12.1 Cardiac Rehabilitation Phases & Metabolic Equivalents

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1 Chapter 1: Introduction & Exam Overview

1.1 ABPMR Part I Exam Overview & Format 1.2 Board Review Strategy & Content Blueprint Breakdown

2 Chapter 2: Musculoskeletal Medicine

2.1 Shoulder & Upper Extremity Diagnostics 2.2 Knee, Hip & Lower Extremity Conditions 2.3 Spine Pathology, Radiculopathy & Myelopathy 2.4 Inflammatory Arthritis, Tendinopathies & Concussion 2.5 Bone Health, Osteoporosis & Metabolic Bone Disease 2.6 Thoracic Outlet Syndrome & Peripheral Nerve Entrapment 2.7 Fracture Rehabilitation & Immobilization Complications 2.8 Overuse Tendinopathies & Regenerative Medicine 2.9 Gait Analysis & Abnormal Gait Patterns

3 Chapter 3: Spinal Cord Injury Rehabilitation

3.1 ASIA Examination & Impairment Scale 3.2 Spinal Cord Injury Syndromes 3.3 Autonomic Dysreflexia & Acute Complications 3.4 Neurogenic Bladder, Bowel & Secondary Complications

4 Chapter 4: Stroke & Neuromuscular Rehabilitation

4.1 Stroke Vascular Syndromes & Acute Assessment 4.2 Stroke Motor Recovery & Hemiplegic Complications 4.3 Spasticity Assessment & Multimodal Management 4.4 ALS, GBS, CIDP & Neuromuscular Disease Rehab 4.5 Multiple Sclerosis & Demyelinating Disease Rehabilitation 4.6 Parkinsonism, Movement Disorders & Functional Neurologic Disorder

5 Chapter 5: Electrodiagnostics (EMG/NCS)

5.1 Nerve Conduction Studies Principles & Physics 5.2 Needle Electromyography & MUAP Analysis 5.3 Mononeuropathies & Radiculopathy Patterns 5.4 Neuromuscular Junction Disorders & Myopathies

6 Chapter 6: Traumatic Brain Injury

6.1 TBI Severity Classification, Glasgow Coma Scale, and Pathophysiology 6.2 Rancho Los Amigos Levels of Cognitive Functioning and Disability Rating Scale 6.3 Neurobehavioral Sequelae and Agitation Management 6.4 Concussion Evaluation, Vestibular-Ocular Dysfunction, and Return-to-Play/Work Protocols

7 Chapter 7: Chronic Pain & Interventional Spine

7.1 Fluoroscopic Spine Interventions 7.2 Opioid Stewardship & Controlled Substance Compliance 7.3 Complex Regional Pain Syndrome, Fibromyalgia & Myofascial Pain 7.4 Spinal Cord Stimulation & Intrathecal Therapy

8 Chapter 8: Amputee Rehabilitation & Prosthetics

8.1 Amputation Surgical Levels & Medicare K-Levels 8.2 Socket Designs & Suspension Systems 8.3 Prosthetic Feet & Microprocessor Knee Mechanisms 8.4 Post-Amputation Care, Residual Limb & Phantom Pain

9 Chapter 9: Pediatric Rehabilitation

9.1 Cerebral Palsy Classification & GMFCS 9.2 Spina Bifida & Myelomeningocele Management 9.3 Muscular Dystrophies & Neuromuscular Disease in Children 9.4 Pediatric Brachial Plexopathy & Congenital Disorders

10 Chapter 10: Prosthetics, Orthotics & Assistive Technology

10.1 Lower Limb Orthoses — AFOs & KAFOs 10.2 Spinal & Upper Extremity Orthoses 10.3 Upper Limb Prosthetics — Body-Powered vs Myoelectric 10.4 Wheelchairs, Seating Systems & Pressure Mapping

11 Chapter 11: Medical Rehabilitation & Outcomes

11.1 Dysphagia Assessment & Management 11.2 Neurogenic Bladder & Bowel Management 11.3 Pressure Injuries & Wound Management 11.4 Outcome Measures & Medical Complications 11.5 Cancer Rehabilitation & Oncologic Rehabilitation 11.6 Burns, Endocrine/Metabolic & Medical Complications Rehabilitation

