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Ehtel Frese, PT, DPT, MHS, CCSEhtel Frese, PT, DPT, MHS, CCS

Ethel Frese, PT, DPT, MHS, CCS
Associate Professor, Department of Physical Therapy, School of Allied Health Professions, St Louis University

Congestive heart failure is a very common reason for hospitalization, with over 1 million congestive heart failure (CHF) admissions per year; readmission rates are 30% at 30-60 days. Identifying methods to reduce the frequency of hospitalization and the associated costs are critically important.

Early exercise training may be useful in reducing morbidity and mortality in CHF. Aerobic and strength training are both key as muscle strength is a key predictor of long term survival, better than peak VO2.

The 6 min walk test is commonly used to measure functional capacity.  A result under 300 meters is associated with increased mortality.  The test is sensitive to changes in cardiac function, and a difference of 99 feet is considered the minimal improvement of clinical  importance according to Ethel Frese.

Exercises with a variety of metabolic equivalent of task or MET level can be used. The lower the MET capacity, the shorter the duration of exercise routines and the higher their weekly frequency.  Frese said exercise training improves a wide variety of physiologic parameters and functional measures.

Frese shared that interval exercise, with periods of higher level exertion, leads to greater increases in exercise capacity compared to steady state training. Bicycle exercise is a good choice for this. Swimming is not recommended due to increased pressure and horizontal position increases venous return.  If aquatic training used, don't immerse above the level of the xiphoid process.

Preventing Rehospitalization of the CHF Patient: A Team Approach Several assessments should be made before exercising the patient with CHF: listen for S3, crackles, check the weight, look for edema, note changes in heart rate, rhythm and blood pressure at rest.  For strength training, use dynamics, not isometrics, using 4-6 exercises 2-3 times/week. Respiratory muscle training alone can increase exercise tolerance. Frese shared that neuromuscular electrical stimulation shows promise as an alternative modality in improving function.

While many elements contribute to likelihood of readmission to the hospital, the brain natriuretic peptide (BNP) level, pedal edema, and Kansas City Cardiomyopathy Questionnaire scores are among most important predictors of rehospitalization.

In summary, critical elements in the approach to treatment of the CHF patient include the use of a multidisciplinary team approach, improved education with the goal of self-management and self-regulation, development of patient centered care plans, accurate communication between transferring and accepting providers,  and the appropriate use of physical therapy and occupational therapy to increase activity levels.
Contributions from Paul McKinney, MD

By Ryan Squire