KNGF-guidelines for physical therapy in cardiac rehabilitation

Clinical practice guidelines for physical therapy in

cardiac rehabilitation
EMHM Vogels,I RJJ Bertram,II JJJ Graus,III HJM Hendriks,IV R van Hulst,V HJ Hulzebos,VI H Koers,VII
T Jongert,VIII F Nusman,IX RHJ Peters,X B Smit,XI S van der Voort.XII

Introduction
These clinical guidelines describe the application of
physical therapy in cardiac rehabilitation. They were
developed by the Royal Dutch Society for Physical
Therapy (KNGF) and follow up the Cardiac
Rehabilitation Guidelines 1995/1996 produced by the
Dutch Cardiology Association and the Dutch Heart
Foundation. In essence, the guidelines provide a
summary of the information contained in the second
section of this document, entitled “Review of the
evidence”, in which the choices made in deriving
guideline recommendations are presented separately.
The guidelines and the review of the evidence can be
read individually. An explanation of the abbreviations
used and the definitions of some important terms and
concepts are given in an appended list of
abbreviations and definitions and a glossary. These
KNGF guidelines on physical therapy in cardiac
rehabilitation are for the use of physical therapists
who work with cardiac patients in rehabilitation
phases I and II.
The (Dutch) physical therapists involved will have
also knowledge of the multidisciplinary Cardiac
Rehabilitation Guidelines 1995/1996 and of a
supplementary publication entitled “Physical therapy
in cardiac rehabilitation”.
Considerations of treatment quality in cardiac
rehabilitation are discussed below in the review of the
evidence.
Cardiac rehabilitation phases:
Phase I: during hospital admission;
Phase II: in the polyclinic rehabilitation setting
(both clinical and polyclinic patients);
Phase III: post-rehabilitation and aftercare phases.
These clinical guidelines describe the goals of
treatment and the end criteria in phase I and the
diagnostic and therapeutic processes in phase II.
Aftercare, which comprises phase III, is not covered
by the guidelines.
Defining cardiac rehabilitation
These KNGF clinical guidelines have been devised for
the implementation of physical therapy in patients
who have had an (acute) myocardial infarction, or
who have undergone a coronary artery bypass
operation, percutaneous transluminal coronary
angioplasty, a heart valve operation, or operative
correction of a congenital heart disorder.

I Lisette Vogels, MSc, physical therapist / social scientist, Department of Research and Development, Dutch Institute of Allied Health
Professions, Amersfoort, The Netherlands
II Rob Bertram, physical therapist, rehabilitation center Beatrixoord, Haren, The Netherlands
III Jean Graus, physical therapist, rehabilitation center Hoensbroek, The Netherlands
IV Erik Hendriks, PhD, physical therapist / clinical epidemiologist and guidelines coordinator, Department of Research and Development,
Dutch Institute of Allied Health Professions, Amersfoort, The Netherlands
V Rob van Hulst, physical therapist, Deventer Hospital, Deventer, The Netherlands
VI Erik Hulzebos, MSc, physical therapist / human movement scientist, University Medical Center Utrecht, Utrecht, The Netherlands
VII Hessel Koers, physical therapist / manual therapist, Groene Hart Hospital, Gouda, The Netherlands
VIII Tinus Jongert, MSc, exercise physiologist, TNO-PG, Leiden, The Netherlands
IX Frank Nusman, physical therapist, Isala Klinieken, Zwolle, The Netherlands
X Roelof Peters, physical therapist, Sint Antonius Hospital, Nieuwegein, The Netherlands
XI Bart Smit, physical therapist, Sint Lucas Andreas Hospital, Amsterdam, The Netherlands
XII Simon van der Voort, physical therapist, Zonnestraal, Hilversum, The Netherlands

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KNGF-guidelines for physical therapy in cardiac rehabilitation

Table 1. Goals of therapy, end criteria and methods of evaluation applicable during the acute and mobilization
phases of rehabilitation phase I.

Acute phase
Physical therapy goals End criteria Evaluation method
Surgical treatment: Physical therapy: Monitoring mucus clearance
• Provide preoperative • No objectively observed and ventilation
pulmonary guidance; pulmonary problems.
• Monitor mucus clearance,
ventilation and treatment Medical:
(if necessary). Post-operative treatment:
• No excess mucus retention
Non-surgical treatment: and no atelectasis;
• Monitor mucus clearance, • Patient is hemodynamically
ventilation and treatment stable;
(if necessary). • No severe rhythm disorders
or conduction abnormalities.

Non-surgical treatment:
• Patient is hemodynamically
stable;
• Enzyme levels decreasing;
• No severe rhythm disorders
or conduction abnormalities.

Mobilization phase
Physical therapy goals End criteria Evaluation method
Surgical treatment and Physical therapy: History-taking2;
non-surgical treatment: • Patient can function at the Risk factor checklist;
• Ensure patient can function intended level of activities of Objective determination of the
at the intended level of daily living; patient’s level of activities
activities of daily living; • Patient has moderate aerobic of daily living by evaluating
• Ensure patient has sufficient capacity (≥ 3 MET’s1); activities.
information to start • Patient has knowledge about
phase II or to proceed heart disease and surgery and
independently, which means can cope adequately with
that the patient: the information;
- can cope sensibly with • Patient has knowledge
the heart disease; of risk factors;
- has knowledge about • Patient can cope adequately
the disease’s nature, with symptoms.
surgery and risk factors;
and
- can react adequately to
any symptoms that might
occur.

1 1 Metabolic Task Equivalent (MET’s) = 3.5 ml of oxygen per kg per minute. Supplement 3 to the review of the evidence gives the metabolic
equivalence (i.e., MET’s values) of different activities.
2 Preferably using a structured questionnaire.

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 KNGF-guidelines for physical therapy in cardiac rehabilitation

Risk factors and prognostic factors
Coronary heart disease risk factors can be split into
two groups: influenceable and non- influenceable risk
factors. Influenceable factors include smoking, lipid
imbalance (e.g., hypercholesterolemia and
hyperlipidemia), hypertension, obesity, physical
inactivity and diabetes mellitus. Non-influenceable
factors include hereditary tendencies, age and sex.
Prognostic factors that influence recovery after acute
myocardial infarction include the residual function of
the left ventricle and the size and location of the
infarct. The patient’s psychological condition,
including factors such as exhaustion, fear and
depression, and the presence of any co-morbid
conditions, such as physical limitations or a
cerebrovascular accident, can have a negative
influence on recovery.
applicable methods of evaluation in these two
subphases are presented in Table 1.
Rehabilitation phase II
Before beginning rehabilitation in the polyclinic (i.e.,
rehabilitation phase II), all patients are screened by
the rehabilitation team after physician referral. The
referral documentation must include, as a minimum,
the information listed in Table 2. The rehabilitation
team consists, at a minimum, of a physician, a
physical therapist, a social worker and a nurse. The
physician in the team, who is usually a cardiologist,
has the final responsibility for treatment.
The exercise capacity of the patient are estimated by a
cardiologist and are classified as either low, medium
or high.

Secondary or tertiary prevention It is recommended that rehabilitation screening is

Preventing the progression of coronary heart disease
depends on modifying the above-mentioned risk
factors. These risk factors include bio-psychosocial
factors, which can limit adaptive potential and can,
therefore, influence balance and ability to increase
load capacity (see Glossary).
Rehabilitation phase I
Activities associated with cardiac rehabilitation
during hospital admission take place in two parts: the
acute phase and the mobilization phase. These phases
occur after treatment, whether an operation was
involved or whether treatment was conservative. The
goals of physical therapy, the end criteria used for
assessing the achievement of these goals, and the
carried out before, or shortly after, hospital discharge.
Patients are screened by the rehabilitation team on
the basis of questions posed in five areas of enquiry
relating to the patient’s physical, psychological and
social functioning and to the presence of
influenceable risky behavior (see Table 3). Physical
therapy diagnosis forms part of the screening.
Answers to questions in the five areas of enquiry are
obtained by using objective measuring instruments,
by clinical observation, and from the patient’s
testimony, which is supplemented by the use of a
self-administered questionnaire, if necessary.
The symptom-limited exercise test (ergometric) is an
objective measuring instrument that can be used to

Table 2. Minimum referral information given by the physician to the rehabilitation team.

• Medical diagnosis;
• Relevant cardiac information, as decided by the physician, including details of:
- hemodynamic stability;
- the location and extent of the infarction and the extent of any left ventricular dysfunction;
- exercise testing results including ECG findings (e.g., the presence of ischemia); and
- heart rhythm disorders or conduction abnormalities.
• Co-morbid conditions;
• Risk factors;
• Medicine use; and
• The cardiologist’s estimate of exercise capacity (i.e., low, medium or high1) and prognosis.

1 For more information, see Table 11 in the review of the evidence.

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KNGF-guidelines for physical therapy in cardiac rehabilitation

Table 3. Questions in the five areas of enquiry used in rehabilitation screening, taken from the Cardiac
Rehabilitation Guidelines 1995/1996:

I. Has physical aerobic capacity been reduced objectively, in terms of the patient’s ability to work and carry
out domestic and leisure activities? Are there any motor limitations that restrict the patient’s functional
abilities?
II. Has physical aerobic capacity been reduced subjectively because of anxiety about aerobic capacity
(including sexual capabilities) or because the patient feels very handicapped?
III. Is there a problem with emotional balance? Does the patient deal with the sickness in a dysfunctional
manner? In other words: What is the difference between the patient’s present and optimal psychological
functioning?
IV. Is there a problem with social functioning? What is the prognosis for the patient’s return to a normal
social role in relation to work, leisure and family relationships? What is the quality and extent of the
patient’s social network?
V. Are there any influenceable risky behaviors, involving, for example, smoking, diet (e.g., leading to
obesity or lipid disorders), physical inactivity, or non-compliance with therapy?

provide answers to the questions posed in area I
above. Physical, psychological and social functioning,
covered in areas II, III and IV, can be determined
objectively using screening questionnaires, which are
currently being developed. Some of these
questionnaires can be used for rehabilitation
screening as well as for evaluating treatment. A risk
factor checklist can be used to determine risk factors
objectively and to relate them to the patient’s
lifestyle, to help answer questions in area V.
Diagnosis
The objectives of the physical therapy diagnostic
process are to investigate the severity and nature of
the health problem in relation to functional
movement and to identify any influenceable
prognostic factors. Of central importance are the
patient’s concerns and goals. The physical therapist
will assess the patient’s health status and identify the
most important disorders, the desired health
condition, any existing influenceable and non-
influenceable risk factors, and the patient’s need for
information. The diagnostic process makes use of the
referral, history-taking, assessment, analysis and the
formulation of a treatment plan. The recommended
measuring instruments are described and explained
in Supplement 2 to the review of the evidence.
History-taking
In history-taking, information is obtained partly by
the rehabilitation team, and includes referral data
from the cardiologist, and partly from the patient
himself or herself. History-taking involves:
• recording the patient’s concerns and goals,
including his or her desired level of activity;
• assessing the patient’s level of activity before the
present health situation developed;
• assessing the overall health situation, including
taking details of:
- the nature and severity of any impairments,
disabilities and problems with social
participation;
- the start and course of the condition;
- any factors that led to the condition (e.g., poor
circulation);
- prognostic and risk factors;
• recording the present situation, including noting
details of:
- any current impairments, disabilities and
problems with social participation associated
with the heart disease;
- present general health status, including
information on functioning, and levels of
activity and participation;
- present treatment, including medications used
and medical treatment received;
- personal factors;
- the patient’s motivation; and
- the patient’s need for information.

