INTRODUCTION:

The WHO defined cardiac rehabilitation as the sum of activities required to influence favorably the underlying cause of the disease, as well as provide the best possible physical, mental and social conditions, so that the patients may, by their own efforts preserve or resume when lost as normal a place as possible in the community¹.

Physical inactivity is the risk factor of coronary artery disease. Regular physical activity increases exercise capacity and plays a role in both primary and secondary prevention of cardiovascular disease^2,3,4,5 exercise training increases cardiovascular functional capacity and decreases myocardial oxygen demand at any level of physical activity⁷. Exercise also improves self confidence⁸ and self esteem⁹ attenuates cardiovascular and neuro humoral responses to mental stress and reduces type a behaviour¹⁰.

Nurses are integral part of our health team, may assess the physical activity habit prescribe exercise and monitor responses to exercise in cardiac patients. Exercise is an important part of rehabilitation. Person needs to exercise 3 times a week to get real benefit from exercise. Try to build up the amount of exercise steadily but gradually¹¹.

Exercise:¹²

It is a type of physical activity. It is structured, planned and repetitive movements that are done to maintain or improve one or more of the characteristics of physical stress.

Benefits of Exercise:¹³

· Improved working ability of the heart, both at rest and on exercise

· Heart becomes more efficient as a pump.

· You may be able to do more work before you experience any exercise symptoms, such as angina.

· Exercise may help to reduce blood pressure both in the short term (during an exercise session it may not increase as much), and in the long term (resting blood pressure may be reduced)

· Exercise helps to widen the vessels our blood travels around the body in. If wider, the flow of blood is made easier and so blood pressure is reduced.

· Exercise may also help to prevent any further development of the fatty plaques which block the blood vessels.

· Exercise can help to improve the circulation of blood in the heart itself so that the heart muscle gets the oxygen it needs to work efficiently.

Preparation for Exercise:

Warm up:

Warming up before any exercise is essential and should be for a minimum of 15 minutes. This allows time for the heart and circulation to adjust so that when your muscles need more oxygen to exercise, it is there. During the warm up your muscles, tendons and ligaments become warmer and your heart rate (pulse) will start to rise. Warm up should start with gentle movement, particularly of the legs which is where we all have the big muscles needing the most oxygen. This movement should become a little more vigorous as the warm up progresses.

1. First Phase: Warm up :

Walking, marching on the spot ways of raising your pulse. Do this for the first 5 minutes of the warm up, starting very gently and gradually increasing the intensity. The purpose is to warm up the muscles in preparation for stretching, and to increase the heart rate gradually.

2. Stretching exercises:

The next 5 minutes of your warm up should be to stretch the muscles that you are going to be using. Only stretch as far as your muscles allow. It is important to remember to keep your feet moving in between the stretches so that your body remains warm and your heart rate is still raised slightly, so maintaining the effects of the first 5 minutes of the warm up.

Upper back stretch

Lock your fingers together with you arms stretched out in front. Lower your head forward to look at the floor. Remember to keep your feet moving. Hold the stretch for 10-15 seconds.

Chest stretch:

Place you hands on your lower back. Gently move your elbows towards each other. Keep your back straight. Remember to keep your feet moving. Hold the stretch for 10-15 seconds.

Lower back and waist mobility:

Side bends. Stand with your feet shoulder width apart either with your hands on your hips or down by your side. Slowly lean to one side from your waist, being careful not to move your hips. Come back to the upright position and lean to the other side. Repeat 5 times.

Calf Stretch:

Press the heel of the back leg into the floor until a gentle

stretch is felt in the calf muscle in the back of the lower leg. If a stretch is not felt, adjust the position by moving the back foot further back and hips forward. Hold the stretch for 10-15 seconds on each leg.

Hamstring Stretch:

With one leg in front of the other, lean forward slightly, placing both hands on the hips. Straighten the front leg and slightly bend the back leg. Keep the head up and continue to lean until a stretch is felt in the back of the forward straight leg. Hold for 10-15 seconds. Repeat on the other leg.

Front of thigh stretch:

Put your left hand on the wall for support. Lift your right knee up in front and hold either your right ankle, back of your hoe or the back of your trousers by your ankle. Keep the supporting leg slightly bent throughout. Move your knees together by lifting your right foot behind the body. Keep the back straight and push the hip forward until a gentle stretch is felt. Hold the stretch for 10-15 seconds and then repeat with the left leg.

Pulse raising (movement) activities:

The final 5 minutes of the war up should be pulse raising activities at a slightly higher intensity than the first 5 minutes. The purpose is to continue to increase the heart rate in preparation for the main exercise session. Walking, marching on the spot, or low level cycling are suitable methods of pulse raising.

Cool down:

It is important you leave enough time at the end of your session to cool down properly. Gradually lower your pace during the cool down. The goal is to bring your body back to its resting state.

