollator to go
down to the dining room for meals or community
events, and took occasional seated rest breaks. As her
strength and endurance improved she was able to
safely ambulate independently with her rollator with
fewer rest breaks.
She met all her long-term goals by the anticipated
date and was discharged from OT services at an
Independent level for shower stall transfers, bathing,
dressing, and simple IADLs within the apartment. She
continued to receive ALF housekeeping services for
heavier chores. Mrs. L. demonstrated appropriate skills
to apply energy-conservation strategies when necessary
and manage her daily weight log. She slowly increased
her tolerance for social activities within the ALF and
local community, participating in trips to the local
library and an antiques fair with her daughter.
Resources
American Heart Association: CHF patient guide and
symptom check list
https://www.heart.org/HEARTORG/Conditions/
HeartFailure/Heart-Failure_UCM_002019_
SubHomePage.jsp
American Heart Association: Heart eating patient guide
http://www.heart.org/HEARTORG/HealthyLiving/
HealthyEating/Healthy-Eating_UCM_001188_
SubHomePage.jsp
PBS, WGBH Boston: The hidden epidemic: heart disease in
America – 10 things you never knew about heart disease
https://www-tc.pbs.org/wgbh/takeonestep/heart/
pdf/10Things.pdf
CHF weight monitoring log chart (free PDF download)
https://www.freeprintablemedicalforms.com/preview/
Congestive_Heart_Failure_Log
American Heart Association: Activity log (free
download)
http://www.heart.org/idc/groups/heart-public/@wcm/@
hcm/documents/downloadable/ucm_445503.pdf
American Heart Association: Blood pressure log (free
download)
http://www.heart.org/idc/groups/heart-public/@wcm/@
hcm/documents/downloadable/ucm_305157.pdf
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| The Role of Occupational Therapy in Cardiac Rehabilitation OCCUPATIONAL THERAPISTS32
The Role of Occupational Therapy
in Cardiac Rehabilitation
(3 CE Hours)
FINAL EXAM
1. Hypertension is either the primary or
contributing cause of almost ________ in the
U.S.A.
a. 1000 deaths each day
b. 1000 deaths each month
c. 2500 deaths each day
d. 2500 deaths each month
2. Which of the following statements regarding
angina is NOT correct?
a. Angina is a complication of coronary artery
disease (CAD) that may develop as the arteries
continue to narrow over time and blood
supply is reduced
b. Angina is commonly classied as either stable
or unstable
c. Treatment for angina includes nitrates, such
as nitroglycerin tablets, or beta-adrenergic
blockers that dilate vessels
d. Typically, women’s angina symptoms are more
easily identied as cardiac related
3. A normal heartbeat begins with an electrical
signal from the sinus node, a single point
within the _________ of the heart.
a. Left atrium
b. Left ventricle
c. Right atrium
d. Right ventricle
4. Heart failure symptoms are classied in stages
from mild to severe. “Moderate limitations with
increased activity demand. For example, fatigue
and dyspnea while ambulating short distances,
climbing one ight of stairs,” are characteristic
of ________.
a. Class I
b. Class II
c. Class III
d. Class IV
5. Around ________ of individuals experiencing
a myocardial infarction (MI)MI die within an
hour after onset before they reach the hospital.
a. 35%
b. 50%
c. 65%
d. 80%
6. During ________, electrical signals re rapidly
from multiple sites in both atria thereby
overwhelming the ventricles, which are unable
to ll and pump in a normal rhythm. As a
result, an individual will experience a rapid and
irregular heartbeat.
a. Atrial Fibrillation (AFib)
b. Coronary Artery Disease (CAD)
c. Heart Failure / Congestive Heart Failure (CHF)
d. Hypertension (HTN)
7. Approximately 95% of ________ develops
without a known etiology, and 5% of cases are
attributed to a comorbid condition such as
chronic kidney disease.
a. Atrial Fibrillation (AFib)
b. Coronary Artery Disease (CAD)
c. Heart Failure / Congestive Heart Failure (CHF)
d. Hypertension (HTN)
8. Commonly referred to as a heart attack, acute
________ is the irreversible damage to heart
muscle as a result of coronary artery obstruction
or prolonged lack of oxygen to cardiac tissue.
a. Atrial Fibrillation (AFib)
b. Coronary Artery Disease (CAD)
c. Hypertension (HTN)
d. Myocardial Infarction (MI)
9. ________ is most commonly attributed to
atherosclerosis, a buildup of fatty, brous
plaque in the coronary arteries that can
progressively narrow the vessels over time
and occlude blood supply to the heart muscle,
increasing the risk of signicant health related
issues.
a. Atrial Fibrillation (AFib)
b. Coronary Artery Disease (CAD)
c. Hypertension (HTN)
d. Myocardial Infarction (MI)
10. ________ is a complex diagnosis that results
from impaired structure and/or function of the
ventricles. It is a chronic progressive condition
that affects the heart’s ability to pump blood to
the body and provide organs and tissues with
necessary oxygen and nutrients.