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 KNGF-guidelines for physical therapy in cardiac rehabilitation
The patient’s most important complaints, including
any activity problems, can be determined using a
specially designed questionnaire, called the patient-
specific complaint questionnaire, and a visual
analogue scale for assessing activity level. The risk
factor checklist should be used to identify risk factors.
Assessment
Functional human movement can be expressed in
terms of physical load and aerobic capacity but is also
affected by the presence of any functional
impairments. Assessment involves observation,
functional evaluation and, if necessary, palpation.
Basically, assessment centers on determining the
levels of functional impairment, activity limitation
and problems with participation, all of which
influence the choice of exercises used in the
rehabilitation program. Activities may be limited in
terms of their nature, duration or quality. In dealing
with psychosocial functioning, the physical therapist
adopts a signaling function. During activity
evaluation, the physical therapist should pay
attention to how the patient deals with the health
problem. For example, does the patient have a fear of
movement? The following measuring instruments or
techniques can be used during assessment: the Borg
scale, an ergometer, MET’s units, the specific activity
scale, the six-minute walking test, and the fear,
angina pectoris and/or dyspnea scale. If indicated by
the physician, heart rate and blood pressure can also
be monitored.
Analysis
Analysis is based on assessment and evaluation. The
physical therapist must obtain answers the following
questions:
1. What is the patient’s health status in terms of
impairments, disabilities and participation
problems? How much can the patient currently
handle, physically, mentally and socially?
2. Are there physical problems that limit increases in
the patient’s physical, mental and social
performance? These may be:
- related to a cardiac disorder (e.g., myocardial
infarction or chronic heart failure); or
- related to other sicknesses or disorders,
including other physical complaints.
3. Are there any other factors that have a negative
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influence on exercise capacity? For example:
- fear, depression, mental handicap or sleep
problems;
- stress or exhaustion;
- lifestyle, involving, for example, smoking,
physical inactivity or eating problems;
- medication use; or
- social problems.
4. How does the patient envisage his or her future
performance of daily activities, leisure activities,
work and hobbies (i.e., the patient’s goals and
expectations)?
5. Is the desired level of performance attainable,
according to the information obtained in
answering questions 2 and 3?
- can any negative factors be influenced?
- if so, negative factors should be reduced or
eliminated and exercise capacity increased;
- if not, the situation should be optimized and
the patient should learn to accept it.
6. Can physical therapy help ameliorate the health
problem? In terms of:
- reducing impairments;
- reducing disabilities;
- reducing participation problems; or
- improving functions, activities and the level of
participation.
In addition to the above-mentioned problem areas,
patients may experience other health problems that
may or may not be related to heart disease. On
occasion, additional physical therapy may be
indicated. These problems are not covered by these
guidelines.
Treatment plan
The rehabilitation team will decide if there are
discrepancies between the patient’s present condition
and the desired level of functioning and determine
whether there is an indication for further
rehabilitation (see the flow chart in Figure 3 in the
review of the evidence). The rehabilitation team,
together with the patient, will formulate therapeutic
goals with help from the answers given to questions
in the five areas of enquiry used in rehabilitation
screening, which were taken from the Cardiac
Rehabilitation Guidelines 1995/1996. These goals are
translated into an individual rehabilitation plan that
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KNGF-guidelines for physical therapy in cardiac rehabilitation
Table 4. Data held by the rehabilitation team that is relevant for physical therapy:
• The physician’s diagnostic and prognostic referral data and information about the patient’s exercise
capacity (See Table 2 above);
• Individual aerobic capacity goals and reasons for any aerobic capacity limitations, such as fear or a
dysfunctional way of coping with heart disease;
• Physical therapist’s diagnosis.
If necessary:
• information about work rehabilitation and prognosis;
• information on the patient’s family.
consists of a number of different modules. If
necessary, these modules can be implemented with
individual guidance. The rehabilitation team decides
when the rehabilitation program will start and which
module the patient should use first. The Cardiac
Rehabilitation Guidelines 1995/1996 describe four
modules: short and long exercise modules (FIT), an
information module (INFO), and a psychoeducational
preparation module (PEP). The KNGF guideline working
group advises the addition of a fifth module, on
relaxation instruction (RELAX). The information given
in these guidelines is divided into exercise programs.
Table 4 provides an overview of the data held by the
rehabilitation team that is relevant to physical
therapists.
Patients who have to employ physical training to
achieve their most important goal must undergo a
symptom-limited aerobic capacity test using an
ergometer to provide relevant information for
therapy.
The following are the six specific goals for physical
therapy (the numbers in square brackets refer to the
goals listed in the Cardiac Rehabilitation Guidelines
1995/1996):
1. Learning to find one’s own physical limits [1].
• The goal is to enable the patient to go about
daily life and to manage at a physical level. By
coming up against objective boundaries, the
patient learns what his or her personal exercise
capacity is and where his or her physical limits
lie.
2. Learning to deal with physical limitations [2].
• The goal is to confront the patient with his or
6 V-08/2003/US
her physical disabilities and to help him or her
learn how to deal with different physical
situations and types of movement. Acceptance
is essential. It is important to encourage the
patient’s active involvement in discovering his
or her level of physical capability.
3. Finding the optimum aerobic capacity level [3].
• The goal is to enable the patient to reach a
desired level of physical capability. Capabilities
are improved up to a level at which the patient
can function better in performing normal daily
activities, work, sports and hobbies.
4. Diagnosis: evaluating aerobic capacity level and
correlating symptoms with objective disorders [4].
• The goal is to assess the patient’s exercise
capacity on a number of occasions. It is
important to find correlations between
symptoms and objective disorders, and to
determine which disabilities the patient has
problems with in daily life. The results of the
diagnostic process provide an insight into the
patient’s exercise capacity and identify
opportunities for increasing these capabilities.
5. Reducing fear of movement [5].
• The goal is to enable the patient to experience
movement, with the hope that, through
experience, fear for movement will decrease.
6. Developing and attaining a physically active
lifestyle [14].
• The goal is to help the patient enjoy
exercising. Providing guidance that enables the
patient to be active at home will reduce the
risk factors associated with an inactive lifestyle.
The patient will learn to integrate exercises
into his or her lifestyle. The idea is that the
 KNGF-guidelines for physical therapy in cardiac rehabilitation
patient will make exercise a normal daily
activity and will, therefore, progress to
rehabilitation phase III.
The physical therapist can also have an influence on
the achievement of other goals, such as achieving
secondary prevention [12–16], acquiring emotional
balance [6], and learning how to deal with heart
disease in a functional manner [7]. Each patient
usually has a combination of goals. If improving
aerobic capacity is not indicated, then goal 1 or 2, or
both, are recommended. If improving aerobic
capacity is indicated, then goal 1 or 3, or both, are
recommended. If there is a subjective decrease in
aerobic capacity, treatment should focus on goal 1 or
5, or both. The problem areas covered by goals 1 and
5 are usually the initial focus of treatment. For
example, the patient must first reduce the level of
fear or learn what his or her personal limits are before
being ready for training. If there is no clear objective
reduction in aerobic capacity, then goal number 4 is
recommended.
It is important that patients are divided into groups
with high, medium or low exercise capacity, as
estimated by the cardiologist and rehabilitation team,
before deciding on an exercise program. It is also
important that the patient’s motor capabilities and
degree of motivation for carrying out activities are
also taken into consideration. Patients who have little
motivation need an exercise program in which the
main exercises can be incorporated into normal daily
activities. This is more enjoyable and ensures better
functioning during exercise.
An exercise program may consist of exercises that
focus on improving health or exercises that focus on
improving performance, or both.
Exercises aimed at improving health involve
practicing skills and activities, and training is less
intensive. Exercises aimed at improving performance
involve physical training. Attention must always be
paid to helping patients enjoy the exercises.
Therapy
The application of physical therapy is based on
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individual rehabilitation schemas, which are drawn
up by the rehabilitation team. If rehabilitation
screening occurs shortly before hospital discharge,
the patient can immediately enter rehabilitation
phase II in the same hospital where screening was
carried out. If rehabilitation screening is carried out
and indications for therapy are determined at the end
of rehabilitation phase I but the patient does not
immediately progress to phase II (for example,
because rehabilitation only starts four weeks after
hospital discharge) or the patient is referred from
another hospital, the physical therapist will repeat
the diagnostic process before therapy starts. During
the therapeutic process, the physical therapist will
evaluate individual goals systematically (see
description of evaluation given below). The
therapeutic process is divided into the following areas
for descriptive purposes: informing and advising,
patient-orientated exercise program, and relaxation
instruction.
In cardiac rehabilitation, the patient’s physical
functioning is of central concern, not his or her
sporting abilities.
Informing and advising
Providing information and advice, and supporting
the patient are both part of physical therapy and fall
under the general category of providing guidance.
The patient’s need for information, advice and
coaching, which becomes apparent during diagnosis,
forms the basis for the patient information plan.
Consultation with practitioners of other disciplines is
important.
The provision of patient education is divided into
four tasks: informing, instructing, educating and
guiding. In practice, these four tasks overlap. Each
task involves a different approach, which depends on
the time and educational aids available, and on the
therapist’s experience. The physical therapist coaches
the patient and helps him or her to make the desired
behavioral adjustments by providing education, by
giving positive feedback, and by enabling the patient
to have positive movement experiences.
The goals of patient education are:
• To provide an insight into the disorder and
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KNGF-guidelines for physical therapy in cardiac rehabilitation
subsequent rehabilitation – the physical therapist
informs the patient about the nature and course
of heart disease, surgery, rehabilitation (including
its goals, therapeutic content and estimated
duration), risk factors and prognosis;
• To improve compliance and increase trust in
therapy – the learning process involves extending
and incorporating the activities and behaviors
learned during treatment into the patient’s daily
life. The patient has to learn to ‘feel’ how to deal
with heart disease;
• To encourage an adequate way of coping with the
condition – the patient should learn what
symptoms mean and how to control them. The
learning process may be based, for example, on
reducing fear of movement. The physical therapist
ensures that the patient does not receive any
unclear or conflicting information. For example,
reassuring information can counteract a negative
view of the cardiac condition and can, therefore,
help prevent unnecessary invalidity. If the
patient’s partner is worried, it is important that
the partner as well as the patient is provided with
information.
Patient-oriented exercise programs
In developing a patient-oriented exercise program, it
is important to take into consideration the patient’s
goals and desires, the patient’s exercise capacity, and
the individual goals and choices made regarding (a)
the priorities of the exercise program, (b) the types of
exercise to be used, and (c) training variables and
loading. If the exercise program is directed at
improving objective aerobic capacity, the choices
made in selecting training variables should be based
on physiological training concepts, such as
specificity, overloading, supercompensation, reduced
output, and reversibility.
(a) Exercise program priorities
The different exercise program priorities are described
below along with the general goals to be achieved
and with individual goals listed in parentheses:
1. Practicing specific skills, with the goal of
increasing general aerobic capacity and strength
during motor activities (goals 1, 2, 3, 5 and 6).
Result: improved performance of the skills and
activities practiced, a higher level of activities of
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daily living, a reduction in risk factors, and
improved postoperative mobility.
2. Aerobic exercise (goals 1, 2 and 3). Result:
increased general aerobic capacity, reduced blood
pressure and heart rate through submaximal
exercise, decreased myo-cardial oxygen uptake,
and a reduction in risk factors.
3. Strength and aerobic exercise (goals 1, 2 and 3).
Result: increased strength and aerobic capacity,
and a higher level of daily activity in housework,
occupational work, sports and hobbies.
4. Learning how to enjoy exercise by practicing
specific functions and activities (goals 5 and 6).
Result: patient enjoys exercising and integrates
exercises into his or her normal lifestyle.
5. Training to reduce risk factors, such as
hypertension, hyperlipidemia, diabetes mellitus,
obesity, inactivity and emotional factors. Result:
increased energy, weight loss, blood pressure
control, controlled insulin responses, and an
active lifestyle.
The treatment used in cardiac rehabilitation is not all
given at the same level. The therapeutic approach can
vary from professional sports training to learning the
most efficient way to tie shoelaces.
(b) Types of exercise
Cardiac rehabilitation involves a wide range of
activities, such as practicing basic skills and daily life
activities, and sports training. Therapy can take the
form of fitness or aerobics exercises, swimming, or
exercises in water. The therapeutic approach chosen
must provide the most appropriate and specific way
of increasing the patient’s daily activities. If therapy is
focused on physical training, use of an ergometer and
sports training are involved. ECG and blood pressure
monitoring are carried out if indicated by the
rehabilitation team.
Ergometers are mostly used during training in high-
risk patients whose ECG recording, blood pressure
and heart rate are being monitored.
(c) Training variables and loading
Examples of training variables are the intensity,
frequency and duration of training, and the length of
the rest intervals. However, training structure is also
 KNGF-guidelines for physical therapy in cardiac rehabilitation

