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1/2Cardiopulmonary Physical Therapy Journal  Vol 23 v No 3 vSeptember 201246

Program Description:Physical Therapy in a Heart Failure Clinic

 Ann Knocke, MS, PT, CCS

Newton Wellesley Hospital, Physical Therapy Department, Wellesley, MA

ABSTRACTAerobic exercise and resistance training have been provento be beneficial for patients with heart failure. Currentreimbursement guidelines exclude these patients from ourtraditional cardiac rehabilitation program, so at NewtonWellesley Hospital a clinic model was developed for thedisease management and exercise of heart failure patients.

Key Words: heart failure, physical therapy, exercise

INTRODUCTIONNewton Wellesley Hospital (NWH) is a 289 bed

teaching hospital located about 15 miles west of Boston,Massachusetts. Our Cardiovascular Health Center offers6 Phase II cardiac rehabilitation classes, serving patientsafter myocardial infarction, coronary bypass surgery,valve surgery, and angina. In addition, we run a diseasemanagement program for patients with heart failure (HF).Referrals come from inpatient admissions for acute onset HFand referrals from cardiologists and primary care physicians.This HF clinic is a nurse practitioner (NP) based clinic thatoffers disease management, education, exercise, and longterm follow-up. There are dieticians and physical therapists

involved in the education and exercise components of theprogram. The program uses a multidisciplinary model,which affords us the opportunity to incorporate each teammember’s expertise into a comprehensive patient care planthat positively impacts outcomes.

The CHF program began in 1996 by a NP and a physicaltherapist. The practitioners recognized the exclusion of HFpatients from traditional cardiac rehabilitation programsand a more flexible, fluid, clinic model was developed. Atthe beginning of the program there were only 5 patientsenrolled at a time, building gradually, with an estimated500 patients participating to date. The current enrollmentincludes 64 patients for the exercise class, which is offeredtwice per week. Patients range in age from 52-92 years,33 males and 31 females. The diagnosis of diastolic HFaccounts for approximately 70% of the current group ofpatients, with the remainder diagnosed with systolic HF.At NWH we have an “identify and connect” program that

alerts the NPs to any patient admitted with a diagnosisof HF. Based on their status and preference, patients areenrolled to nursing only visits or nursing visits with exercisePatients are also referred by their cardiologist directly to theclinic from NWH and outlying hospitals.

Upon entrance into the program patients undergo anevaluation by the NP, assessing current physical status andmedical regiment, with particular attention to signs andsymptoms of HF and weight gain. Brain naturetic peptide(BNP) level is followed closely, as well as renal function, in

the titration and selection of medications. At each visit thepatients are reassessed by an NP, or nurse, for vital signs,weight, breath sounds, edema, and symptoms. If a patienhas gained more than 3 pounds (1.4 kg) since the priorsessions, the patient is not permitted to exercise.

Prior to entering the exercise program, patients areevaluated by a physical therapist. This evaluation includesa musculoskeletal screening, 6 minute walk test withtelemetry monitoring, balance screening, and self-report oprior and current exercise routines. Following the results othe six-minute walk test (6MWT), a target heart rate rangeis determined, at 50% to 70% of 220-age.1-4 Patients areeducated in the use of the Borg 6-20 rating of perceived

exertion scale, with instruction to work at a level of 11-13,or moderate exercise.1-4

Exercise prescription is then determined, following theAmerican Heart Association and the American College ofSports Medicine guidelines.5 Intensity is recommendedto be within the target heart rate range and/or perceivedexertion rating of 11-13 (moderate level). Duration istargeted at 30 to 40 minutes of aerobic exercise, beginningwith the amount the patient is able to perform at the time.Frequency is recommended to be 5 to 7 days per weekPatients are monitored with telemetry for the first 3 exercisesessions, and then continue without telemetry unless thereare rhythm or ectopy concerns. Patients are monitoredfor heart rate and blood pressure throughout the exercisesessions, and after 5 minutes of recovery. Oxygen saturationis measured as well. The examination and management opatients in the HF clinic is outlined in Figure 1.

