Cardiopulmonary, oncological, and pediatric rehabilitation. Cardiac rehabilitation: phases, functional assessment, risk stratification, exercise prescription, and training models. Pulmonary rehabilitation. PRM interventions in patients with cancer. PRM interventions for post-COVID condition and post-infectious functional impairments. Basic principles of PRM in pediatric patients

01Cardiac rehabilitation

Cardiac rehabilitation is the help a person gets after a heart event to get back to full life and avoid the next event. It is not only exercise. European guidance names its core parts: assessment, exercise training, physical activity advice, diet, weight, blood pressure, lipids, glucose, stopping smoking, psychological support, education and adherence to medicines.

The logic is simple. A damaged heart is often not the main limit to activity. Weeks of rest after an event weaken the legs, and fear stops people moving. Training makes the muscles take more oxygen from each litre of blood, so the heart has to pump less for the same walk; it lowers resting heart rate and blood pressure, improves the lining of the arteries and helps every risk factor at once.

Who is offered it:

• after an acute coronary syndrome (STEMI, NSTE-ACS), PCI or coronary bypass surgery;
• stable angina;
• chronic heart failure, also after a device (CRT, ICD, ventricular assist device) or heart transplantation;
• after valve surgery or transcatheter valve implantation;
• peripheral arterial disease, and as prevention in people at high risk.

Phases

In phase I, effort rises in small steps measured in METs (1 MET is the energy used sitting at rest, about 3.5 mL of oxygen per kg per minute): sitting and self-care at 1 to 2 METs, walking on the ward at 2 to 3 METs, a flight of stairs at about 4 METs. Each step is stopped if there is chest pain, breathlessness, a fall in blood pressure, an arrhythmia or a heart rate more than about 20 to 30 beats above rest.

Functional assessment

Before training, the team measures the heart's state and the person's capacity, to set a safe dose and a baseline.

The double product (heart rate times systolic pressure) tracks the heart's own oxygen demand: angina appears at about the same double product each time, which is why training, by lowering heart rate and pressure for a given task, lets the patient do more before angina.

Risk stratification

Risk stratification asks: how likely is this patient to have a dangerous event during exercise? The answer sets how much supervision and monitoring the training needs, not whether the patient trains.

Some conditions rule out exercise training until they are treated, because exercise would push an unstable heart over the edge:

• unstable angina or a recent acute coronary syndrome not yet stabilised;
• uncontrolled arrhythmias, high-degree heart block;
• decompensated heart failure;
• severe symptomatic aortic stenosis or obstructive cardiomyopathy;
• acute myocarditis or pericarditis, acute pulmonary embolism or DVT, aortic dissection;
• uncontrolled hypertension (resting pressure above about 180/110 mmHg);
• fever and acute illness.

Exercise prescription

Exercise is prescribed like a drug, with a dose. The dose has four parts, FITT: frequency, intensity, time and type.

The 2020 ESC guidelines grade intensity this way:

1. 1

   Find the peak

   From a symptom-limited exercise test, not 220 minus age, especially on beta-blockers, which blunt the heart rate.
2. 2

   Heart rate reserve

   Peak heart rate minus resting heart rate.
3. 3

   Target (Karvonen)

   Resting heart rate plus the chosen fraction of the reserve; for example rest 60, peak 160, at 60 per cent: 60 + 0.6 × 100 = 120 per minute.
4. 4

   Check it feels right

   Borg 12 to 13, "somewhat hard": the patient can talk but not sing.
5. 5

   Progress

   First lengthen the sessions, then raise the intensity, every 1 to 2 weeks as tolerated.

Stop a session for chest pain, unusual breathlessness, dizziness, a drop in systolic pressure with effort, a new arrhythmia or ST depression of more than about 2 mm.