Table 5. Determining exercise intensity, and hence aerobic capacity level, in a training session lasting 20–60

Relative intensity (%) Borg scale score Exercise intensity

HR-max* VO2-max * or
HR-reserve*
< 35% < 30% < 10 very light
35–59% 30–49% 10–11 light
60–79% 50–74% 12–13 medium
80–89% 75–84% 14–16 heavy
> 90% > 85% > 16 very heavy

* HR-max = maximum heart rate; VO2-max = maximum oxygen uptake; HR-reserve = HR-max - resting
heart rate.

This table has been reproduced with permission from WB Saunders Company. Source: Pollock ML, Wilmore JH. Exercise in health and disease:
evaluation and prescription for prevention and rehabilitation. Second edition. Philadelphia: WB Saunders; 1990. © 2000

important. General indications of training variable
values according to exercise program priorities, as
noted above, are:
1 and 4.
Practicing specific functions, skills and activities
while encouraging the patient to enjoy exercise:
training frequency should be 2–3 times a week.
2. Aerobic exercise: training intensity should be at
40–85% of maximum oxygen uptake and at 11–16
on the Borg scale; training should consist of a
warm-up period, aerobic training, and a cooling-
down period, and should last 20–60 minutes;
training frequency should be 3–7 days a week.
3. Strength and aerobic exercise: training intensity
should be at 40–50% of maximum strength; each
training session should comprise 1–3 sequences of
10–15 repetitions with pauses lasting 1–2 minutes;
resistance should increase with time, both
relatively and absolutely; training frequency
should be 2–3 times a week. Circuit training
should last for 20–30 minutes and should consist
of a warm-up period, strength training, and a
cooling-down period.
4. Reduction of risk factors: exercises that have a
longer duration, lower intensity and higher
frequency are recommended for patients with
obesity, hypertension, diabetes mellitus (type-II),
and lipid disorders.
Individual exercise programs are devised using the
results of tests of maximum symptom-limited aerobic
capacity. Table 5 shows the relationship between
exercise intensity, percentage maximum heart rate
(HR-max), heart rate reserve (HR-reserve) or
maximum oxygen uptake (VO2-max), and Borg scale
score. The reserve heart rate, which is defined as the
maximum heart rate minus the heart rate in a resting
state, is used during training when VO2-max is
unknown. The Karvonen formula is used to derive
the heart rate during training, as follows:
heart rate during training = heart rate in the resting
state + (X/100 x HR-reserve),
where X = target percentage VO2-max.
Relaxation instruction
Progressive relaxation, autogenic training and deep-
breathing therapy are the approaches to relaxation
used during instruction. The important elements of
these methods were used to develop the relaxation
instruction approach used in the Cardiac
Rehabilitation Guidelines 1995/1996. The specific
type of instruction given is formulated to meet the
patient’s needs and to suit the patient’s current
situation. Relaxation instruction takes place during
exercise, as active relaxation, and during rest periods,
as passive relaxation, or it could form part of warm-
up or cooling-down activities. Relaxation instruction
can also be provided by itself in a separate treatment
session. The need for relaxation instruction
determines therapy frequency. Two or three sessions

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KNGF-guidelines for physical therapy in cardiac rehabilitation

Table 6. Final evaluation criteria

• The patient has achieved the specified goals.

• The patient has partially achieved the specified goals and it is expected that the patient will achieve all
the goals by himself or herself and be self-sufficient in performing activities.
• The patient has not met the specified goals but it is thought that the patient’s maximum capacity has
already been reached. (The patient is sent back to the rehabilitation team.)

are necessary to determine whether instruction can Reporting

be given in a group setting or individually. There are
very few patients in whom this amount of instruction
is enough to learn relaxation methods, usually more
than five or six sessions are required. Evaluation
carried out after more than five or six sessions
indicates that most patients can relax successfully
without follow-up sessions. However, a small number
of patients will still need individual relaxation
instruction. These are usually patients who have
difficulty following instructions or relaxing. It is
important that the physical therapist also pays
attention to psychosocial factors.
Evaluation
In addition to carrying out continuous evaluation
during treatment, thorough evaluations should take
place every four weeks during treatment, or more
frequently if necessary, and at the end of therapy.
Table 6 outlines the final evaluation criteria and Table
7 describes the desired end result for each goal along
with the recommended means of evaluating the
achievement of these goals.
The rehabilitation team evaluates the rehabilitation
process during and at the end of treatment by using
information about the treatment process and
treatment results and gives advice on aftercare. The
rehabilitation team decides if rehabilitation is still
needed or if it should be ended. Reporting is carried
out in accordance with KNGF guidelines on reporting.
Aftercare
The patient is given information that encourages
activity after rehabilitation. This could be
information on, for example, continuing
independently with training, such as walking or
cycling, or joining a gym. It is important that the
patient chooses a sport or activity that he or she
enjoys to ensure that it will be continued for a long
time. Patients and their partners can also be given
information about local heart patient clubs (e.g.
Heart-in-Movement and Heart Care Federation clubs
in the Netherlands) and heart rehabilitation programs
(e.g., Corefit).

Evaluating the effects of therapy must be carried out

during treatment as well as at the end. The evaluation
method chosen depends on the individual goal.

