Cardiac rehabilitation home exercise guidelines

The information in this leaflet should be used as a guide only for structuring and returning to exercise following a cardiac event. Remember that these are general guidelines and that you may have additional needs or medical concerns that are not addressed in this information. If you want to discuss your individual exercise plan or have specific concerns please contact the Cardiac Rehabilitation team for more information.

Please read this leaflet through before starting your exercises. If there is anything you do not understand seek advice from the cardiac rehabilitation team before starting the exercises.

Regular exercise training is an important part of your recovery and long term prevention from a cardiac event. Exercise can reduce your risk of future cardiac events, reduce your risk of cardiac mortality and hospital admissions from cardiac causes, but also has benefits on reducing risk of many other conditions including (but not limited to) cancers, diabetes, mental health problems, musculoskeletal and joint pains, high blood pressure and high cholesterol and osteoporosis. It is important however to exercise in a safe way to reduce the risk of injuries, angina and arrhythmia (abnormal heart rhythms), and this document outlines the key principles to follow when exercising in your own time. These are mirrored in our exercise classes and so will be familiar if you have attended a group or 1-2-1 session previously.

Exercise safety

You should not start exercise and should contact your GP or cardiac rehabilitation team if:

• Your heart beat feels irregular and this is new to you.
• You feel unwell, have a fever or any other temporary illness.
• Your heart rate is much faster or slower than is normal for you.
• You have new or recurrent symptoms of breathlessness or angina.
• You feel very tired/fatigued.

You should stop exercise immediately if:

• You feel light headed, dizzy or faint.
• You feel chest pain (angina).
• Your breathing becomes uncomfortable.
• Your heart beat becomes irregular.

Effort rating

When participating in any activity it is important that you are able to rate how demanding or strenuous that particular activity is for you. This is called ‘Rating your Perceived Exertion (RPE)’ and is a very good tool for keeping the intensity of your activities safe.

When rating your exertion you should think of how the entire body is feeling at that moment in time. Think of the strain and fatigue in both your muscles and your breathing. If your muscles are aching and feel very heavy, you are likely to be working at a hard intensity and should ease off slightly. If you find your breathing becomes uncomfortable and you cannot continue to talk, you are probably over exerting yourself and should slow down.

The ideal range to work at to encourage cardiovascular benefits is between the ‘light’ to ‘somewhat hard’ range. If you perceive your exertion as ‘hard’ or any further down the scale from this, you should reduce the intensity of the activity i.e. reduce your speed or resistance.

RPE scale

• 6 - No exertion at all
• 7 to 8 - Extremely light
• 9 to 10 - Very Light
• 11 to 12 - Light
• 13 to 14 - Somewhat hard
• 15 to 16 - Hard (heavy)
• 17 - Very Hard
• 18 - Extremely hard
• 19 to 20 - Maximal

At a ‘light’ to ‘somewhat hard’ intensity you should feel warm, possibly slightly sweaty and your breathing should be deeper and faster. You should still be able to talk. If you are struggling to talk during activity, you are likely to be working too hard and should reduce the intensity.

High Intensity Interval training

For some individuals, the moderate continuous training discussed above may not be your preference or how you are used to training. There is more emerging evidence of the benefits and safety for High Intensity Interval training (HIIT) with individuals with a cardiac diagnosis. However prior to starting this type of training we would recommend you have discussed this with one of the exercise physiologists to ensure this is appropriate for you. Please get in touch with the team for more specific advise if you feel this applies to you.

Goal setting

Goal setting is a very effective way of improving your health, function and activity status. When setting personal goals you should always consider the SMARTER principle (table shown below). This will help to ensure that the goals you set are realistic and appropriate for you. Once you have achieved your goal you may need to review and set new goals to keep motivated. If you have a long term goal, setting shorter term or smaller steps that work towards your long term goal can be more manageable and help to keep you motivated as you can see that progress is occurring.

SMARTER principle

Specific

Be specific not general, you are more likely to succeed. A general goal would be, ‘get fit.’ But a specific goal would say, ‘complete my walking programme three days a week.’

Measurable

Establish criteria for measuring progress towards the achievement of each goal you set. Measuring your progress enables you stay on track, reach your target dates, and

experience the exhilaration of achievement that spurs you on to reach your goal.

How many days per week do you walk? How far or for how long do you walk? Recording this information on a home activity record may help.

Achievable

Set goals that are important to you, not just something that sounds good. This will enable you to adapt your attitude, ability and motivation to reach these goals. Walking five days a week may sound good, however three days a week may be more easily achieved as a starting goal.

Realistic

A realistic goal is one that you are both willing and able to work towards. Ask yourself, do I truly believe this goal can be accomplished? You may feel that walking five days a week is too much for you, in which case a goal of three days a week may be more realistic at this stage.