Training models

• Continuous moderate-intensity training: the classic model: steady walking or cycling. Safe, simple, the basis for most patients.
• Interval training: short bouts at higher intensity alternating with recovery. High-intensity interval training (for example 4 bouts of 4 minutes at 85 to 95 per cent of peak heart rate) raises VO₂peak somewhat more in stable, low- and moderate-risk patients, and many find it less boring.
• Resistance training: added once aerobic training is established; strength makes daily tasks (carrying shopping, getting up) take a smaller share of maximum effort.
• Inspiratory muscle training: in heart failure with weak breathing muscles.
• Centre-based, home-based, hybrid and telerehabilitation: home and digital programmes give similar results for low- and moderate-risk patients and reach people who cannot travel; the high-risk start in a centre.
• Inpatient programmes in a rehabilitation clinic, used in central Europe after major surgery or a complicated event.

Other work fits the patient's day: walking on level ground and stairs, household tasks, return to driving when cleared, sexual activity (about 3 to 5 METs, like climbing two flights of stairs), and return to work.

Heart failure

In heart failure the muscles themselves change: fewer mitochondria, fewer capillaries, early fatigue. So training helps even when the pump does not improve much. The programme starts low (sometimes at 30 to 40 per cent of VO₂peak, short intervals), rises slowly and adds resistance and inspiratory muscle training. Daily weight is checked: a gain of about 2 kg in three days means fluid retention and a review before training.

Other cardiovascular conditions

• Hypertension. Regular aerobic exercise lowers blood pressure by about 8 mmHg systolic and 5 mmHg diastolic in people with hypertension, close to what one drug does; resistance and isometric handgrip training help too. Avoid heavy straining with a held breath while pressure is uncontrolled.
• Peripheral arterial disease. Supervised walking is first-line for intermittent claudication: walk until moderate to near-maximal calf pain, rest until it goes, walk again, for 30 to 60 minutes at least three times a week for at least 12 weeks. Walking at the edge of pain grows collateral vessels and makes the calf muscles use oxygen better, so the distance walked before pain grows.
• Chronic venous disease: exercises for the calf muscle pump (ankle pumps, walking), leg elevation, compression and weight control; avoid long standing and heat on the legs.
• Orthostatic hypotension: gradual changes of position, leg crossing and muscle tensing, compression, fluids; tilt table training in some patients.

02Pulmonary rehabilitation

Pulmonary rehabilitation is exercise training, education and behaviour change, built on a thorough assessment, to improve the body and the mood of people with chronic lung disease and help them keep healthy habits.

The logic is the breathlessness spiral. Breathlessness makes people avoid effort; avoiding effort weakens the legs; weak legs make more lactic acid at a lower effort, which drives breathing harder; so the same walk becomes more breathless. Rehabilitation breaks the spiral in the muscles, not the lungs: FEV1 barely changes, but trained legs need less ventilation for the same task.

Who benefits:

• COPD, the best-studied: anyone limited by breathlessness (mMRC grade 2 or more, the same as MRC grade 3 or more), and after a hospital stay for an exacerbation;
• bronchiectasis, interstitial lung disease, asthma with poor exercise tolerance, pulmonary hypertension, cystic fibrosis;
• before and after lung surgery and transplantation;
• after critical illness and COVID-19.

a typical programme, at least twice a week supervised

6–12weeksa typical programme, at least twice a week supervised

the average gain in COPD

about 40 mmore on the 6-minute walkthe average gain in COPD

start within this time after discharge for an exacerbation

3weeksstart within this time after discharge for an exacerbation

Assessment

• Lung function: spirometry (FEV1, FVC, their ratio, obstructive or restrictive pattern), lung volumes and diffusing capacity (DLCO) where needed.
• Breathlessness and its impact: the mMRC dyspnoea scale and the COPD Assessment Test (CAT).
• Exercise capacity: the 6-minute walk test or the incremental shuttle walk test, the 1-minute sit-to-stand test, oxygen saturation on effort (if it falls below about 88 per cent, oxygen during training), CPET where needed.
• Muscles: quadriceps and grip strength, inspiratory and expiratory mouth pressures (MIP, MEP).
• The rest: nutrition and body composition, anxiety and depression, heart disease, and the patient's goals.

