Cardiac Rehab
Content
Introduction Recovering from a cardiac event may involve some lifestyle changes. After any cardiac event (heart attack, surgery, angioplasty or angina) it can take up to 6-8 weeks for your heart to recover to a level at which you are ready to resume all your normal activities. Your age and how active you were before your cardiac event, and your psychological reaction to what has happened will all affect the speed of recovery. Everyone makes progress at a different rate.
1
Exercise
Exercise can help you to return to a full and active lifestyle and may help to prevent further damage to your heart. The best form of exercise is one that you really enjoy and can fit into your daily routine. Exercise has many beneficial effects, such as: ‡ Decreasing blood pressure ‡ Reducing stress ‡ Improving stamina ‡ Controlling blood sugar levels ‡ Lowering cholesterol levels ‡ Helping you loose fat and gain muscle Over the course of the next few months you should follow a progressive exercise programme. This will ensure you get the benefits of exercise without overdoing it or doing too much too soon. What type of exercise? You should do something that uses your leg muscles in steady rhythmic movement - initially walking is the best thing, or cycling. As you become fitter you can add other activities such as exercise classes, dancing, tennis, badminton, golf and swimming. (If you have had surgery, you should not swim for three months afterwards.)
2
How long should you exercise? At first, exercise only for short periods: 5-10 minutes, 1-2 times per day. You build up to 30 minutes of exercise on at least 5 days a week. Always start and finish sessions with warm-up/ cool down exercises. This gives the heart time to adjust to the altered levels of activity and so reduces the risk of sudden changes in blood pressure and abnormal heart rhythms. How hard should you exercise? In order to benefit, you need to exercise at a pace that makes you warm and increases your heart rate and breathing. To help you judge the right level we use the following scale (which we refer to as the Borg Scale): 0 1 2 3 4 5 6 7 8 9 10 nothing at all very light fairly light moderate fairly hard hard hard very hard very tiring very very hard exhausting
Rating your exertion whilst you are exercising involves noticing how your whole body feels, in particular paying attention to your breathing - is it slow or fast, do you feel tight in your chest or struggling to catch your breath?
3
The programme (i) WARM-UP / COOL DOWN (LEVELS 1-3) Do these exercises immediately before and after your walk. You can do them standing or sitting in an upright chair. Stand or sit tall, shoulders down and back and tummy muscles pulled in. ‡ March on the spot for 30 seconds. ‡ Roll shoulders forwards; then up to the ears; then down & back six times. ‡ Swing alternating arms as if walking briskly. ‡ Repeat whole sequence three times. MAIN
EXERCISE
1 Walking Fairly light / moderate 5 mins 1-2 times daily 2 Walking Fairly light / moderate 10 mins 1-2 times daily 3 Walking Fairly light / moderate 15 mins 1-2 times daily
Now that you can walk at a moderate pace for 15 minutes you may like to add some variety to your exercise plan. Cycling is excellent for your heart and can be done instead of walking. As before, start off slowly with 5-10 minutes, at a pace that feels fairly light to moderate. Gradually build up.
4
Frequency
Perceived exertion
Exercise
Level
Time
The programme (ii) WARM-UP / COOL DOWN (LEVELS 4-6) At the start of your walk, spend 5 minutes walking slower than your exercise pace. This prepares your muscles and heart for the brisker pace. At the end of your walk, again spend 5 minutes walking slower than your exercise pace. This allows your heart and muscles to gently recover.
MAIN
EXERCISE
4 Walking 5 Walking 6 Walking
Moderate Moderate Moderate
20 mins 25-30 mins 30-60 mins
1-2 times daily 1-2 times daily daily
Once you can walk at a moderate pace for 30-60 minutes, you may like to add dancing, golf, tennis or badminton to your programme. Stay noncompetitive & keep exertion fairly light /moderate. Overall, you should be aiming to do 30 minutes of exercise on five days of the week.