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 KNGF-guidelines for physical therapy in cardiac rehabilitation
Table 7. Physical therapy goals and means of evaluating the achievement of these goals.
Goal End result
1. Learn about Patient knows own
physical limits physical limits and
activity levels achievable
2. Learn to cope with Patient can cope with
physical limitations physical limitations
3. Optimize aerobic Aerobic capacity is
capacity level optimum for the patient
4. Make a diagnosis There is insight into the
patient’s capabilities
5. Overcoming fear of Patient is no longer
reduced aerobic afraid to perform physical
capacity activities
6. Developing an active Patient has an active
lifestyle lifestyle
7. Attaining knowledge Patient has knowledge
about secondary about secondary
prevention prevention
8. Learning to relax Patient has knowledge
about relaxation and can •
use this information
to relax
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Means of evaluation When used in the program
• the top five problem Beginning and end
areas are identified
and scored using
a questionnaire
• activity problems are
identified and scored
using the fear,
dyspnea and/or angina
pectoris scale
• Borg scale scores on
exhaustion, chest pain
and shortness of breath
are obtained
• if necessary, heart rate
and blood pressure are
monitored
• questionnaire Beginning and every
(as in goals 1 and 2) four weeks
• ergometer
• MET’s units, specific
activity scale, six-
minute walking test
• all methods used in Continuous monitoring
evaluating goal 3 during rehabilitation
• scoring before, during
and after movement
activities, Borg scale
score (see goals 1 and 2)
• history-taking and Beginning and end
observation
• history-taking Beginning and end
• start of rehabilitation
phase III activities
• risk factor checklist Beginning and end
• questionnaire During and at the end
flow chart
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KNGF-guidelines for physical therapy in cardiac rehabilitation
Review of the evidence
General introduction
The guidelines on cardiac rehabilitation issued by the
Royal Dutch Society for Physical Therapy (KNGF)
provide a guide to the physical therapy of patients
who are eligible for cardiac rehabilitation. The
guidelines describe a methodical approach to the
diagnostic and therapeutic processes involved in
providing physical therapy.
The guidelines were developed by the Dutch Physical
Therapy Association for Cardiac and Vascular Diseases
(NVFH), the Royal Dutch Society for Physical Therapy
(KNGF) and the Dutch Institute of Allied Health
Professions (NPi). They are consistent with the Cardiac
Rehabilitation Guidelines 1995/1996 developed by
the Dutch Cardiology Association (NVVVC) and the
Dutch Heart Foundation (NHS).1,2 The guidelines are
multidisciplinary and interdisciplinary and have been
developed for rehabilitation therapists who are
directly involved with the practical treatment of
patients who require cardiac rehabilitation in
rehabilitation phase II. The rehabilitation team
consists, at a minimum, of a physician, a physical
therapist, a social worker and a nurse. The physician
in the team, who is usually a cardiologist, has the
final responsibility for treatment. If necessary,
information on the patient is discussed by the team
and it is decided whether practitioners of other
disciplines should be involved, such as a nutritionist,
a psychologist, a rehabilitation physician, a primary
care physician, or an occupational physician. The
rehabilitation process should be designed to meet the
individual patient’s needs, as expressed in the
Individual Rehabilitation Plan concept. These clinical
guidelines have been developed for circumstances in
the Netherlands.
Definition
KNGF guidelines are defined as “a systematic
development from a centrally formulated guide,
which has been developed by professionals, that
focuses on the context in which the methodical
physical therapy of certain health problems is applied
and that takes into account the organization of the
profession”.3,4
12
Objective of the KNGF guidelines on cardiac
rehabilitation
The objective of the guidelines is to describe the
optimal physical therapy, in terms of effectiveness,
efficiency and tailored care, for patients who are
eligible for cardiac rehabilitation and who have had
an acute myocardial infarction, or who have
undergone coronary artery bypass grafting,
percutaneous transluminal coronary angioplasty, a
heart valve operation, or operative correction of a
congenital heart disorder. Guideline
recommendations are based on current scientific
knowledge and the physical therapy provided should
result in a decrease in symptoms and in
improvements in the patient’s functions and levels of
activity participation.
In addition to the above-mentioned objectives, KNGF
guidelines are explicitly designed:
• to adapt the care provided to take account of
current scientific research and to improve the
quality and uniformity of care;
• to provide some insight into, and to define, the
tasks and responsibilities of the physical therapist
and to stimulate cooperation with other
professions; and
• to aid the physical therapist’s decision-making
process and to assist in the use of diagnostic and
therapeutic interventions.
To promote implementation of the guidelines,
recommendations have been made concerning the
levels of professionalism and expertise needed to
ensure that treatment is carried out in accordance
with the guidelines.
Main clinical questions
The group that formulated these guidelines set out to
answer the following questions:
• How many patients are eligible for cardiac
rehabilitation in the Netherlands, in terms of
incidence and prevalence?
• Which health problems can be described in this
group of patients?
• Which risk factors and prognostic factors are
known and can be influenced by physical
therapy?
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 KNGF-guidelines for physical therapy in cardiac rehabilitation
• What is the normal course of development in
patients eligible for cardiac rehabilitation?
• Which parts of the physical therapy approach to
treatment and prevention are valid in this group
of patients and what are the effects of different
forms of treatment, such as movement programs
(e.g., exercises), relaxation instruction,
psychoeducational interventions, and the
provision of advice and information?
• Which diagnostic and evaluative measuring
instruments are useful?
Formation of the monodisciplinary working group
In May 1998, a monodisciplinary working group of
professionals was formed to find answers to these
clinical questions. In forming the working group, an
attempt was made to achieve a balance between
professionals with experience in the area of concern
and those with an academic background. Patients’
desires and preferences were expressed via the Dutch
Heart Foundation. All members of the working group
stated that they had no conflicts of interest in
participating in the development of these guidelines.
Guideline development took place from May 1998
until June 2000.
Monodisciplinary working group procedure
The guidelines were developed in accordance with
concepts outlined in a document entitled “A method
for the development and implementation of clinical
guidelines”.3–6 This document includes practical
recommendations on the strategies that should be
used for collecting scientific literature. Below, in this
review of the evidence for these guidelines, details are
given of the specific terms used in literature searches,
the sources searched, the publication period of the
searched literature, and the criteria used to select
relevant literature. The recommendations made on
therapy are almost entirely based on scientific
evidence. If no scientific evidence was available,
guideline recommendations were based on the
consensus reached within the working group or
between professionals working in the field. External
experts commented on guideline recommendations.
Once the draft guidelines were completed, they were
sent to a secondary working group comprising
external professionals or members of professional
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organizations, or both, so that a general consensus
with other professional groups or organizations and
with any other existing monodisciplinary or
multidisciplinary guidelines could be achieved.
The members of the working group individually
selected and graded the documentation collected on
the basis of the quality of the scientific evidence.
Even though the scientific evidence was collected by
individuals or smaller subgroups, the results of the
process were presented to and discussed by the whole
working group. Thereafter, a final summary of the
scientific evidence, which included details of the
amount of evidence available, was made. In addition
to scientific evidence, other important considerations
were taken into account in formulating
recommendations, such as: the achievement of a
general consensus, cost-effectiveness, the availability
of resources, the availability of the necessary expertise
and educational facilities, organizational matters, and
the desire for consistency with other
monodisciplinary and multidisciplinary guidelines.
Validation by intended users
Before they were published and distributed, the
guidelines were systematically reviewed, for the
purpose of validation, by the target group that would
use the guidelines in the future. The draft KNGF
guidelines on cardiac rehabilitation were tested in
daily practice by members of the working group who
were working in different environments in order to
provide an overall appraisal of the guidelines. The
working group included nine physical therapists who
tested the guidelines in their own working
environments, with their own teams, or with other
professionals working in their field. The comments
and criticisms made by the physical therapists were
recorded and discussed by the working group. If
possible or desirable, they were taken into account in
the final version of the guidelines. The final
recommendations on practice, then, are derived from
the available evidence and take into account the
other above-mentioned factors and the results of the
guideline evaluation carried out by intended users
(i.e., physical therapists).
During the period 2001–2003, a prospective cohort
study was conducted that involved cardiac
13
KNGF-guidelines for physical therapy in cardiac rehabilitation
rehabilitation patients who were treated according to
the guidelines. Before the start of the study,
documentation and reporting forms were developed
for distribution at the end of the study. Patients’
opinions were sought during the study and an
attempt was made to identify organizational aspects
of treatment that could be improved, for example, by
obtaining information about the cost implications of
applying guideline recommendations. Another goal
was to identify criteria for ascertaining whether
guidelines are being followed (i.e., process indicators),
for determining the results of therapy (i.e., outcome
indicators), and for determining the extent of care
(i.e., benchmarks). The results of this prospective
cohort study will be included in the first revision of
the guidelines.
Composition and implementation of the
guidelines
The guidelines comprise three parts: the practice
guidelines themselves, a schematic summary of the
most important points of the guidelines, and a review
of the evidence. Each part can be read individually.
Immediately after publication of the guidelines and
their distribution among members of the Dutch
Physical Therapy Association for Cardiac and Vascular
Diseases (NVFH), a prospective cohort study was
started, which involved implementation of the
guidelines in eleven hospitals and rehabilitation
centers. In addition, the guidelines were
implemented in accordance with the standard
method of implementation, which has been
described elsewhere.3–7
Introduction to these guidelines
This section describes the choices made in arriving at
the recommendations given in the KNGF guidelines on
physical therapy in cardiac rehabilitation. The
guidelines are based on Dutch Cardiac Rehabilitation
guidelines,1,2 United States guidelines9–12 and recent
scientific literature on cardiac rehabilitation, since
1994. Literature was collected using the Cochrane
Library 1999 Issue 2, MEDLINE (November 1994 to
1999) and CINAHL (September 1994 to 1999). The
following terms were used in literature searches: heart
disorder, (acute) myocardial infarction (AMI), coronary
artery bypass graft (CABG), percutaneous transluminal
14
coronary angioplasty (PTCA), heart valve operation,
and operative correction of congenital heart
disorders, together with the additional terms: exercise
therapy, movement therapy, physical therapy,
postoperative care, cardiac rehabilitation, clinical
trial, randomized clinical trial, protocol, meta-
analysis, and reviews (in both Dutch and English).
Literature was also provided by working group
members.
Rehabilitation phases I, II and III
Cardiac rehabilitation involves actions that take place
in the following phases: during hospital admission
(phase I), during rehabilitation in the polyclinic
(phase II), and after rehabilitation and during
aftercare (phase III).1,13 KNGF guidelines focus on
phase II, as do the multidisciplinary guidelines. The
details of rehabilitation in phase I are given in
summary form because the period of hospital
admission has been increasingly shortened and
rehabilitation treatment in this phase consequently
reduced. Rehabilitation in phase III does not take
place in the institutional healthcare sector and is not,
therefore, covered by these guidelines. Phase III
focuses on individual sporting and recreational
activities. In the Netherlands, physical therapists in
primary healthcare sectors are involved in treatment
related to sport and recreation, which may include
Heart-in-Movement and Heart Care Federation clubs,
the Corefit heart rehabilitation program, and physical
therapy sports centers.
Defining cardiac rehabilitation
“Cardiac rehabilitation involves the rehabilitation of
normal activities after a cardiac incident.
Rehabilitation focuses on optimizing physical,
psychological and social activities, so that the patient
can regain a normal place in society, and on
influencing risk factors.”14 The KNGF guidelines are
based on this definition with the addition of the
following: “Cardiac rehabilitation involves strategic
training and education to promote adequate coping
behavior and optimal functioning in normal daily
life, such that the patient’s quality of life is improved,
and individual limitations and participation problems
are reduced”.15
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 KNGF-guidelines for physical therapy in cardiac rehabilitation
Impairments, limitations and participation
problems
The physical therapist describes health problem in
cardiac patients in terms of impairments (functional
or structural), disabilities (affecting activities), and
participation problems. These terms are defined in
the International Classification of Impairments,
Disabilities and Handicaps (ICIDH-2 Beta-2 1999).16
Quality of life is also assessed during the evaluation
of paramedical and medical treatments. Quality of
life involves physical, psychological and social
components, which are related to the patient’s
perception of whether treatment is having an effect
on his or her daily life. The treatment goal of
improving quality of life is especially important for
those patients in whom full recovery is not possible.
Defining cardiac rehabilitation patients
The KNGF clinical guidelines on physical therapy in
cardiac rehabilitation have been developed for
patients who have had an (acute) myocardial
infarction, or who have undergone coronary artery
bypass grafting, percutaneous transluminal coronary
angioplasty, a heart valve operation, or operative
correction of a congenital heart disorder.
Rehabilitation in all these types of patient is
practically identical. This target group coincides with
that described in (Dutch) Multidisciplinary Cardiac
Rehabilitation Guidelines.2 Additional screening is
necessary for patients suffering from angina pectoris,
chronic heart failure, hypertrophic obstructive
cardiomyopathy that has not been treated surgically,
heart rhythm disorders (for example, after ablation
therapy) and atypical thoracic complaints, and for
those with a pacemaker or an implantable
cardioverter-defibrillator, or who have had a heart
transplant.1
Pathogenesis
After a cardiac incident, both objective and subjective
aerobic capacity may be reduced. The patient’s
aerobic capacity level ‘objectively’ depends on motor
characteristics such as strength, speed, flexibility,
perseverance and coordination, as well as on the
potential application of these characteristics in
normal daily activities, sport, work and hobbies.
Other impairments and limitations can also have an
influence on functioning. Aerobic capacity may be
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reduced subjectively by fear, invalidity, depression or
a limited social life.1 Emotional disturbances and
social factors may also lead to disorders. Fear,
aggressiveness and depression can predominate and
are often associated with sleeping difficulties,
exhaustion, emotional lability, libido problems, and
eating, memory and concentration disorders.1
Acceptance of a reduced social life can also have an
influence.1 It is possible that a patient may deal with
his or her heart disease inappropriately. Negative or
overpowering reactions from a partner or from the
patient’s environment can unnecessarily limit or
stress the patient. Problems with fulfilling social roles
are usually secondary consequences of physical
limitations or psychological difficulties. However,
elements in the patient’s environment, such as an
unhelpful employer, can inhibit the return to optimal
social functioning.1,2
Epidemiology
In 1997 in the Netherlands, there were 14,274 deaths
related to cardiac infarctions: 8,064 men and 6,210
women. In that same year, 27,199 hospital
admissions were directly related to cardiac
infarctions. In general, the women affected were
older than the men. Men had an average hospital
stay of 10 days, and women stayed for 11.5 days on
average.17 In 1995, 14,709 open-heart operations
were completed in the Netherlands.18 Cardiac
rehabilitation generally takes place in specialized
clinics and almost never in the primary healthcare
sector.1,19 In 1999, the Dutch Heart Foundation
reviewed the availability of cardiac rehabilitation in
the Netherlands.20 The results showed that, in 1998,
98 locations provided group rehabilitation in
polyclinics (rehabilitation phase II). In that same
year, 17,000 patients attended polyclinic cardiac
rehabilitation programs. The largest subgroups of
these patients had suffered from acute myocardial
infarctions (46%) or had had coronary artery bypass
graft operations (30%). Smaller subgroups received
cardiac rehabilitation after percutaneous transluminal
coronary angioplasty (11%), valve operations (7%) or
chronic heart failure (3%), or after receiving a
diagnosis of angina pectoris or heart rhythm disorder
(3%). (The percentages given are all approximate.)
Exercise therapy, which was given in groups with
physical therapy guidance, appeared to be more
15
KNGF-guidelines for physical therapy in cardiac rehabilitation