Time-based

Every goal should have a time frame. For example, “I want to lose 5lb - when do you want to lose it by? You may set yourself a time period of several weeks to reach the point where you are able to complete your walking programme three times a week.

Evaluated

Having goals that can be regularly evaluated can help to keep you on track. If you are measuring how often you are walking in a home activity record, you might want to set aside some time to review your record to see if you are on track towards your goal.

Revised

Having evaluated your progress, you may want to revise your goal. This won’t always be the case, and if you are on track to meet your target you can just keep things as they are.

Other times you may want to revise your goal. For example if you are finding it easy to walk three days a week you can think about increasing your goal to four or five days per week. Or if there has been a spell of bad weather that has stopped you from walking you may want to swap to an alternative form of exercise such as marching or stepping that can be done indoors.

The F.I.T.T. principle

When setting exercise/activity goals or targets it is advisable to consider the F.I.T.T principle, a basic philosophy of what is necessary to gain the best benefits from your activities. Below would be the recommendations for a cardiac patient, however you may need to start at a lower level if you are new to exercising, I.E start with a Time of 10 minutes.

F - Frequency

Three to five days a week

I - Intensity

Perceived exertion rating of 11 – 14 (light to somewhat hard). 60 – 80% heart rate max.

T - Time

20 to 60 minutes not including warming up and cooling down.

T - Type

Aerobic endurance (cardiovascular) training, for example, walking or cycling.

Warm-up (15 minutes)

The aim of the warm-up is to gradually raise your heart rate whilst gently loosening up your main joints and muscles. You should start slow and gradually increase the size and speed of your movements.

The warm-up is essential before all exercise sessions and comprises of four essentials: circulation booster, mobility component, pulse raiser and stretching.

Circulation booster

Key safety points:

• Repeat each exercise for 30 to 45 seconds.
• Keep movements small and close to the body at a slow speed.

Mobility component

1. Ankle activators

Key safety points:

• Maintain good posture throughout.
• If balance is compromised, use wall for support.
• Repeat five to eight times on each side.

2. Hip activator (repeat steps 2 and 3 for 30 to 45 seconds) Key safety points:

• Gradually raise the hands up towards hip height.
• Maintain good posture throughout.

3. Shoulder rolls (repeat five to eight times) Key safety points:

• Keep the head position natural throughout.
• Maintain good posture throughout.
• Make bigger circles each time.
• Keep your breathing regular and comfortable.
• Try to keep your feet marching while completing this exercise

Step 1: Glide your shoulders forwards and raise up.

Step 2: Roll the shoulders back.

Step 3: Bring the shoulders back to a resting position.

Pulse raiser

Repeat the exercises used during the ‘circulation booster’, this time gradually introducing the arm movements seen below:

Complete two circuits:

• Circuit one – introduce one arm
• Circuit two – introduce both arms.

Toes in front = arms up in front.

Toes to the side = Arms up at the sides.

Heels in front = biceps curl.

Key safety points:

• Repeat each exercise for 30 to 45 seconds.
• Increase the range of movement.
• Increase the speed gradually towards a light intensity (RPE 11).
• Keep arms below shoulder height.

Stretching

All stretches during the warm-up should be held for a minimum of eight seconds. If the stretch is performed correctly, one stretch on each muscle is sufficient. Between each stretch, march the feet for 10-15 seconds. This helps to keep the heart rate raised and maintain adequate circulation.

Calf stretch

1. Starting with a comfortable base, take one step forward.
2. Place your hands on the front leg at thigh height. Now check that your toes are pointing forwards.
3. Gently lean forwards keeping your back leg straight and your heels flat on the floor.
4. When you feel the stretch in the calf muscle, hold for eight seconds.
5. Gently relax the stretch and repeat on the opposite side.

Shoulder stretch

1. Extend one arm out in front.
2. Use the opposing arm to guide the stretching arm across the body.
3. When you feel the stretch in the muscle at the front of your arm or in the back of the shoulder, hold for eight seconds.
4. Gently relax the arm down and repeat on the opposite side.

Hamstrings (back of thigh) stretch

1. Starting with a comfortable base, bend the knees.
2. Place one leg out in front with the heel on the ground.
3. Place your hands on the opposite thigh.
4. Allow your bottom to sit down as if sitting on an imaginary seat.
5. Feel the stretch in the hamstrings and hold for eight seconds.

Quadriceps stretch

1. Use the wall or a chair for support.
2. Flex one leg, then using your hand, guide the foot up to your bottom.
3. When you feel the stretch in the thigh hold for eight seconds.

Conditioning phase (20 to 30 minutes)

What type of exercise should I do?

The conditioning phase should consist predominantly of cardiovascular / endurance based exercises.

These exercises generally involve the use of the larger muscle groups such as those in the legs. When arm movements are incorporated the exercise demands tend to be slightly higher, therefore we can use the arms to alter the intensity of many exercises. You can look to introduce arm movements to activities like walking if the intensity feels too easy, on the other hand if the intensity is getting too hard you should look to reduce the amount of arm work, this should help to reduce the intensity of the exercise.