· A thorough cool down for 10minutes reduces the risk of fainting or dizziness that could result from a sudden drop in blood pressure if you suddenly stop exercising.

· Cooling down also reduces the risk of disturbances in your heart rhythm that could happen if you stop exercising suddenly.

(These factors reduce the risk of sudden heart problems and should be taken very seriously)

· Stretching during the cool down also helps to reduce any muscle soreness that may be caused by the activity

· The cool down should be performed at a gradually slower speed. The aim is to bring your body back to its resting state gradually.

The Final Stage:

Cool Down:

Cooling down exercise allows blood pressure to return to normal slowly and will prevent dizziness occurring. Heat and waste products are removed from the exercising muscle groups, which reduces the risk of stiffness and aching later on. The cool down should last for at least 10 minutes.

It can include:

1. Gentle exercises, i.e. slow walking – this can be the last 10 minutes of your walk.

2. A selection of the pulse raising warm-up exercises done at very slow speed

3. Gentle and slow mobilizing exercises from the warm up

4. Stretches from the warm up – holding for 15-20 seconds (examples in the back of this handout) At the end of the cool down you should have recovered from the exercise. Your heart rate and breathing rate should have returned to what it was before you started to exercise.

What you May Experience While Exercising:

Normal Whilst Exercising – Keep Going	Stop Exercising if any of the following are present
Breathing – faster and deeper	Inappropriate levels of breathlessness
Feel your muscles working	Chest pain or your usual angina pain
Heart beating faster	Pulse irregular (unless this is normal for you)
Skin will become warm	Excessive sweating
Slightly sweaty	Dizziness
	Feelings of unusual and excessive tiredness
	Unusual pain, not associated with muscle soreness (can be anywhere in your body)

Sensible Precaution:

· Exercise only you feel well

· Make sure that you have eaten a light meal approximately 1-2 hours before exercising

· Do not exercise in the extremes of temperature

· Know your capabilities

· Wear proper clothing

CONCLUSION:

The important role of nurses in cardiac rehabilitation is exercise therapy. Furthermore the hospital, home bridging nature of the programme also created a model for interfacing acute care and rehabilitative care.

REFERENCES:

1. Who.int.in

2. Morris CK, Froelicher VF. Cardiovascular benefits of physical activity. Herz..1991; 16:222-236 (Medline) (Order article via Infotrieve)

3. Chandrashekhar Y, Anand IS. Exercise as a coronary protective factor. Am Heart J.. 1991; 122: 1723-1739. (Medline) (Order article via Infotrieve)

4. Smith SC Jr, Blair SN, Criqui MH, Fletcher GF, Fuster V, Gersh BJ, Gotto AM, Gould KL, Greenland P, Grundy SM, Hill MN, Hlatky MA, Houston-Miller N, Krauss RM, LaRosa J, Ockene IS, Oparil S, Pearson TA, Rappaport E, Starke RD, and the Secondary Prevention Panel. Preventing heart attack and death in patients with coronary disease. Circulation.. 1995; 92: 2-4.

5. Wenger NK, Froelicher ES, Smith LK, Ades PA, Berra K, Blumenthal JA, Certo CM, Dattilo AM, Davis D, DeBusk RF, et al. Cardiac Rehabilitation as Secondary Prevention. Clinical Practice Guidline No. 17. Rockville, Md: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research and the National Heart, Lung, and Blood Institute; October 1995. ACHCPR Publication No. 96-0672.

6. Paffenbarger RS Jr, Hyde RT, Wing AL, Hsieh CC. Physical activity, all-cause mortality, and longevity of college alumni. N Engl J Med.. 1986; 314:605-613 (Abstract).

7. Folkins CH, Sime WE. Physical fitness training and mental health. Am J Psychol. 1981; 36: 373-389.

8. Blumenthal JA, Emery CF, Walsh MA, Cox DR. Kuhn CM, Williams RB, Williams RS. Exercise training in healthy type A middle-aged men: effects on behavioral and cardiovascular responses. Psychosom Med. 1988; 50:418-433. (Abstract/Free Full Text)

9. Blumenthal JA, Fredrikson M, Kuhn CM, Ulmer RL, Walsh-Riddle M, Appelbaum M. Aerobic exercise reduces levels of cardiovascular and sympathoadrenal responses to mental stress in subjects without prior evidence of myocardial ischemia. Am J Cardiol.. 1990; 65:93-98. (Medline) (Order article via Infotrieve).

10. Kottke TZ, Solberg LI, Brekke ML, Initiation and Maintenance of patient behavioural change. J.Gen Intern. Med. 1990; 5; 562-567.

11. Oxford medical dictionary

12. www.bcf.nhs.uk

Received on 25.04.2014 Modified on 24.09.2014

Asian J. Nur. Edu. and Research 5(2): April-June 2015; Page 283-286

DOI: 10.5958/2349-2996.2015.00056.7