Components

Breathing techniques

• Pursed-lip breathing: breathing out slowly through lips held as if whistling keeps a back-pressure in the airways, so floppy airways in COPD stay open longer and trapped air leaves. Breathing slows and breathlessness eases.
• Diaphragmatic breathing and breathing control: slow, relaxed breathing with the lower chest. Useful in many patients, but in severe COPD with a flat, overinflated diaphragm it may increase effort, so it is not forced on everyone.
• Thoracic expansion and segmental breathing: deep breaths aimed at one part of the chest, with a hold at the top, to open collapsed areas.
• Breathing pattern retraining for dysfunctional breathing (fast, upper-chest, sighing breathing), common in asthma and after COVID-19.

Airway clearance

Mucus that sits in the airways blocks them and feeds infection. Clearance techniques use airflow, gravity and vibration to move it up.

The aerosol therapy topic covers nebulised saline and drugs, often given just before airway clearance.

Acute respiratory disease and other conditions

• Pneumonia and acute bronchitis: in the acute phase, rest during fever, sitting up, breathing exercises, coughing and early walking; positioning with the healthy lung down improves oxygenation in one-sided pneumonia. Training starts once the fever has gone. See acute bronchitis.
• Intensive care: positioning (head of the bed up 30 to 45 degrees, prone position in severe ARDS), regular turning, early mobilisation.
• Asthma: regular exercise is encouraged. A long warm-up and a reliever inhaler before exercise prevent exercise-induced bronchoconstriction; swimming in warm, humid air is well tolerated.

03Rehabilitation in patients with cancer

More people now live for years after cancer, and many live with its effects and those of its treatment: fatigue, weakness, pain, nerve damage, lymphoedema, heart damage, bone loss. Oncological rehabilitation aims to keep or restore function at every stage. A classic scheme (Dietz) names four aims:

The main problems

• Cancer-related fatigue, the commonest symptom. Rest does not fix it; exercise is one of the best treatments.
• Deconditioning and muscle loss (cachexia, steroids, bed rest).
• Chemotherapy-induced peripheral neuropathy (platinum drugs, taxanes, vinca alkaloids): numb feet, poor balance, falls. Balance training, foot care, aids.
• Lymphoedema after lymph node removal or radiotherapy (arm after breast cancer, leg after gynaecological or prostate cancer).
• Cardiotoxicity (anthracyclines, trastuzumab, chest radiotherapy).
• Bone metastases and treatment-related osteoporosis, with fracture risk.
• Pain, shoulder stiffness after breast surgery, trismus and neck stiffness after head and neck cancer, cognitive problems, anxiety, depression, sexual problems and loss of work.

Exercise in cancer

The 2019 ACSM international roundtable reviewed the evidence and set a simple dose:

• aerobic exercise of moderate intensity, at least 30 minutes, at least 3 times a week, and
• resistance exercise at least 2 times a week, at least 2 sets of 8 to 15 repetitions of the major muscle groups at 60 per cent or more of the one-repetition maximum,
• for at least 8 to 12 weeks.

This dose improves fatigue, anxiety, depression, physical function and quality of life. In breast cancer-related lymphoedema, supervised resistance training that starts light and progresses slowly is safe and does not worsen the swelling. Overall, the message is "avoid inactivity": some movement is better than none, during and after treatment.

Safety follows from the treatment's effects:

Lymphoedema

Lymph fluid that cannot drain collects in the tissues; the limb swells, feels heavy and becomes fibrous. Complete decongestive therapy has two phases: first reduce the swelling with manual lymph drainage (a gentle skin massage that moves fluid towards working lymph nodes), multilayer compression bandaging, exercise and skin care; then maintain it with compression garments, exercise and skin care for life. Infection (cellulitis) is treated early, because each episode damages the lymph vessels further.

Physical agents in cancer

• TENS may be used for pain away from the tumour, and in palliative care for comfort.
• Photobiomodulation (low-level laser inside the mouth) is recommended to prevent oral mucositis in adults having high-dose chemotherapy before stem cell transplantation and in head and neck radiotherapy, with or without chemotherapy; it is not proven for treating mucositis once present.
• Cold, positioning, gentle massage away from the tumour, and hydrotherapy when the skin and counts allow.