5
Frequency
Perceived exertion
Exercise
Level
Time
How to use the exercise programme The programme has six levels. Begin at a level you can easily achieve (for most people this will be at level 1 or 2). You should feel warm, but not over-heated, and your breathing should be faster, but not so fast that you feel uncomfortable and are unable to carry out a conversation. ‡ÿ Stay on this level for as long as it is exerting you fairly lightly to moderately. If it feels too hard, drop down a level. If it feels fairly light to moderate, stay on this level until it starts to feel very easy or very light, then it is time to move up to the next level. ‡ Once you reach level 6 of the programme you are doing just the right amount of exercise to benefit your heart. Some people reach this level very quickly, others may take a year or more! It is important to progress slowly at a pace that you feel comfortable with. ‡ Some of you will also be joining an exercise group in the hospital, where we can help you to choose activities and sports to make your exercises more varied and enjoyable.
6
Sexual activity Many people with heart disease continue to enjoy sexual activity. Following a heart attack or surgery it is usually perfectly safe to resume sexual activity as soon as you feel ready. Find a position that suits you and your partner. Apply the same common sense as with exercising. As a rough guide, if you can climb up and down two flights of stairs without discomfort you are fit enough to resume sexual activity. If you experience angina or discomfort during sexual intercourse, it is advisable to stop and administer GTN spray/tablets if applicable and wait until you are pain-free before resuming.
Stress and relaxation
Stress varies for different people but usually stems from an imbalance between the demands being made on you & how you think you can cope. Remember that a certain amount of stress is normal and healthy. However, too much can cause harm and trigger a stress response, which is your body’s attempt to cope with a difficult situation. You need to find a balance between life’s demands and your coping resources.
7
Type of stress Stress can come from within you (internal) or from outside (external), for example: Internal - poor diet, lack of consistency within work or personal life, unresolved conflicts. External - noise, pollution, poor working conditions, bereavement, marriage breakdown. Fight or flight The automatic reaction to a threatening situation is known as the ‘fight or flight’ response. It equips us to fight or escape from an enemy - or in this case the difficult situation. Worrying thoughts, memories or events can turn on adrenaline - part of nature’s way of helping you cope with danger.
8
Effects of stress Emotional Anxiety: nervousness tension phobias panic attacks Depression: sadness lowered self-esteem apathy fatigue Guilt and shame Physical Moodiness Increased heart rate Loneliness Increased blood pressure Anger Difficulty breathing Muscle contraction / aches Hot and colds spells Dilated pupils Frequent urination Numbness &tingling sensation Increased blood glucose levels Mental Difficulty in concentrating Difficulty in making decisions Frequent forgetfulness Increased sensitivity to criticism Negative self-critical thoughts Distorted ideas More rigid attitudes
9
Behavioural Difficulty sleeping Emotional outbursts/aggression Excessive eating/loss of appetite Excessive drinking and smoking Accident prone Avoidance of particular situations Inactivity
Effects on health Coronary heart disease Hypertension and strokes Stomach ulcers/nausea/colitis Migraine/headaches/skin rashes Diarrhoea Organisational Absenteeism Poor industrial relations High accident rate Poor productivity Job dissatisfaction
10
Why is stress common in people who have heart problems? Having any kind of heart problem can be a frightening experience, not only for you but also for your family. It is natural to be worried even if it is difficult to put into words exactly why. People often experience some degree of anxiety about the possibility of another cardiac event; or the success of the operation that took place; or how well they will cope at home. A cardiac event can be a blow to your selfconfidence, especially if you have not had any serious health problems before and it is easy to become depressed. In the first few weeks after your cardiac event or surgery there are so many things going on and so much to think about that depression may not be obvious. Depression can be experienced in different ways: ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Sadness Loss of enjoyment in hobbies Loss of interest in sex Low self-esteem Poor concentration Sleeping badly Lack of appetite Constant tiredness Short temper
11
These problems usually settle down if, and when, the person returns to work and life starts getting back to normal. It is important to remember that anxiety and depression is common and often relieved by help. Discussing your thoughts and feelings with someone who has gone through the same experience as you may ease your problems. Many rehabilitation centres have selfhelp groups, which can give long-term support therapy where it is needed. Also your GP surgery may offer support and counselling. Relaxation Relaxation allows mental and physical tension to be released. The type of relaxation that really makes a difference in dealing with stress and tension is regular, daily practice of some form of deep relaxation. It is a skill that has to be learnt until it becomes second nature, and is more than simply sitting down and taking it easy for a few moments. Some people find using a relaxation tape helps focus their mind, which enables relaxation. Find one that suits you, often a favourite piece of soothing music is all that is needed to create an atmosphere in which you are more able to relax – avoid any heavy music with a regular beat! You may like to make your own relaxation tape.