12 Chapter 12: Cardiopulmonary Rehabilitation

12.1 Cardiac Rehabilitation Phases & Metabolic Equivalents 12.2 Pulmonary Rehabilitation & COPD Management

13 Chapter 13: Foundational Rehabilitation Concepts

13.1 Kinesiology, Biomechanics & Functional Anatomy 13.2 Rehabilitation Pharmacology & Medication Management 13.3 Research Methodology, Biostatistics & Evidence-Based Practice 13.4 Nutrition, Metabolism & Energy Expenditure in Rehabilitation 13.5 Diagnostic Procedures: Imaging, MSK Ultrasound, Urodynamics & Neuropsych Assessment

12.1 Cardiac Rehabilitation Phases & Metabolic Equivalents

Key Takeaways Explain This Topic AI

Cardiac rehabilitation is structured into four distinct phases: Phase I (inpatient acute/early recovery, MET 1-3, target HR resting + 20 post-MI or +30 post-CABG), Phase II (outpatient ECG-monitored telemetry 12-36 sessions), Phase III (outpatient unmonitored maintenance 6-12 months), and Phase IV (long-term community wellness).

Strict sternotomy precautions post-CABG require avoiding bilateral upper extremity elevation above 90 degrees, avoiding pushing/pulling >10 lbs, and limiting lifting to 5-10 lbs for 6 to 8 weeks to prevent sternal dehiscence.

One Metabolic Equivalent (MET) represents resting oxygen consumption (3.5 mL O2/kg/min). Functional activity classification ranges from MET 1 (rest), MET 2-3 (light self-care/dressing), MET 3-4 (walking 3.0 mph/light housework), MET 5-6 (walking 4.0 mph/gardening), to MET 7-8 (jogging 5.0 mph/heavy manual labor).

The Borg Rating of Perceived Exertion (RPE 6-20 scale) correlates linearly with heart rate (RPE x 10 ≈ HR) and serves as the primary intensity monitoring tool for patients on beta-blockers or with chronotropic incompetence where target heart rate equations are invalid.

Target exercise intensity for Phase II cardiac rehabilitation is RPE 12-14 ('somewhat hard'), corresponding to 40%-80% heart rate reserve or VO2 peak.

Last updated: July 2026

Overview of Cardiac Rehabilitation

Cardiac rehabilitation is a comprehensive, evidence-based secondary prevention intervention designed to optimize physical, psychological, and social functioning in individuals recovering from acute cardiovascular events or cardiac surgery. Key candidates include patients post- myocardial infarction (MI) , coronary artery bypass graft (CABG) surgery, percutaneous coronary intervention (PCI) , stable angina, heart valve repair/replacement, heart transplantation , or stable chronic heart failure ( L V E F ≤ 35 % LVEF \le 35\% L V EF ≤ 35% ). The physiatrist leads the multidisciplinary team in risk stratification, exercise prescription, and monitoring for cardiac complications.

Phases of Cardiac Rehabilitation

Cardiac rehabilitation is structured into four sequential phases, progressing from acute inpatient recovery to lifelong independent maintenance.

Phase I: Inpatient Acute / Early Recovery Phase

Setting & Duration : Initiated in the inpatient acute care setting post-event or surgery, lasting 2 to 5 days for uncomplicated cases.

Core Goals : Prevent bed-rest complications (e.g., muscle deconditioning, orthostatic hypotension, deep vein thrombosis, atelectasis), facilitate early ambulation, provide risk-factor education, and prepare for discharge.

Hemodynamic Limits & Target Heart Rate :

Post-MI Target Heart Rate : Resting HR + 20 bpm (upper limit ≤ 120 bpm \le 120\text{ bpm} ≤ 120 bpm ).

Post-CABG Target Heart Rate : Resting HR + 30 bpm (upper limit ≤ 120 bpm \le 120\text{ bpm} ≤ 120 bpm ).

Blood Pressure Limits : Resting SBP < 200 mmHg < 200\text{ mmHg} < 200 mmHg and DBP < 110 mmHg < 110\text{ mmHg} < 110 mmHg .