Below are just a few examples of exercises which can be used to improve your health and cardiovascular fitness.

There are also a number of online resources that can be utilised to aid exercising at home. Addenbrooke’s Cardiac Rehabilitation have resources to view on our website, as do British Heart Foundation.

Cardiac rehabilitation service

Cardiac rehabilitation at home (opens in a new tab)

Walking

Walking is a fundamental activity that can provide a good level of cardiovascular exertion. Walking speed will vary from one individual to the next. The important thing to consider is how hard the body is working. Set the speed of your walking at a level where you feel you are exerting yourself to a light to somewhat hard intensity (see effort rating).

Key points

• Remember to incorporate both a warm- up and cool-down phase into your walks
• Walk at a speed you would describe as a moderate intensity
• Initially try to increase the duration of your walks as apposed to the intensity
• Aim to walk 30min per day, 5 days per week.
• You may find it easier to accumulate several shorter (10 or 15min) duration bouts throughout the day.

Pedometers

Pedometers can be a useful tool for monitoring you activity levels.

Cycling

Cycling is a fantastic non weight bearing activity that can be used to improve our cardiovascular systems. Before using a cycle you should consider the following points:

Seat height

Stand by the side of the bike and adjust the seat height to be level with your hip bone. Once on the bike push one peddle down to the lowest point. At this point your leg should be slightly bent (at a two degree to five degree angle).

Gripping the handlebars

Be sure not to grip the handlebars too tightly. This will result in greater increase in your heart rate and blood pressure.

Gears

Keep the gears low to start. The added resistance from the gears will also raise your heart rate and blood pressure.

Effort rating

Keep your effort rating at a light to somewhat hard intensity. Adjust the gears and/or the cycling speed to help you remain in this range.

Stepping

Stepping is again an activity that involves the use of those large muscles in the legs and is therefore cardiovascular in nature. Some people like to use a self erecting step like those used in the cardiac rehabilitation classes. However, most houses will have some form of step which can be utilized for this activity.

For safety reasons try to place as much of the foot on the step as possible. When descending, avoid stepping too far away from the step.

Taking regular counts of the number of complete steps you achieve over a specific time period can be used to monitor your progress on the step.

Rowing, jogging and swimming

These activities, when performed at a moderate intensity over a continued period of time, will promote improvements to the cardiovascular system. However, they often demand a greater amount of energy than those activities already mentioned. You should therefore be confident that your endurance capacity is sufficient to compete with this greater demand before attempting these exercises.

If you have any concerns with regards to what activities you can and cannot do, please contact the cardiac rehabilitation team.

Exercise duration

The duration of the conditioning phase will vary depending on the individual; the exercise mode; and the stage of recovery you are at. When starting a new activity, begin with a duration that you feel you will be comfortable with (this may be five to ten minutes for some). You can then begin to increase the duration over time, working towards a total duration of 30 minutes.

If losing weight is one of your goals you should over time try to increase the duration of you exercise bouts towards 60min.

How hard should I exercise?

The optimal intensity for safe and effective cardiovascular exercise is between 60 and 80% of an individual’s maximum heart rate. Depending on the individual and stage of recovery you may be advised to exercise at more specific areas of this range. If you would like further advice regarding HR targets please liaise with your cardiac rehabilitation team.

We would simply advise that you exercise to an intensity you would describe as ‘Light to Somewhat Hard’ according to your individual RPE (effort rating scale on page 1).

Cool down (10 to 15 minutes)

• Using many of the activities involved in the warm-up.
• Starting at an intensity slightly lower than that worked at during the conditioning phase, with both arms involved.
• Gradually reduce the intensity by steadily lowering the arms and decreasing the speed.

Caution

Never stop exercising suddenly, gradually reduce your intensity.

• The final stages should consist of just leg work at a very slow speed.
• Finish the cool down by repeating the gentle stretches used in the warm–up, holding each stretch for a minimum of ten seconds during this phase.

Points to Remember

• A ‘light’ to ‘somewhat hard’ (moderate) intensity is sufficient to encourage health benefits.
• Ensure you always perform a warm-up and cool-down. These should be below a ‘Light’ intensity.
• Avoid holding your breath whilst performing stretches.
• Arm work will increase the intensity of activities. (Reduce your arm work if you are finding the activities difficult).
• Fluid intake at regular intervals during exercise is advised.
• Exercise is not advised immediately after a heavy meal. (Leave two hours for digestion).
• Avoid stopping exercise abruptly. (Keep the legs marching or complete the cool-down).
• Always have your GTN (if applicable to your diagnosis) available during exercise.

Good luck with your activities. Don’t hesitate to call should you require any further advice. Addenbrooke’s Cardiac Rehabilitation Service - 01223 216985