12
5 MINUTES OF SIMPLE RELAXATION This is a simple form of relaxation for occasions when you only have a short time to spare. It is more comfortable in a chair with armrests, but it can be done in an upright chair. Try to ensure a full five minutes of undisturbed quiet. ‡ Sit upright & well back in the chair so that your thighs and back are supported. Rest your hands lightly on the arms of the chair or in your lap. ‡ Close your eyes gently, settle down comfortably and begin by breathing, out first then breathe in, easily and just as much as you need. Now breathe out slowly with a slight sigh, like a balloon slowly deflating. ‡ Do this once more very slowly and as you breathe out feel the tension begin to drain away. Then go back to your ordinary breathing, even, quiet and steady. ‡ Now direct your thoughts to each part of your body in turn, to the muscles and joints. The order of relaxation is as follows: ‡ Think first about your left foot. Your toes are relaxed and still. Check up on this because some people move them when they are tense. Your foot is resting easily on the floor.
13
‡ Now your right foot/toes/ankles. Next concentrate on your thighs and legs. ‡ The back muscles relax when the back of a chair supports your spine. ‡ Let your abdominal muscles become soft and relaxed. No need to hold the stomach in tightly it rises and falls as you breathe quietly. ‡ Now the fingers of the left hand - they should be curved, limp and quite still. Do the same for the fingers of the right hand. ‡ Let the feeling of relaxation spread up your arms to the shoulders. Let your shoulders relax. Let them drop easily. Feel them relax further than you thought they could. ‡ Relax your neck muscles. ‡ Let your face relax. Let the expression come off it. Make sure your teeth are not held tightly together. Let your jaw relax. This will mean that your checks and lips are relaxed, as there is no need to keep up an expression. ‡ Relax your forehead so it feels a little higher and wider than before. ‡ Now become aware of an all over sensation of relaxation, of quiet and rest. Feel peaceful, rested and quiet. ‡ Stay like this, listening to your breathing. Try to picture a relaxing scene in your mind. Imagine relaxing music. Keep concentrating on your breathing and staying relaxed.
14
‡ When your relaxation time is up - start to wiggle your hands and legs a little, then open your eyes and sit quietly for a moment. - have a stretch, perhaps a yawn, feel refreshed and alert again! Choosing an appropriate method There are other methods of relaxation, all beneficial, but very much to individual taste. You may need to find out if there are any classes near you. Alexander technique Music Deep breathing methods Hobbies Massage and Aromatherapy Meditation Physical activity Tai chi Yoga Pilates These are all general principles, which may help you after you leave hospital. Remember you can always seek further advice from your cardiac rehabilitation team at the Royal Free on 0207 794 0500 ext. 3145, who will be happy to support you through recovery from your cardiac event.
15
Useful contacts
NHS Direct 0845 4647
Your GP for access to counsellors; or ring the following direct: Highgate Counselling Services 020 8883 5427 Hampstead Counselling Service 020 7485 7335 Tavistock Clinic (18-26 years) 020 7447 3742 MIND MIND Crisis Samaritans 020 7272 6797 020 7272 7722 020 7734 2800
Some organisations may charge a fee for counselling sessions.