specialized than in 1993. In 1998, institutions
generally provided more than two exercise programs,
in which patients were categorized as having a
physically good condition or a physically poor
condition. Around 85% of all institutions offered
relaxation instruction, usually as part of the exercise
program (81%), but sometimes individually (48%).20
Risk factors and prognostic factors
The cause of almost all coronary heart disease is
arteriosclerosis. Arteriosclerotic processes and damage
to coronary arteries depend on existing risk factors.
Influenceable risk factors include smoking, lipid
disorders (e.g., hypercholesterolemia and
hyperlipidemia), hypertension, obesity, depression,
diabetes mellitus, stress and physical inactivity.2 Non-
influenceable risk factors include hereditary
tendencies, age and sex.
The most important prognostic factors determining
the chance of survival and quality of life after the
acute phase of a myocardial infarction are left
ventricular function and the amount of vascular
damage in the coronary system.25 Other prognostic
factors that are important for recovery are the
patient’s psychological state, which may be affected
by exhaustion, fear or depression, and co-morbid
conditions, such as physical limitations or a
cerebrovascular accident. Taking part in a
rehabilitation program after a myocardial infarction
increases the patient’s quality of life. This is especially
the case for those whose quality of life is low or
whose level of cardiovascular risk is low.26
Secondary and tertiary prevention
The prevention of coronary heart disease involves
adopting measures that focus on behavioral change,1
stopping smoking, and increasing regular physical

Definitions
Lipid imbalance: There are different forms of imbalance such as hyperlipidemia (i.e., high blood levels of
triglycerides and cholesterol) and hypercholesterolemia (i.e., a high blood cholesterol level).15 A cholesterol
level between 5 and 6.5 mmol/l is slightly high, between 6.5 and 8 mmol/l high, and greater than 8 mmol/l
very high. (Source: Dutch cholesterol consensus document).16

Hypertension: Hypertension is defined as a systolic blood pressure (SBP) of 140 mmHg or more or a diastolic
blood pressure (DBP) of 90 mmHg or more, or both, in persons not taking medications for high blood
pressure.17 For adults over 18 years of age, the following hypertension categories are used:17
• grade 1 (mild hypertension): SBP of 140–159 mmHg or DPB of 90–99 mmHg;
• grade 2 (medium hypertension): SBP of 160–179 mmHg or DBP of 100–109 mmHg;
• grade 3 (severe hypertension): SBP > 180 mmHg or DBP > 110 mmHg.

Obesity: The most commonly used method for assessing body weight is the Quetelet index (QI), which is
also referred to the body mass index (BMI). To obtain the QI, body weight in kilograms is divided by body
height in meters squared. The World Health Organization proposed the following weight classification for
adults on the basis of the QI:18
• normal weight: QI = 18.5–24.9 kg/m2;
• overweight (level I): QI = 25.0–29.9 kg/m2;
• obesity (level II): QI = 30.0–39.9 kg/m2;
• morbid obesity (level III): QI > 40 kg/m2.
People with obesity are at a higher risk of physical inactivity, hypertension and hypercholesterolemia
because they are overweight.1

Diabetes mellitus: In diabetes, there is absolute (type-I diabetes) or relative (type-II diabetes) insulin
deficiency, which leads to hyperglycemia. People with diabetes area t a higher risk of developing
retinopathy, nephropathy, vascular diseases and neuropathy.15

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 KNGF-guidelines for physical therapy in cardiac rehabilitation

Quality criteria for physical therapy facilities28

• Emergency procedures must exist for incidents affecting personnel or infrastructure;
• Telephones must be available in all treatment areas;
• A resuscitation team with experience in advanced life support must be available (during rehabilitation,
there must be, on location, a minimum of two trained individuals who are experienced in basic life
support);
• A physician must be available during rehabilitation;
• The treatment area must be multifunctional, for example, including an exercise gym where group
therapy can also be given;
• Treatment areas must be provided with equipment (e.g., a treadmill, an exercise bicycle or a rowing
machine) that can be used with an ergometer;
• There must be alarms in exercise, shower and changing areas;
• There must be areas for private conversations;
• There must be a meeting area.

activity. Healthy eating habits have a positive
influence on such risk factors as being overweight,
hypercholesterolemia, and hypertension. Additional
instruction is necessary for patients who find it
difficult to take medications or to develop trust in
therapy.2
Physical therapist’s role
The physical therapist’s specific role in the
rehabilitation team concerns the patient’s functional
movement. On the basis of history-taking and
functional assessment, the physical therapist analyses
the patient’s movement capabilities and limitations,
identifies influenceable risk factors, and develops a
treatment plan. The main goal of physical therapy is
to influence the patient’s movement capabilities
positively so that his or her participation in society is
optimized. The patient’s interests are central in
devising the treatment plan, and the patient and
physical therapist must work well together as a
team.27
Physical therapy qualifications
Physical therapists working with patients in cardiac
rehabilitation have knowledge and experience that
they acquired while obtaining their physical therapy
qualifications. In the Netherlands, they will know
about publications such as the “Cardiac
Rehabilitation Guidelines 1995/1996” and “Physical
therapy in cardiac rehabilitation”. They must have
adequate knowledge and experience of behavior-
orientated principles, the methodical provision of
patient information, group training techniques, and
guiding exercise. Patients can work towards several
goals using one or more exercises and the physical
therapist must adjust activities, as appropriate.2
Dutch physical therapists who provide instruction on
relaxation therapy in groups must follow a basic
course entitled “Relaxation instruction”, which is
provided by the Dutch Heart Foundation. Providing
individual therapy involving deep-breathing and
relaxation techniques necessitates specialized
education in subjects such as haptic therapy, the
Feldenkrais method, deep-breathing therapy and
psychosomatic therapy.
Rehabilitation phase I
Once a diagnosis has been made and surgery carried
out, therapy in this phase involves the provision of
appropriate medical treatment, early mobilization,
and giving information on heart disease, on any
associated surgery and on risk factors and prevention.
Referral data should include the diagnosis, the dates
of the infarct and operation, details of any
complications, and the reasons for referral.
Additional referral information detailing the patient’s
current level of mobility and the cardiologist’s advice
may be necessary. Table 8 provides an overview of
information the cardiologist may provide.
Diagnosis
History-taking provides the physical therapist with
information about: the patient’s concerns; the

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KNGF-guidelines for physical therapy in cardiac rehabilitation

Table 8. Cardiac information that may be provided by a cardiologist. Reproduced, in an adapted form, from a
report on a 1994 symposium on cardiac rehabilitation. 29 NYHA = New York Heart Association classification.

Non-surgical Surgical
• medical condition on admission • type of operation:
• thrombosis: yes/no - number of bypasses
• reperfusion: yes/no - arterial or venous grafts
• size of myocardial infarction: • valve:
- creatine kinase and creatine kinase vtype of valve operation
(MB fraction)
- levels • left ventricular function
- echographic wall-motion score
- left ventricular resting function • cardiac complications (e.g., rhythm disorders,
• myocardial infarction location pericardial fluid, pleural fluid or decompensation)
• complications: • non-cardiac complications (e.g., atelectasis,
- rhythm disorders infiltration, wound problems or cerebrovascular
- cardiac decompensation accident) and co-morbid conditions
- post-infarct angina pectoris • cardiac history
- NYHA grading • test results:
- cardiac aneurysm - thorax X-ray
• cardiac history - echography
• test results: - ergometric tests*
- thorax X-ray - lung function
- ejection fraction
- coronary angiography
- ergometric tests*
- thallium scintigraphy
- lung function • medication
• relevant laboratory results: hemoglobin and • diagnosis
cholesterol levels • reasons for referral
• medication • psychological information
• diagnosis • work rehabilitation information and prognosis
• reasons for referral • family information
• psychological information
• work rehabilitation information and prognosis
• family information

* For more information, see Table 14

activity level needed for normal functioning in daily Therapy

life; health problems before, during and after the
infarction; risk factors; co-morbid complaints; the
patient’s way of coping with the infarction and the
subsequent operation; the patient’s need for
information; the patient’s work, living and family
situations; and sporting, hobby and recreational
activities.
The actions taken during cardiac rehabilitation are
divided into (a) actions taken after conservative
treatment and (b) actions taken after surgical
treatment.
(a) Rehabilitation after conservative treatment
The duration of rehabilitation phase 1 depends on

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 KNGF-guidelines for physical therapy in cardiac rehabilitation

Table 9. Functional classification of patient activities during the mobilization phase.

Functional class I Functional class II Functional class III

- sitting up in bed with
assistance;
- carrying out activities
associated with personal
hygiene;
- sitting with assistance;
- sitting in a chair for 15–30
minutes two or three times a
day.
- sitting up in bed without
assistance;
- standing without assistance;
- carrying out activities
associated with personal
hygiene while sitting in the
bathroom;
- walking within the bedroom
and to the bathroom, with or
without assistance.
- sitting and standing without
assistance;
- carrying out activities
associated with personal
hygiene while sitting or
standing in the bathroom;
- walking short distances
(15–30 m) in the hallway with
assistance approximately
three times a day.