04Post-COVID condition and post-infectious functional impairment

What it is

The WHO defines post COVID-19 condition as symptoms in someone with probable or confirmed SARS-CoV-2 infection, usually 3 months from the onset, that last at least 2 months and cannot be explained by another diagnosis. NICE NG188 uses time windows: acute COVID-19 up to 4 weeks, ongoing symptomatic COVID-19 from 4 to 12 weeks, and post-COVID-19 syndrome beyond 12 weeks; "long COVID" covers the last two.

Symptoms come in clusters and fluctuate: fatigue, breathlessness, cough, chest tightness, palpitations and dizziness on standing, "brain fog", poor sleep, muscle and joint pain, anxiety and low mood, and loss of smell and taste.

Assess before exercising

Exercise helps many people, but harms some. So four things are checked first:

Rehabilitation

• Pacing and energy conservation: plan, prioritise and spread activity within the "energy envelope", with rest before exhaustion. With post-exertional malaise this is the core treatment.
• Symptom-titrated exercise: without post-exertional malaise, start low and increase only if symptoms do not flare the next day; low-intensity aerobic and resistance work, recumbent or seated at first if orthostatic intolerance.
• Breathing: breathing pattern retraining for dysfunctional breathing, pulmonary rehabilitation for those with lung damage.
• Autonomic symptoms: fluids and salt (if no contraindication), compression garments, recumbent exercise (rowing, cycling, swimming), counter-manoeuvres.
• Cognitive rehabilitation, sleep hygiene, psychological support, and a phased return to work or school.

Other post-infectious impairment

The same approach applies after other severe infections. After a stay in intensive care, post-intensive care syndrome combines weakness (ICU-acquired weakness), cognitive problems and anxiety or post-traumatic stress; rehabilitation starts in the unit and continues after discharge. Guillain-Barré syndrome after an infection needs neurorehabilitation (see peripheral nervous system disorders). Post-viral fatigue after other infections, such as glandular fever, follows the same rules of pacing and careful progression.

05Basic principles of rehabilitation in children

A child is not a small adult

Paediatric rehabilitation works with a body and a brain that are still growing. Its goal is not only to restore what was lost but to help a child reach skills that would have come with development: sitting, walking, using the hands, talking, playing, going to school, and later living independently.

Assessment in children

Milestones (head control by 3 to 4 months, sitting by 6 to 9 months, walking by 12 to 18 months), primitive reflexes that should fade (Moro, asymmetric tonic neck, palmar grasp), and tools such as the Gross Motor Function Measure (GMFM), the GMFCS and MACS in cerebral palsy, the 6-minute walk test, balance scales and quality-of-life questionnaires (PedsQL).

Main conditions

• Cerebral palsy, a group of permanent disorders of movement and posture caused by a non-progressive disturbance of the developing brain: the brain lesion does not progress, but the muscles, bones and joints change as the child grows. The GMFCS (Gross Motor Function Classification System) grades mobility from level I (walks without limitations) to level V (transported in a wheelchair) and predicts the course. Interventions with the strongest evidence are early and goal-directed: task-specific training, constraint-induced movement therapy and bimanual training for the hand, strength training, botulinum toxin with stretching and casting for focal spasticity, orthoses, and hip surveillance with X-rays.
• Neuromuscular disease such as Duchenne muscular dystrophy: stretching and night splints to delay contractures, submaximal aerobic activity, avoid exhausting eccentric exercise that damages fragile muscle, and respiratory care.
• Spina bifida, brain injury, brachial plexus birth palsy, torticollis.
• Scoliosis: scoliosis-specific exercises and, in a growing child with a moderate curve, a brace, which reduces progression to surgery.
• Respiratory disease: airway clearance every day and exercise in cystic fibrosis; exercise and breathing education in asthma.
• Heart disease, cancer, prematurity, juvenile idiopathic arthritis, developmental coordination disorder.

Physical agents in children

Children feel heat and current differently, may not report pain clearly, and their growth plates are open. So physical agents are used sparingly and at lower doses, never on a child who cannot report pain unless the dose is surely safe, and ultrasound and diathermy are not applied over open growth plates. Electrical stimulation (NMES, FES) can help strengthen muscles in cerebral palsy and spina bifida when the child cooperates.