What is the role of physical therapy (PT) in cardiac rehabilitation across different phases?

Physical Therapy's Role in Cardiac Rehabilitation Across Phases

Physiotherapists serve as essential members of the multidisciplinary cardiac rehabilitation team, delivering supervised exercise training, conducting functional capacity assessments, and prescribing individualized exercise programs across all three phases of cardiac rehabilitation. 1, 2, 3

Phase 1: Inpatient Cardiac Rehabilitation

Physical therapy during hospitalization focuses on early mobilization and patient education following acute cardiovascular events (MI, acute coronary syndrome, cardiac surgery). 3

Key PT responsibilities include:

• Basic cardiovascular risk factor identification and initial assessment 3
• Problem-focused physical examination with emphasis on cardiovascular stability and musculoskeletal limitations 3
• Patient education on cardiac event recovery expectations and disease management 3
• Psychological support initiation 3

Important caveat: Phase 1 protocols currently lack strong evidence-based exercise prescription principles compared to later phases. 3

Phase 2: Early Outpatient Cardiac Rehabilitation (Most Critical Phase)

Phase 2 represents the most evidence-based and clinically impactful period, typically beginning within 3-6 months post-event and demonstrating the strongest mortality reduction benefits. 3

Core PT functions in Phase 2:

Assessment and Evaluation

• Functional capacity evaluation using graded exercise testing (treadmill or cycle ergometry) 1, 3
• Comprehensive cardiovascular risk factor assessment 3
• Psychosocial assessment to identify barriers to exercise adherence 3
• Review of diagnostic and laboratory studies before program initiation 3

Exercise Prescription and Delivery

• Structured, supervised exercise sessions with prescribed intensity based on individual assessment 3
• Exercise modalities include stationary bicycle, treadmill, calisthenics, walking, or jogging 2
• Regular aerobic exercise at moderate intensity as the standard approach 2
• ECG telemetry monitoring based on patient risk status and exercise intensity 2
• Individualized exercise modification based on hemodynamic changes and musculoskeletal limitations 3

Supervision requirements: Physical therapy services must be delivered under direct physician supervision, with the physician immediately available and accessible (though not necessarily physically present in the exercise room) for emergency response. 3

Staffing mandate: All PT staff must complete basic life support (BLS) training, with at least one staff member holding advanced cardiac life support (ACLS) certification. 3

Clinical Outcomes Delivered by PT-Led Exercise

• Reduction in all-cause mortality (OR 0.73,95% CI 0.54-0.98) with exercise-only interventions 2
• Probable reduction in overall hospital admissions (RR 0.70,95% CI 0.60 to 0.83; number needed to treat: 14) 4
• Possible reduction in HF-specific hospitalization (RR 0.59,95% CI 0.42 to 0.84; number needed to treat: 25) 4
• Clinically important improvement in disease-specific quality of life (Minnesota Living With Heart Failure questionnaire: MD -7.11 points) 4

Phase 3/4: Long-Term Maintenance Cardiac Rehabilitation

Physical therapy transitions to less intensive supervision with focus on independent exercise and sustained physical activity promotion. 3

PT responsibilities include:

• Continued exercise training with reduced supervision intensity 3
• Promotion of independent exercise and long-term physical activity adherence 3
• Periodic functional capacity reassessment 3
• Ongoing cardiovascular risk factor monitoring 3

Evidence limitation: Phase 3/4 evidence focuses more on quality of life maintenance than mortality reduction compared to Phase 2. 3

Alternative Delivery Models for PT Services

Home-Based Programs

Home-based cardiac rehabilitation achieves equivalent efficacy and safety to center-based programs with potentially higher adherence. 2

• Appropriate for low-risk, clinically stable patients 2
• Requires active ongoing contact through home visits, telephone consultations, or technology platforms 2
• Explicitly recommended by US, UK, and Australian/New Zealand guidelines as equivalent alternative 2

Center-Based Programs (Traditional Standard)

• Conducted in hospital, physician's office, or community facility settings 2
• Medically supervised group sessions with direct ECG monitoring for high-risk patients 2
• Physician supervision presumed met when services performed on hospital premises 3

Technology-Based Models

Telerehabilitation and technology-based programs represent emerging alternatives, especially critical for low-income and middle-income countries where cardiac rehabilitation services are scarce. 1

Multidisciplinary Integration

Physical therapists must work within a comprehensive multidisciplinary team including cardiologists, general practitioners, nurse specialists, dietitians, and psychologists, all trained in core competencies for cardiac rehabilitation delivery. 1, 2

Close communication between the treating physician and the PT-led cardiac rehabilitation team is essential to maximize effectiveness and promote long-term behavioral change. 2

Critical Implementation Challenges

Despite robust evidence, cardiac rehabilitation remains severely underutilized globally, with only 5-50% of eligible patients receiving rehabilitation services. 1, 2

Referral rates vary significantly by diagnosis:

• Post-MI: 29% 2
• Post-PCI: 51% 2
• Post-CABG: 75% 2
• Heart failure: <10% 2

Access barriers disproportionately affect older adults, women, non-white and ethnic minority groups, and patients with multimorbidity. 2