Functional class IV Functional class V Functional class VI

- carrying out activities - walking in the hallway - walking without assistance
associated with personal without assistance for a 3–6 times a day.
hygiene and bathing; distance of 75–150 m three or
- walking short distances four times a day.
(45–60 m) with minimal
assistance three or four times
a day.

This table has been reproduced with permission from the American College of Sports Medicine ( ACSM). Source: American College of Sports
Medicine. ACSM guidelines for exercise testing and prescription. Philadelphia and Baltimore: Lippincott William & Wilkins; 2000. © 2000.

the size of infarct and any complications that arise
within five to ten days, on average. During the acute
phase, the patient will be in hospital for cardiac care
and will stay there for a few days. For patients with
pulmonary problems, such as chronic obstructive
pulmonary disease, physical therapy focuses on
monitoring mucus clearance and ventilation. The end
criterion for physical therapy is that there are no
longer any objective signs of pulmonary difficulty.
The acute phase ends when the patient meets the
following criteria: there is hemodynamic stability, the
relevant enzyme levels have been reduced, there are
no serious rhythm disturbances or conduction
disorders, and all pulmonary complications have
been eliminated.
After the acute phase, the patient is moved to another
hospital ward where mobilization can begin. During
this mobilization phase, the physical therapist helps
the patient achieve the desired level of daily activity
(see Table 9). It is also the physical therapist’s
responsibility to inform the patient about heart
disease, coping with symptoms, medical treatment,
risk factors and the level of activity desirable during
rehabilitation at home. The optimum levels of
physical activity and stress to be applied during
treatment depend on the patient’s current exercise
capacity. The end criteria for physical therapy are: the
patient can function at the desired level of activities
of daily living; the patient’s aerobic capacity level has
improved, both subjectively and objectively, to
greater than 3 MET’s; the patient has knowledge
about heart disease and can deal responsibly with the
condition; the patient has knowledge about risk
factors; and the patient understands how he or she
can deal appropriately with symptoms. To achieve
these, the physical therapist must, therefore,
determine the patient’s normal level of activities of
daily living and identify any risk factors.
During rehabilitation, the physical therapist should
be alert to signs of patient distress and overloading
(see Table 10). Vascular problems are indicated when
angina pectoris, dyspnea or exhaustion occurs during

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KNGF-guidelines for physical therapy in cardiac rehabilitation
Table 10. Symptoms of overloading during exercise.
• angina pectoris;
• left ventricular systolic disfunctions;
- shortness of breath;
- excessive exhaustion for the level of physical activity;
• rhythm disorders;
- faster than expected heart rate for the level of physical activity;
- irregular heart rate, alterations in normal rhythm;
• abnormally high or low blood pressure;
• fainting;
• dizziness;
• orthosympathetic responses (e.g., sweating or pallor).
low-level exercise. Dyspnea is an important symptom
of serious stenosis of the left coronary artery or the
frontal descending coronary artery. Abnormally high
blood pressure is a systolic pressure above 250 mmHg
and a diastolic pressure above 120 mmHg. A diastolic
pressure that is more than 25 mmHg higher than in
the resting state can indicate coronary heart disease.
The occurrence of hypotension or low blood pressure
at higher levels of exertion can indicate left
ventricular difficulty. This is usually seen in patients
with serious ischemic heart disease or chronic heart
failure. Supraventricular rhythm disorders can occur
in heart disease, or may be secondary to endocrine or
metabolic factors, or may result from the use of
certain medicines. Ventricular rhythm disorders may
be associated with mitral valve prolapse, with
hypertrophic and idiopathic cardiomyopathies (i.e.,
heart muscle disorders), and with heart valve
disorders.10
(b) Rehabilitation after surgical treatment
Rehabilitation phase 1 includes preoperative and
postoperative phases. In the preoperative phase, the
patient is prepared for the operation. The treatment
goal in this phase is to inform the patient about
previous lung disorders and other potential problems
(e.g., paralysis, muscle disease or Bechterew’s disease)
that could have a negative effect on postoperative
recovery. Preexisting lung disorders are treated if
indicated by a physician or pulmonologist.
Preoperative pulmonary therapy consists of:
explaining the goals of physical therapy, teaching
techniques for improving ventilation, teaching about
20
methods of mucus clearance, and advising
patients.30,31 The postoperative phase is split into two
phases: the first immediately follows the operation
when the patient is in the intensive care unit and
lasts, on average, one or two days; the second, the
mobilization phase, lasts 4–10 days in the recovery
ward. The goals of physical therapy in intensive care
are to identify problems with mucus clearance and
ventilation and, if necessary, to teach techniques for
coughing, blowing and breathing (see Figure 1). In
the mobilization phase, the treatment goals are
identical to those following myocardial infarction,
with additional information being given about the
operation. The physical therapist should provide the
patient with information about the pain occurring in
the operated areas and about wound care. Guidelines
developed by Dutch clinical physical therapy
rehabilitation teams in university hospitals, and
entitled “Guidelines for peri-operative physical
therapy of the lung with abdominal and heart
surgery”,30 advise the following: provide appropriate
breathing exercises that concentrate on maximizing
inspiration and that involve holding deep breaths for
a few seconds. Teaching effective coughing, blowing
and forced expiration techniques is useful for helping
mucus clearance. Particular attention should be paid
to encouraging the patient to become self-reliant
during mobilization as early as possible.
Rehabilitation phase II
The need for rehabilitation in the polyclinic is
indicated in the physician’s referral documentation.
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 KNGF-guidelines for physical therapy in cardiac rehabilitation

Operation

Risk assessment Physical therapy assessment

This table has been reproduced with permission from the Rehabilitation Department of the Academic Medical Center of the University of Amsterdam, the Netherlands. Guidelines for peri-operative physical therapy
Figure 1. Postoperative physical therapy of the lung after cardiac surgery. From the University of Amsterdam Academic Medical Center in the Netherlands, 1997.30,31

Diagnosis • nature of operation: 1. History-taking:

- complexity - pain
- duration - mucus production
- complications - shortness of breath
• time on respirator
• clinical information: 2. Assessment:
- temperature - breathing pattern
- blood gas analysis - coughing and blowing techniques
- thorax X-ray - ability to follow instructions
• medication: - degree of consciousness
- painkillers
- mucolytics

Analysis
Combination of preoperative and postoperative:
higher risk

Treatment plan

higher risk
1. Improve ventilation: 3. Advice:
- maximum inspiration Patient:
- chronic obstructive pulmonary disease, - maximum inspiration
pressed-lip breathing five time per hour
Physician:
2. Improve mucus removal: - painkillers
of the lung with abdominal and heart surgery. University of Amsterdam, the Netherlands: 1997. © 2000.

- effective coughing and blowing - mucolytics

- manual compression Nurse:
- forced expiration techniques - change position in bed
- mobilization

No risk High risk

Therapy Treatment period:
• monitor on first postoperative day
and continue as long as needed,
depending on clinical improvement
depending on clinical
Treatment period:
• start on the day of the operation
and continue as long as needed,
depending on clinical improvement
Treatment frequency:
• day 0: 1 per day
• day 1: 1 or 2 per day
• day 2: 1 per day
• day 3: depending on clinical improvement

Evaluation

Clinical information: Other factors:

• fever (> 38°C) • mucus production
• positive mucus laboratory results • pain
• abnormal thorax X-ray • slow mobilization phase
• abnormal blood gas concentrations • moderate ability to follow
• abnormal blood oxygen saturation instructions
KNGF-guidelines for physical therapy in cardiac rehabilitation

Table 11. Guidelines for determining level of risk.

Risk level Characteristics

Low • normal left ventricular function (i.e., ejection fraction > 50%);
• absence of complex arrhythmias while resting and during aerobic capacity exercises;
• no complications during the clinical phase (i.e., absence of chronic heart failure and
symptoms of ischemia);
• hemodynamic stability while resting and during aerobic capacity exercises;
• no symptoms (e.g., absence of angina pectoris during aerobic capacity exercises);
• functional capacity greater than 7 MET’s1;
• absence of depression.
For a patient to be classified as low-risk, it is assumed that all the characteristics in this category are present.

Medium • moderate limitation of left ventricular function (i.e., ejection fraction = 35–49%);
• symptoms, including angina pectoris, occur during or after exercising at a medium
aerobic capacity level (i.e., 5–6.9 MET’s).
All patients who do not fit into the low-risk or high-risk categories are classified as medium risk.

High • poor left ventricular function (i.e., ejection fraction < 35%);
• status after successful resuscitation;
• complex ventricular arrhythmias while resting and during aerobic capacity exercises;
• myocardial infarction or heart operation with complications such as cardiac shock,
congestive heart failure or symptoms of repeated or persistent ischemia;
• hemodynamic instability during aerobic capacity exercises, especially systolic blood
pressure reduction or chronotropic incompetence with increasing exercise;
• symptoms, including angina pectoris, occur during or after light aerobic capacity
exercises
(< 5 MET’s);
• functional capacity less than 5 MET’s2;
• clinically significant depression.
For a patient to be classified as high-risk, it is assumed that at least one of the characteristics listed in this
category is present.

1 metabolic task equivalent (MET’s) = 3.5 ml of oxygen per kg per minute.

2 If a functional capacity measurement is not available, the variable is not included in risk factor
determination.
* the working group made the following changes: < 50% was changed to > 50%; 40–49% was changed to
35–49%; < 40% was changed to < 35%; and “previous myocardial infarction or sudden death” was
changed to “status after successful resuscitation”.