16
1
Exercise
Exercise can help you to return to a full and active lifestyle and may help to prevent further damage to your heart. The best form of exercise is one that you really enjoy and can fit into your daily routine. Exercise has many beneficial effects, such as: ‡ Decreasing blood pressure ‡ Reducing stress ‡ Improving stamina ‡ Controlling blood sugar levels ‡ Lowering cholesterol levels ‡ Helping you loose fat and gain muscle Over the course of the next few months you should follow a progressive exercise programme. This will ensure you get the benefits of exercise without overdoing it or doing too much too soon. What type of exercise? You should do something that uses your leg muscles in steady rhythmic movement - initially walking is the best thing, or cycling. As you become fitter you can add other activities such as exercise classes, dancing, tennis, badminton, golf and swimming. (If you have had surgery, you should not swim for three months afterwards.)
2
How long should you exercise? At first, exercise only for short periods: 5-10 minutes, 1-2 times per day. You build up to 30 minutes of exercise on at least 5 days a week. Always start and finish sessions with warm-up/ cool down exercises. This gives the heart time to adjust to the altered levels of activity and so reduces the risk of sudden changes in blood pressure and abnormal heart rhythms. How hard should you exercise? In order to benefit, you need to exercise at a pace that makes you warm and increases your heart rate and breathing. To help you judge the right level we use the following scale (which we refer to as the Borg Scale): 0 1 2 3 4 5 6 7 8 9 10 nothing at all very light fairly light moderate fairly hard hard hard very hard very tiring very very hard exhausting
Rating your exertion whilst you are exercising involves noticing how your whole body feels, in particular paying attention to your breathing - is it slow or fast, do you feel tight in your chest or struggling to catch your breath?
3
The programme (i) WARM-UP / COOL DOWN (LEVELS 1-3) Do these exercises immediately before and after your walk. You can do them standing or sitting in an upright chair. Stand or sit tall, shoulders down and back and tummy muscles pulled in. ‡ March on the spot for 30 seconds. ‡ Roll shoulders forwards; then up to the ears; then down & back six times. ‡ Swing alternating arms as if walking briskly. ‡ Repeat whole sequence three times. MAIN
EXERCISE
1 Walking Fairly light / moderate 5 mins 1-2 times daily 2 Walking Fairly light / moderate 10 mins 1-2 times daily 3 Walking Fairly light / moderate 15 mins 1-2 times daily
Now that you can walk at a moderate pace for 15 minutes you may like to add some variety to your exercise plan. Cycling is excellent for your heart and can be done instead of walking. As before, start off slowly with 5-10 minutes, at a pace that feels fairly light to moderate. Gradually build up.
4
Frequency
Perceived exertion
Exercise
Level
Time
The programme (ii) WARM-UP / COOL DOWN (LEVELS 4-6) At the start of your walk, spend 5 minutes walking slower than your exercise pace. This prepares your muscles and heart for the brisker pace. At the end of your walk, again spend 5 minutes walking slower than your exercise pace. This allows your heart and muscles to gently recover.
MAIN
EXERCISE
4 Walking 5 Walking 6 Walking
Moderate Moderate Moderate
20 mins 25-30 mins 30-60 mins
1-2 times daily 1-2 times daily daily
Once you can walk at a moderate pace for 30-60 minutes, you may like to add dancing, golf, tennis or badminton to your programme. Stay noncompetitive & keep exertion fairly light /moderate. Overall, you should be aiming to do 30 minutes of exercise on five days of the week.