Permissible Intensity : Restricted to low-level exertion ( 1.0 to 3.0 METs ), including bedside hygiene, sitting in a chair, active range-of-motion, and short hallway ambulation.

Sternotomy Precautions : For post-CABG or open cardiac surgery via median sternotomy, strict sternal precautions are maintained for 6 to 8 weeks to ensure bone healing and prevent sternal dehiscence:

Restrict lifting, carrying, pushing, or pulling to 5 to 10 lbs .

Avoid bilateral upper extremity elevation above 90 degrees .

Avoid pushing up from a chair using upper arms during transfers.

Hug a sternal chest pillow tightly against the sternum during coughing or transfers.

Phase II: Outpatient ECG-Monitored Aerobic Conditioning

Setting & Duration : Initiated 1 to 3 weeks post-discharge in an outpatient center, spanning 12 to 36 sessions (3 sessions/week over 4 to 12 weeks).

Telemetry ECG Monitoring : Employs continuous or intermittent telemetry ECG monitoring to detect exercise-induced ST-segment shifts, angina, or complex arrhythmias.

Exercise Prescription (FITT Principle) :

Frequency : 3 to 5 days per week.

Intensity : 40% to 80% of Heart Rate Reserve (HRR) or V O 2 peak VO_2\text{ peak} V O 2 ​ peak , or target Borg RPE 12 to 14 ('somewhat hard').

Time : 20 to 60 minutes of continuous or interval aerobic exercise per session (with 5–10 min warm-up/cool-down).

Type : Aerobic activities (treadmill walking, stationary cycling, arm ergometry, elliptical training).

Progressive Resistance Training : Low-weight resistance training (1–5 lbs, 10–15 repetitions at RPE 11–13) can be introduced after 2 to 4 weeks of stable aerobic training in Phase II (or 5–8 weeks post-CABG with a stable sternum).

Risk Stratification :

Low Risk : LVEF > 50 % > 50\% > 50% , no exercise-induced angina or ST depression, no complex arrhythmias.

Moderate Risk : LVEF 40 % – 49 % 40\%–49\% 40%–49% , mild-to-moderate angina or ST depression ( > 1 mm > 1\text{ mm} > 1 mm ) at moderate workloads ( > 5 – 7 METs > 5–7\text{ METs} > 5–7 METs ).

High Risk : LVEF < 40 % < 40\% < 40% , severe exertional ischemia, post-infarct angina, or complex ventricular arrhythmias at low workloads ( < 5 METs < 5\text{ METs} < 5 METs ). High-risk patients require continuous ECG telemetry for 18 to 36 sessions.

Phase III: Outpatient Unmonitored Maintenance

Setting & Duration : Outpatient facility setting lasting 6 to 12 months .

Features : ECG telemetry is discontinued ( unmonitored phase ). Patients exercise independently with periodic supervision, focusing on maintaining aerobic capacity and solidifying permanent health behavior changes.

Phase IV: Long-Term Community Maintenance & Wellness

Setting & Duration : Lifelong, self-directed program in community fitness facilities (e.g., YMCA) or home environments.

Features : Completely unmonitored physical activity, focusing on long-term adherence to aerobic exercise, Mediterranean/DASH diet, smoking cessation, and stress management.

Phase Setting & Duration ECG Telemetry Intensity & Target HR Primary Goals & Key Precautions

Phase I Inpatient acute; (2–5 days) Continuous bedside telemetry 1.0–3.0 METs; Post-MI: Resting HR + 20 bpm; Post-CABG: Resting HR + 30 bpm Early ambulation, prevent deconditioning.; Sternal precautions : No lifting >5-10 lbs, no arm elevation >90° for 6-8 wks.

Phase II Outpatient supervised; (12–36 sessions) Continuous / intermittent telemetry 40%–80% HRR / V O 2 peak VO_2\text{ peak} V O 2 ​ peak ; Borg RPE 12–14 Aerobic conditioning, functional recovery.; Resistance training added after 2-4 wks if stable.