This table has been reproduced with permission from the American Association of Cardiovascular and Pulmonary Rehabilitation. Guidelines for
cardiac and secondary prevention programs, 3rd edition. Champaign, IL: Human Kinetics; 1999.(51)

Additional screening is carried out by the
rehabilitation team to ascertain indications for
therapy.2 Referral information should, at a minimum,
include the physician’s diagnosis, relevant
cardiological diagnostic information, details of any
heart rhythm or conduction disorders, details of any
risk factors, and details of medicine usage. The
cardiologist will appraise the patient’s exercise capacity
and estimate the level of risk using all diagnostic
information available (see Table 11). A low risk level is

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 KNGF-guidelines for physical therapy in cardiac rehabilitation

Table 12. Questions in the five areas of enquiry used in rehabilitation screening, taken from the Cardiac
Rehabilitation Guidelines 1995/1996:(1,2)

I. Has aerobic capacity been reduced objectively, in terms of the patient’s ability to work and carry out
domestic and leisure activities? Are there any motor limitations that restrict the patient’s functional
abilities?
II. Has aerobic capacity been reduced subjectively because of a fear of physical activity (including sexual
activity) or because the patient is highly aware of being disabled?
III. Has the patient’s emotional balance been threatened? Does the patient cope with the condition
inadequately? In other words: Is there a relationship between present and optimal psychological
functioning?
IV. Is social functioning threatened? What is the prognosis for the patient’s return to a normal social role in
relation to work, leisure and family relationships? What is the quality and extent of the patient’s social
network?
V. Are there any influenceable risky behaviors, involving, for example, smoking, diet, physical inactivity, or
non-compliance with therapy?

associated with a high degree of physical capability,
and vice versa.
The rehabilitation team screens patients by means of
questions on five areas of enquiry relating to the
patient’s physical and social functioning and to the
presence of risky behavior (see Table 12). Evaluation
criteria provide a guide to the patient’s present and
future functional status. Screening is carried out by
means of a clinical assessment, a maximum symptom-
limited aerobic capacity test, and a psychological
assessment. If these objective measures coupled to
clinical judgement fail to provide sufficient
information to answer screening questions, it is
necessary to use a questionnaire to obtain additional
information about the patient’s physical, psychological
and social functioning, about risk factors and about
the lifestyle choices made by the patient. In this
situation, screening is distinct from evaluation. The
decision on which questionnaire to use can be made
with the aid of the “Leiden Screening Questionnaire
for Heart Patients (LSVH)”33 and the “Maastricht
Screening Questionnaire for Heart Patients (MSVH)”.34
These screening questionnaires both include elements
that are used in rehabilitation evaluation. For example,
the “Quality of Life after Myocardial Infarction
Instrument (QLMI)’35 forms part of the “Leiden
Screening Questionnaire for Heart Patients”. Moreover,
the questionnaires cover physical, psychological and
social factors as well as quality of life. The “Medical
and Psychological Questionnaire for Heart Patients
(MPVH)”,36 the “Maastricht Questionnaire on
Exhaustion and Depression (MV)” and the “Cardio Fear
Test (HAT)” together give an assessment of the patient’s
level of life satisfaction. A checklist of risk factors is
used to assess risky lifestyles objectively (question V in
Table 12). It can also be useful to look at specific
characteristics of the patient, such as the patient’s
personality and whether the patient’s partner is being
overprotective.37,38 The physical therapist’s diagnosis
forms part of the screening process carried out by the
rehabilitation team.
Diagnosis
In diagnosis, the goals of physical therapy are to
determine the severity and cause of any health
problems affecting the patient’s mobility and whether
it is possible to influence them. The starting point is
the patient’s concerns and needs. The physical
therapist will investigate the patient’s health
problems and symptoms, the health state the patient
wishes to attain, the existence of any factors that
hinder or promote recovery, and the patient’s
information needs. The diagnostic process involves
history-taking, assessment and analysis.
History-taking
In history-taking, information is obtained partly by
the rehabilitation team, and includes referral data
from the cardiologist, and partly from the patient

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KNGF-guidelines for physical therapy in cardiac rehabilitation

himself or herself. See Table 13 for details.
The clinical guidelines advise using a standard
questionnaire during history-taking, especially for
those carrying out history-taking for the first time. In
addition to the assessment techniques described
above in the introduction to rehabilitation phase II,
use can also be made of the “Patient-specific
complaints” questionnaire, of specific visual analogue
scales, and of “numerical rating scales” for
quantifying the nature, duration and extent of
activity problems. For details, see Supplement 2 on
measuring instruments.
Assessment
The physical therapist should determine the patient’s
aerobic capacity level using the maximum symptom-
limited exercise test and estimate of the skill level
needed by the patient to carry out the motor
functions involved in his or her normal daily
activities. The physical therapist must taken into
account coordination, movement efficiency, muscle
strength, flexibility and the patient’s psychological
state. The patient’s psychological state indicates to
the physical therapist which course of treatment
should be followed. The working group advises that
measuring instruments should be used during
assessment, for example: the MET’s method, which
quantifies the activities the patient finds most

Table 13. Details of history-taking.

Investigating the patient’s concerns:

• Which activities are most problematic?
• What is the desired level of activity?
• How does the patient experience the consequences of heart disease and what are his or her expectations
of treatment, including physical therapy?

Investigating the patient’s level of activity before the present health problem, and the course of the
health problem and its prognosis:
• Which impairments, limitations and problems with social participation does the patient experience as a
result of heart disease?
• Which physical disorders were caused by the heart disease?
• Which emotional disorders were caused by the heart disease?
• Briefly describe how the patient’s symptoms relate to the onset and progression of the condition.
• Which underlying factors contributed to the disorder?
- disease course (e.g., poor circulation)
- prognostic and risk factors:
- local: e.g., left ventricular function or coronary artery condition (one, two or three vascular
disorders?)
- general: risky behavior such as an inactive lifestyle, smoking, stress (e.g., sleep problems), fear or
depression.
- treatment and the effects of treatment.

Investigating the present situation:

• Which impairments, limitations and problems with social participation does the patient experience as a
result of heart disease?
• What is the patient’s present level of activity in terms of functioning, activities and social participation?
• Personal information:
- social information: family situation, occupation and family health history;
- what demands does the patient’s environment place on him or her?
• How well-motivated is the patient?
• What is the patient’s need for information?

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 KNGF-guidelines for physical therapy in cardiac rehabilitation
difficult because of duration, quality, fear or dyspnea;
the Borg scale, which can quantify exhaustion, chest
pain and shortness of breath (heart rate and blood
pressure can also be monitored); the Specific Activity
Scale; and the six-minute walking test. For more
information, see Supplement 2 on measuring
instruments.
Analysis
Analysis involves assessment and evaluation. The
physical therapist must obtain answers to the
following questions:
1. What is the patient’s health status in terms of
impairments, limitations and problems with social
participation? How much can the patient
currently handle, physically, mentally and
socially?
2. Are there physical problems that limit increases in
the patient’s physical, mental and social
performance? Are these:
• related to a cardiac disorder (e.g., myocardial
infarction); or
• related to other diseases or disorders, including
other physical complaints?
3. Are there any other factors that have a negative
influence on exercise capacity?
• fear, depression, mental handicap or sleeping
problems;
• stress or exhaustion;
• smoking, physical inactivity or eating
problems;
• medication use; or
• social problems.
4. How does the patient envisage his or her future
performance of daily activities, leisure activities,
work and hobbies (i.e., the patient’s goals and
expectations)?
5. Is the desired level of performance attainable?
• can any negative factors be influenced?
• if so, negative factors should be reduced or
eliminated and exercise capacity increased;
• if not, the situation should be optimized and
the patient should learn to accept it.
6. Can physical therapy help ameliorate the health
problem? In terms of:
• reducing impairments;
• reducing limitations;
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• reducing participation problems; or
• improving functional activities and the level of
participation.
In addition to the above-mentioned problem areas,
patients may experience other health problems
related to heart disease. On occasion, additional
physical therapy may be indicated. These problems
are not covered by these guidelines.
Treatment plan
The rehabilitation team will decide if there are
discrepancies between the patient’s present condition
and the desired level of functioning and determine
whether there is an indication for rehabilitation. The
rehabilitation team, together with the patient, will
formulate therapeutic goals with help from the
answers given to questions in the five areas of
enquiry used in rehabilitation screening, which were
taken from the Cardiac Rehabilitation Guidelines
1995/1996. These goals are translated into an
individual rehabilitation plan that consists of a
number of different modules. If necessary, these
modules can be implemented with individual
guidance. The rehabilitation team decides when the
rehabilitation program will start and which module
the patient should use first. The Cardiac
Rehabilitation Guidelines 1995/1996 describe four
modules: a short exercise module, a long exercise
module, an information module, and a
psychoeducational preparation module. The KNGF
guideline working group advises the addition of a
fifth module, on relaxation instruction.
The physical therapist must receive all relevant
referral information from the rehabilitation team
before the first treatment session. The referral
information should include: the medical diagnosis
and prognosis; an estimate of the patient’s exercise
capacity; individual goals for physical aerobic
capacity; details of possible influenceable factors,
such as fearfulness or inappropriate coping strategies;
and the physical therapy diagnosis. Extra information
may include details of the patient’s occupation,
family and environment.
For patients who are referred for ‘physical training’, it
is necessary to obtain relevant diagnostic and
25
KNGF-guidelines for physical therapy in cardiac rehabilitation

Table 14. Information recorded during ergometric testing.

• the patient’s current exercise capacity, expressed in terms of VO2, MET’s units or watts, as derived from
symptom-limited tests;
• the protocol in use;
• the cardiologist’s estimate of aerobic capacity level based on cardiograms made before, during and after
physical exertion (there are criteria for cardiac ischemia and rhythm disorders and the practical
consequences of these conditions);
• resting heart rate, maximum achievable heart rate, and heart rate after recovery;
• blood pressure while resting, during exertion and during recovery;
• reasons for not completing the tests;
• medication use before and during testing;
• the patient’s subjective symptoms during testing (e.g. angina pectoris or dyspnea).

prognostic information using the symptom-limited
exercise test (i.e., using an ergometer). Therapeutic
goals then depend on cardiac capacity, the maximum
symptom-limited heart rate, maximum aerobic
capacity, and maximum acceptable exercise
duration.2 The maximum symptom-limited exercise
test for cardiac patients indicates maximum oxygen
consumption (peak VO2) and, thereby, maximum
aerobic capacity.2 Table 14 outlines the information
that can be obtained from ergometric tests.
There are six specific goals of physical therapy, which
correspond to goals specified by multidisciplinary
guidelines (the numbers in square brackets refer to
the goals listed in the Cardiac Rehabilitation
Guidelines 1995/1996):1,2
1. Learning to find one’s own physical limits [1].
2. Learning to deal with physical limitations [2].
3. Finding the optimum aerobic capacity level [3].
4. Diagnosis: evaluating the aerobic capacity level
and correlating symptoms with objective disorders
[4].
5. Reducing fear of movement [5].
6. Developing and attaining a physically active
lifestyle [14].
The physical therapist can also have an influence on
the achievement of other goals, such as achieving
secondary prevention [12–16], acquiring emotional
balance [6], and learning how to deal with heart
disease in a functional manner [7]. Each patient
usually has a combination of goals. If improving
aerobic capacity is not indicated, then goals 1 and 2
are recommended. If improving aerobic capacity is
indicated, then goals 1 and 3 are recommended. If
there is a subjective decrease in aerobic capacity,
treatment should focus on goals 1 and 5. The
problem areas covered by goals 1 and 5 are usually
the initial focus of treatment. For example, the
patient must first reduce the level of fear or learn
what his or her personal limits are before being ready
for training. If there is no clear objective reduction in
aerobic capacity, then goal number 4 is
recommended.1
Goals must be clearly formulated at the beginning of
treatment. For example, it is preferable to formulate
goals such as “the patient should able to cycle” or
“the patient should able to continue with sexual
activities” rather than “the patient has overcome fear
of movement”. A goal such as “improving lifestyle
activities” is better formulated as “the patient should
able to walk twice a day for 30 minutes”.2
On the basis of information obtained during
diagnosis, the patient can be allocated to an exercise
group in which rehabilitation exercises match the
patient’s exercise capacity. Corstjens et al.39
developed three exercise groups:
1. an exercise group for, usually young, patients with
high exercise capacity;
2. a less-intensive exercise group for less physically
capable patients; and
3. a functional exercise group for, usually elderly,
patients with poor exercise capacity.
It is important when allocating patients to exercise