5
Frequency
Perceived exertion
Exercise
Level
Time
How to use the exercise programme The programme has six levels. Begin at a level you can easily achieve (for most people this will be at level 1 or 2). You should feel warm, but not over-heated, and your breathing should be faster, but not so fast that you feel uncomfortable and are unable to carry out a conversation. ‡ÿ Stay on this level for as long as it is exerting you fairly lightly to moderately. If it feels too hard, drop down a level. If it feels fairly light to moderate, stay on this level until it starts to feel very easy or very light, then it is time to move up to the next level. ‡ Once you reach level 6 of the programme you are doing just the right amount of exercise to benefit your heart. Some people reach this level very quickly, others may take a year or more! It is important to progress slowly at a pace that you feel comfortable with. ‡ Some of you will also be joining an exercise group in the hospital, where we can help you to choose activities and sports to make your exercises more varied and enjoyable.
6
Sexual activity Many people with heart disease continue to enjoy sexual activity. Following a heart attack or surgery it is usually perfectly safe to resume sexual activity as soon as you feel ready. Find a position that suits you and your partner. Apply the same common sense as with exercising. As a rough guide, if you can climb up and down two flights of stairs without discomfort you are fit enough to resume sexual activity. If you experience angina or discomfort during sexual intercourse, it is advisable to stop and administer GTN spray/tablets if applicable and wait until you are pain-free before resuming.
Stress and relaxation
Stress varies for different people but usually stems from an imbalance between the demands being made on you & how you think you can cope. Remember that a certain amount of stress is normal and healthy. However, too much can cause harm and trigger a stress response, which is your body’s attempt to cope with a difficult situation. You need to find a balance between life’s demands and your coping resources.
7
Type of stress Stress can come from within you (internal) or from outside (external), for example: Internal - poor diet, lack of consistency within work or personal life, unresolved conflicts. External - noise, pollution, poor working conditions, bereavement, marriage breakdown. Fight or flight The automatic reaction to a threatening situation is known as the ‘fight or flight’ response. It equips us to fight or escape from an enemy - or in this case the difficult situation. Worrying thoughts, memories or events can turn on adrenaline - part of nature’s way of helping you cope with danger.
8
Effects of stress Emotional Anxiety: nervousness tension phobias panic attacks Depression: sadness lowered self-esteem apathy fatigue Guilt and shame Physical Moodiness Increased heart rate Loneliness Increased blood pressure Anger Difficulty breathing Muscle contraction / aches Hot and colds spells Dilated pupils Frequent urination Numbness &tingling sensation Increased blood glucose levels Mental Difficulty in concentrating Difficulty in making decisions Frequent forgetfulness Increased sensitivity to criticism Negative self-critical thoughts Distorted ideas More rigid attitudes
9
Behavioural Difficulty sleeping Emotional outbursts/aggression Excessive eating/loss of appetite Excessive drinking and smoking Accident prone Avoidance of particular situations Inactivity
Effects on health Coronary heart disease Hypertension and strokes Stomach ulcers/nausea/colitis Migraine/headaches/skin rashes Diarrhoea Organisational Absenteeism Poor industrial relations High accident rate Poor productivity Job dissatisfaction
10
Why is stress common in people who have heart problems? Having any kind of heart problem can be a frightening experience, not only for you but also for your family. It is natural to be worried even if it is difficult to put into words exactly why. People often experience some degree of anxiety about the possibility of another cardiac event; or the success of the operation that took place; or how well they will cope at home. A cardiac event can be a blow to your selfconfidence, especially if you have not had any serious health problems before and it is easy to become depressed. In the first few weeks after your cardiac event or surgery there are so many things going on and so much to think about that depression may not be obvious. Depression can be experienced in different ways: ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Sadness Loss of enjoyment in hobbies Loss of interest in sex Low self-esteem Poor concentration Sleeping badly Lack of appetite Constant tiredness Short temper
11
These problems usually settle down if, and when, the person returns to work and life starts getting back to normal. It is important to remember that anxiety and depression is common and often relieved by help. Discussing your thoughts and feelings with someone who has gone through the same experience as you may ease your problems. Many rehabilitation centres have selfhelp groups, which can give long-term support therapy where it is needed. Also your GP surgery may offer support and counselling. Relaxation Relaxation allows mental and physical tension to be released. The type of relaxation that really makes a difference in dealing with stress and tension is regular, daily practice of some form of deep relaxation. It is a skill that has to be learnt until it becomes second nature, and is more than simply sitting down and taking it easy for a few moments. Some people find using a relaxation tape helps focus their mind, which enables relaxation. Find one that suits you, often a favourite piece of soothing music is all that is needed to create an atmosphere in which you are more able to relax – avoid any heavy music with a regular beat! You may like to make your own relaxation tape.