Phase III Outpatient unmonitored; (6–12 months) None (unmonitored) Borg RPE 12–15; 50%–85% HRR Maintenance of aerobic capacity, self-monitoring of heart rate and exertion.

Phase IV Community / Home; (Lifelong) None Borg RPE 12–15 Long-term wellness, lifestyle maintenance, secondary prevention.

Metabolic Equivalents (METs) in Rehabilitation

A Metabolic Equivalent (MET) represents resting basal oxygen consumption ( V O 2 VO_2 V O 2 ​ ), defined as 3.5 mL O2/kg/min in a resting adult.

Clinical Application & Activity Spectrum

Baseline Living Requirement : A capacity of 3.0 to 4.0 METs is required for basic independent community living and personal self-care.

Work Capacity Clearance : Sedentary desk work requires 1.5 to 2.0 METs , whereas heavy manual labor requires 7.0 to 8.0+ METs .

• MET Range Exertion Level ADL / Self-Care Examples Recreational / Occupational Examples
• MET 1.0 – 1.5 Rest / Minimal Lying quietly, sitting in chair, watching TV Typing, writing, computer desk work

MET 2.0 – 3.0 Light Seated grooming, shaving, sponge bath, dressing Walking slowly (2.0 mph), playing cards, seated craft work

MET 3.0 – 4.0 Light-to-Moderate Standing warm shower, sweeping floors, vacuuming Walking at 3.0 mph, light gardening, archery, bowling

MET 5.0 – 6.0 Moderate Digging in garden, push-mowing lawn Walking briskly (4.0 mph), cycling 10-12 mph, ballroom dancing

MET 7.0 – 8.0 Vigorous Carrying heavy loads up stairs, shoveling snow Jogging (5.0 mph), singles tennis, moderate lap swimming

MET > 8.0 Very Vigorous Heavy agricultural shoveling Running (6.0+ mph), competitive basketball, cross-country skiing

Borg Rating of Perceived Exertion (RPE)

The Borg Rating of Perceived Exertion (RPE) scale is a validated numerical tool (6 to 20) constructed to correlate linearly with heart rate in healthy adults ( R P E × 10 ≈ Heart Rate in bpm RPE \times 10 \approx \text{Heart Rate in bpm} RPE × 10 ≈ Heart Rate in bpm ).

Clinical Utility in Patients on Beta-Blockers

Patients taking beta-adrenergic blockers (e.g., metoprolol, carvedilol) or those with chronotropic incompetence exhibit a blunted heart rate response during exercise, rendering age-predicted target heart rate formulas inaccurate. In these patients, the Borg RPE scale serves as the gold standard for prescribing exercise intensity.

• Borg Score Perceived Exertion Level % Heart Rate Reserve (% HRR) Rehabilitation Clinical Target
• 6 Rest / No exertion < 20% Baseline resting state
• 11 – 13 Fairly light to Somewhat hard 40%–60% Phase I discharge / Early Phase II warm-up
• 12 – 14 Somewhat hard 60%–70% Primary target intensity for Phase II & III aerobic conditioning
• 15 – 16 Hard (Heavy) 70%–85% Advanced aerobic training in low-risk Phase III/IV patients
• 19 – 20 Maximal exertion 100% Exhaustive exercise stress testing endpoint
• Exercise Precautions & Termination Criteria
• Absolute Contraindications to Exercise Rehabilitation

Acute myocardial infarction within 2 days .

Unstable angina pectoris.

Uncontrolled cardiac arrhythmias causing symptoms or hemodynamic instability.

Symptomatic severe aortic stenosis .

Uncontrolled symptomatic heart failure.

Acute pulmonary embolism, pulmonary infarction, or deep vein thrombosis.

Acute myocarditis, pericarditis, or aortic dissection.

Criteria for Immediate Exercise Termination

Drop in SBP > 10 mmHg > 10\text{ mmHg} > 10 mmHg below baseline with increasing workload accompanied by ischemic symptoms.

Moderate to severe angina pectoris (Grade 3 or 4).

Central nervous system symptoms (ataxia, dizziness, presyncope).

Sustained ventricular tachycardia or ST elevation > 1.0 mm > 1.0\text{ mm} > 1.0 mm in non-Q wave leads.