OCCUPATIONAL THERAPISTS The Role of Occupational Therapy in Cardiac Rehabilitation | 33
a. Coronary Artery Disease (CAD)
b. Heart Failure / Congestive Heart Failure (CHF)
c. Hypertension (HTN)
d. Myocardial Infarction (MI)
11 ________: An imaging technique used to
diagnose heart conditions. It is the primary
procedure used to evaluate arterial blockages
and is typically conducted under sedation.
a. Angiogram
b. Bibasal consolidation
c. Cardioversion
d. Debrillation
12. ________: A non-surgical reperfusion procedure,
also known as coronary angioplasty, that uses
a catheter to open an occluded vessel or place
a stent in order to improve blood ow to the
heart.
a. Coronary artery bypass graft (CABG)
b. Implantable Cardioverter Debrilator (ICD)
c. Percutaneous coronary intervention (PCI)
d. Telemetry
13 ________: a form of arteriosclerosis that
specically refers to an increase in lipids,
cholesterol, or other substances that restrict
arterial blood ow
a. Atherosclerosis
b. Cardiac cachexia
c. Hypercholesterolemia
d. Ischemia
14. ________: A disturbance in the heart’s normal
rhythm resulting in a heart rate over 100 beats
per minute.
a. Bradycardia
b. Cardiac cachexia
c. Orthopnea
d. Tachyarrhythmia
15. ________: An instrument developed to measure
an individual’s performance satisfaction with
their independent living skills. The tool is
a self-report questionnaire and consists of
two subscales. Subscale I identies 24 items
associated with home management; subscale
II contains 22 items related to social and
community activities.
a. Barthel Index (BI)
b. Interest Checklist
c. Satisfaction with Performance Scaled
Questionnaire (SPSQ)
d. The Mini Mental State Examination (MMSE)
16. ________: A 25-item, self-report, 7-point Likert
scale tool used to assess resilience in adults,
including their ability to adjust successfully
after a major life event.
a. Canadian Occupational Performance Measure
(COPM)
b. Functional Independence Measure (FIM®)
c. Resilience Scale for Adults (RSA)
d. Short Portable Mental Status Questionnaire test
(SPMSQ)
17. ________: A process of passive, active, and
progressive movement during critical illness to
counter the effects of sedation and immobility
that may lead to neurocognitive decits and
physical debilitation. It may be performed by
any member of the interdisciplinary team,
including OTs.
a. Cardiac/sternal precautions
b. Early mobilization
c. Instrumental activities of daily living (IADL)
re-training
d. Stress management / relaxation strategies
18. Considering Case Study #1: As part of OT
intervention, Mr. S. was introduced to ________
so that he could continue to participate in
his meaningful daily tasks while maintaining
intensity parameters set by his cardiology team.
a. Ejection fractions (EFs)
b. Holter and Event Monitors
c. Implantable Cardioverter Debrilators (ICDs)
d. Metabolic equivalents (METs)
19. Considering Case Study #2: ________ was an
important step in empowering Mr. P. to take
responsibility for his health and minimizing the
risk of future cardiac events.
a. Addressing disease management education to
help implement lifestyle changes
b. Asking for help from his ex-wife and family
c. Working approximately 60 hours a week in the
retail industry
d. None of the above
20. Considering Case Study #3: To help her perform
tasks more efciently and with less fatigue, Mrs.
L. was ________.
a. Advised to seek out community volunteers
b. Instructed on using energy conservation
strategies
c. Presented with healthier leisure options
d. Taught to identify the warning signs associated
with burnout and anger
| The Role of Occupational Therapy in Cardiac Rehabilitation OCCUPATIONAL THERAPISTS34
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The Role Of Occupational Therapy
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OCCUPATIONAL THERAPISTS The Role of Occupational Therapy in Cardiac Rehabilitation | 35
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THE ROLE OF OCCUPATIONAL THERAPY
IN CARDIAC REHABILITATION
(3 CE HOURS)