12
5 MINUTES OF SIMPLE RELAXATION This is a simple form of relaxation for occasions when you only have a short time to spare. It is more comfortable in a chair with armrests, but it can be done in an upright chair. Try to ensure a full five minutes of undisturbed quiet. ‡ Sit upright & well back in the chair so that your thighs and back are supported. Rest your hands lightly on the arms of the chair or in your lap. ‡ Close your eyes gently, settle down comfortably and begin by breathing, out first then breathe in, easily and just as much as you need. Now breathe out slowly with a slight sigh, like a balloon slowly deflating. ‡ Do this once more very slowly and as you breathe out feel the tension begin to drain away. Then go back to your ordinary breathing, even, quiet and steady. ‡ Now direct your thoughts to each part of your body in turn, to the muscles and joints. The order of relaxation is as follows: ‡ Think first about your left foot. Your toes are relaxed and still. Check up on this because some people move them when they are tense. Your foot is resting easily on the floor.
13
‡ Now your right foot/toes/ankles. Next concentrate on your thighs and legs. ‡ The back muscles relax when the back of a chair supports your spine. ‡ Let your abdominal muscles become soft and relaxed. No need to hold the stomach in tightly it rises and falls as you breathe quietly. ‡ Now the fingers of the left hand - they should be curved, limp and quite still. Do the same for the fingers of the right hand. ‡ Let the feeling of relaxation spread up your arms to the shoulders. Let your shoulders relax. Let them drop easily. Feel them relax further than you thought they could. ‡ Relax your neck muscles. ‡ Let your face relax. Let the expression come off it. Make sure your teeth are not held tightly together. Let your jaw relax. This will mean that your checks and lips are relaxed, as there is no need to keep up an expression. ‡ Relax your forehead so it feels a little higher and wider than before. ‡ Now become aware of an all over sensation of relaxation, of quiet and rest. Feel peaceful, rested and quiet. ‡ Stay like this, listening to your breathing. Try to picture a relaxing scene in your mind. Imagine relaxing music. Keep concentrating on your breathing and staying relaxed.
14
‡ When your relaxation time is up - start to wiggle your hands and legs a little, then open your eyes and sit quietly for a moment. - have a stretch, perhaps a yawn, feel refreshed and alert again! Choosing an appropriate method There are other methods of relaxation, all beneficial, but very much to individual taste. You may need to find out if there are any classes near you. Alexander technique Music Deep breathing methods Hobbies Massage and Aromatherapy Meditation Physical activity Tai chi Yoga Pilates These are all general principles, which may help you after you leave hospital. Remember you can always seek further advice from your cardiac rehabilitation team at the Royal Free on 0207 794 0500 ext. 3145, who will be happy to support you through recovery from your cardiac event.
15
Useful contacts
NHS Direct 0845 4647
Your GP for access to counsellors; or ring the following direct: Highgate Counselling Services 020 8883 5427 Hampstead Counselling Service 020 7485 7335 Tavistock Clinic (18-26 years) 020 7447 3742 MIND MIND Crisis Samaritans 020 7272 6797 020 7272 7722 020 7734 2800
Some organisations may charge a fee for counselling sessions.
16