Modes of exercise include treadmills, upright andrecumbent bikes, elliptical machines, and NuStep™machines. The NuStep™ is a seated stepping and uppeextremity exercise machine. It is well tolerated by patientswith common comorbidities such as back pain, balancedifficulties, and lower extremity weakness; this is one ofthe preferred machines by our patients. Considerations

Address correspondence to: Ann Knocke MS, PT, CCS,Newton-Wellesley Hospital, Washington Street, New-ton, MA Ph: (617) 243-6172 (aknocke@partners.org).

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are taken into account for orthopedic impairments, pain,balance abnormalities, and personal preferences. Patientsare encouraged to experiment with various machines

for variety and carryover to health clubs or senior centerexercise rooms, as well as for determining the best machineto purchase for home.6,7 When appropriate, patientsare referred for individual physical therapy services, forexample balance training, which can be coordinated onthe same visit day as the clinic.

Exercise is progressed as tolerated, with verydeconditioned patients beginning with 5 minutes of exercise,followed by a rest period, continuing in intervals. Morefit individuals begin with 30 minutes continuous exercisethe first session, with warm-up and cool-down as well.Light resistance exercise is added when appropriate, taughtindividually with an emphasis on simple exercises that can

be reproduced at home. Stretching is recommended andinstructed for the working muscle groups. The HF programruns for 12 months throughout which patients can movefrom one phase to another if their medical status changes(Figure 2).

The diagnosis of HF is not recognized by Medicare asa Cardiac Rehabilitation diagnosis; thus, patients are billedonly for the nursing visits. One of the primary goals of theprogram is to prevent readmissions for HF. Our 30 day allcause readmission rate at NWH was recently estimated at15% with 7.5% for acute HF. National estimates in thesame time period were 24% all cause and 17% acute HFreadmissions. As health policy evolves and reimbursement

may be spread over the course of an illness, rather thanservice based, this model may prove to be very cost effectivefor HF patients.

SUMMARYIn summary, we have developed a disease management

program that incorporates physical therapist directedexercise training for our HF patients. This allows us to servethis population despite their falling outside the traditionalcardiac rehabilitation model. Our patients benefit fromthe more frequent nursing assessments, training effects,

and social interactions that the clinic provides. As onepatient reported, “The program has increased my mobilityendurance, capacity, and tolerance. It has taught me howto care for myself.”

REFERENCES1. Bartlo P. Evidence-based application of aerobic and

resistance training in patients with congestive hear

failure.  J Cardiopulm Rehabil Prev . 2007;27:368-375.2. Mandic S, Tymchak W, Kim D, et al. Effects of aerobic oaerobic and resistance training on cardiorespiratory andskeletal muscle function in heart failure; a randomizedcontrolled pilot trial. Clin Rehabil . 2009;23(3):207-216

3. Arslan S, Erol MK, Gundogdu F, et al. Prognostic valueof a 6-minute walk test in stable outpatients with hearfailure. Tex Heart Inst J . 2007;34(2)166-169.

4. Haass, M, Zugck, C, Kubler, W. The 6 minute walking testa cost-effective alternative to spiro-ergometry in patientswith chronic heart failure? Z Kardiol . 2000;89(2):72-80

5. American College of Sports Medicine. ACSM’s Guidelinesfor Exercise Testing and Prescription. Lippincott William

& Wilkins; 2010.6. Bresnick B. Encouraging exercise in older adults withcongestive heart failure. Geriatr Nurs. 2004;25(4):204211.

7. Parish TR, Kosma M, Welsch MA. Exercise training fothe patient with heart failure: Is your patient readyCardiopulm Phys Ther J. 2007;18(3):12-20.

Figure 1. Examination and management of patients in theheart failure clinic.

 

Nursing check ‐ in

Weight

Heart rate

Blood pressure

Lung and heart sounds

Leg edema 

Exercise Session

5 min warm‐up

20‐30 min aerobic exs

5 min cool‐down

strength training

Check out by PT

5 min seated rest

HR and BP

Blood sugar 

Figure 2. The 3 phases of the heart failure clinic.

 

Clinic level II:

Twice weekly nursing 

assessment, exercise session 

with physical  therapists

6 months 

Clinic level I:

Once weekly nursing 

assessment, exercise  session 

with 

physical 

therapists

3 months

Maintainance :

Physical therapist assessment  

and 

exercise 

session

3 months

Erratum

Figure 1. Representative PA and lateral plain-film radiographs.

The complete radiograph from Sobush et al (June 2012 issue) wasinadvertently cut off. The full image is reprinted here.