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 KNGF-guidelines for physical therapy in cardiac rehabilitation
groups to bear in mind that high-frequency programs
are more effective in counteracting psychological
complaints40 and low-frequency programs are more
effective in encouraging self-sufficiency and self-
confidence.37
Therapy
The physical therapy approach is based on individual
rehabilitation schemas, which are drawn up by the
rehabilitation team. If rehabilitation screening occurs
shortly before hospital discharge, the patient can
immediately enter rehabilitation phase II in the same
hospital where screening was carried out. If
rehabilitation screening is carried out and indications
for therapy are determined at the end of
rehabilitation phase I but the patient does not
immediately progress to phase II (for example,
because rehabilitation only starts four weeks after
hospital discharge) or the patient is referred from
another hospital, the physical therapist will repeat
the diagnostic process before the start of therapy.
Below, the effects of specific treatments used in
cardiac rehabilitation are described along with their
implications for the guidelines. The evidence used in
developing guideline recommendations comes from
United States 1995 clinical practice guidelines
number 17 on cardiac rehabilitation9 and from
scientific literature published between 1994 and
1999. In the present clinical practice guidelines,
conclusions are based on systematic reviews. The
standard of scientific evidence is regarded as being at
one of three levels: level A, in which conclusions
have been based on scientific data from randomized
clinical trials and on statistical results; level B, in
which conclusions have been based on observational
studies or on randomized clinical trial with less
consistent results; and level C, in which conclusions
have been based on the consensus view of
experienced and knowledgeable experts. The target
group for these clinical guidelines includes the target
group for KNGF guidelines. The guidelines have also
been developed for patients with angina pectoris and
chronic heart failure, and for those who have
received heart transplants.
Effects of cardiac rehabilitation programs
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Cardiac rehabilitation programs that focus on
physical training, developing a healthy lifestyle, and
relaxation techniques help patients to recover and
increase aerobic capacity, slow down atherosclerotic
processes, and reduce the risk of further cardiac
events.1,2,28,41–43
Oldridge et al.44 and O’Connor et al.45 showed using
meta-analyses that total and cardiovascular mortality
rates in patients who had had myocardial infarctions
were 20–25% lower in those who followed cardiac
rehabilitation programs than in control groups.
However, the number of non-fatal recurrent
infarctions was not lowered significantly by these
programs. According to the authors of both meta-
analyses, no definite conclusions can be drawn about
the effects of physical therapy in rehabilitation
because most studies involved other measures in
addition to physical training. Kugler, Seelbach and
Krüskemper46 showed that physical therapy
rehabilitation programs also have positive effects on
fear and depression. Meta-analyses of multifactorial
cardiac rehabilitation programs tend to focus on
improving physical functions, providing information
about healthy lifestyles, and increasing quality of life.
These analyses show that there were favorable
impacts on cardiovascular mortality, recurrent
infarction, blood pressure, cholesterol levels, and
eating behavior.9,47–49 Cost-effectiveness analyses
show that cardiac rehabilitation decreases medication
use.2
Training effects and aerobic capacity
Training that focuses on the recovery, maintenance
and improvement of aerobic capacity provides
objectively improved aerobic capacity without
causing significant cardiovascular complications or
other negative effects (scientific evidence: level A).
Aerobic training that improves aerobic capacity and
leads to adaptations in cardiac and peripheral
musculature is the most effective.9 Recently, this
conclusion has been confirmed by Dugmore et al.50
and Stahle et al.51 In the randomized clinical trial
published by Dugmore et al.,50 acute myocardial
infarction patients were given guided aerobic training
three times a week for 12 months. The effects in these
patients were compared with those in a control group
in which patients did not receive any training. After a
27
KNGF-guidelines for physical therapy in cardiac rehabilitation
Table 15. Effects of aerobic training on the cardiorespiratory system. Source: Jongert et al.(52)
• lowers heart rate;
• increases heart pump output volume;
• increases heart minute volume during maximum-intensity exercise;
• increases blood volume and hemoglobin level;
• increases artery-vein oxygen differential;
• lowers blood pressure;
• increases VO2-max;
• increases anaerobic threshold;
• increases maximum respiratory minute volume;
• increases ventilation;
• increases lung diffusion capacity;
• increases lung volume and capacity.
follow-up period of five years, improvements were
observed in cardiorespiratory status, psychological
well-being and quality of life. There was also a
reduction in the risk of early death and
improvements in work and occupational
performances. Stahle et al.’s51 randomized trial
compared the physiological effects of aerobic training
and giving exercise advice in a group of elderly
patients (> 65 years old) with those of a program
providing only exercise advice. Significant
improvements in aerobic capacity and well-being
were found in the group of patients who took part in
the aerobic training program. Table 15 outlines the
effects of aerobic training on the cardiorespiratory
system.
Effects of strength training
Strength training improves muscle strength and
muscle aerobic capacity in patients who have
clinically stable coronary heart disease and has
positive effects on the performance of daily life
activities and work (scientific evidence: level B).9 In a
review, Verrill et al.53 showed that high-resistance
training increases muscle circumference by means of
hypertrophic changes. Circuit training at a lower
level of resistance improves muscle strength, bone
density, mineral balance and aerobic capacity. This
was confirmed by a study carried out by Brechue and
Pollock.54 More research is needed to determine the
safety and effectiveness of strength training in other
groups of coronary and cardiac patients.9,53 Verrill et
al.53 advise patients to take part in strength training
28
programs to screen for cardiovascular complications
and for specific medical conditions. They give the
following exclusion criteria for intensive muscle
strength training: abnormal hemodynamics or
ischemia noted on ECG recordings during aerobic
activities, poor left ventricular function (i.e., an
ejection fraction of less than 30%), unstable angina
pectoris, acute heart failure, malignant hypertension,
uncontrolled rhythm disorders, and serious aortic
stenosis or aneurysm. Verrill et al. recommend
strength and resistance exercises for patients with
functional capacities of 6 MET’s or more. Low-risk or
medium-risk patients (see Table 11 above) who have
functional capacities of less then 6 MET’s should use
low-resistance exercises.
A randomized controlled study55 that assessed high-
intensity strength training programs, at 80% of
maximum, showed that they were safe and that they
were effective in increasing muscle strength and in
improving physical condition. The exclusion
criterion for these programs was that the patient was
not able to participate fully in an aerobic training
program, for example, because of uncontrolled
rhythm disorders (see the exclusion criteria described
above). In addition, Beniamini et al.55 concluded that
high-intensity muscle strength training under
medical supervision can be well-tolerated when given
as a supplement to aerobic training or to a cardiac
rehabilitation program, and that it results in
increased muscle strength and aerobic capacity,
thereby enabling daily activities to be carried out
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 KNGF-guidelines for physical therapy in cardiac rehabilitation
Table 16. Effects of strength training on skeletal muscle. Source : Jongert et al.(52)
• functional hypertrophy;
• increased mitochondrial numbers (mitochondrial hypertrophy);
• increased capillary circulation;
• increase in muscle enzymes;
• increased energy-rich phosphate level.
more easily. Table 16 outlines the effects of strength
training on skeletal muscle.
Other effects of exercise
• Less angina pectoris in patients with coronary
heart disease, and fewer symptoms of chronic
heart failure in patients with left ventricular
systolic dysfunction (scientific evidence: level B).
The symptoms of angina pectoris are also reduced
by psychological and education interventions,
counseling, and behavioral change (components
of multifactorial rehabilitation).9
• In the past, exercise programs, with or without
psychological and educational preventative
measures and stress management, have been
shown to have positive effects on psychological
functioning.41,46,56 However, these findings have
not been supported by more recent
research.49,57,58 These inconsistencies have had
the result that additional screening is now carried
out in heart patients in order to ensure good
healthcare, to ensure that personal goals are met,
and to assess the relationships between different
components of exercise programs and the results
achieved.49
• Positive effects on social functioning (scientific
evidence: level B). Exercise programs improve
social functioning.9
• Exercise programs combined with educational and
psychological interventions also influence:
smoking (scientific evidence: level B),
hyperlipidemia (scientific evidence: level B),
obesity (scientific evidence: level C) and
hypertension (scientific evidence: level B). Cardiac
rehabilitation involving only exercise programs
has a smaller effect on these risk factors.9 In a
randomized clinical trial, Vergès et al.59 showed
that patients with chronic heart disease who
completed intensive rehabilitation programs,
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which included educational components, reacted
better to hyperlipidemia treatment than patients
who did not undergo cardiac rehabilitation. The
educational component of the program promotes
secondary prevention by providing knowledge
about low-lipid diets and by increasing trust in
therapeutic recommendations concerning diet
and medication use.
• Cardiac rehabilitation in patients who have had a
myocardial infarction or who have received a
coronary artery bypass graft leads to increased
participation in exercise after rehabilitation
(scientific evidence: level B). The effect is short
lived, however, and it is, therefore, advisable to
provide further cardiac rehabilitation on a long-
term basis to encourage both exercise and the
adoption of an active lifestyle. It is important to
encourage patients to find a form of exercise that
they enjoy and that they find easy to continue.9
Pathophysiological effects 9
• Exercise programs administered in combination
with extensive dietary control and any necessary
hyperlipidemia medications slow the progression
of coronary arteriosclerosis, as observed
angiographically, and are, therefore,
recommended. Rehabilitation that involves only
an exercise program has been shown to be less
effective (scientific evidence: level A/B).
• There is no evidence showing that exercise
programs influence the development of a
collateral coronary circulation or cause consistent
changes in cardiac hemodynamic measurements
made during cardiac catheterization. Exercise
programs for patients who have chronic heart
failure and, therefore, also reduced ventricular
ejection fractions, result in positive changes in the
peripheral musculature and are, therefore,
recommended for improving muscle function
29
KNGF-guidelines for physical therapy in cardiac rehabilitation

(scientific evidence: level B).
• Exercise programs reduce myocardial ischemia
(scientific evidence: level B).
• Exercise programs have small positive effects on
the ventricular ejection fraction and on
abnormalities in ventricular wall motion.
However, they are not recommended for
improving ventricular systolic function. Exercise
programs have different effects on left ventricular
function in patients who are recovering from
frontal infarctions, who exhibit Q waves in their
ECGs and who have left ventricular dysfunction
(scientific evidence: level B).
• Exercise programs have no consistent effects on
ventricular rhythm disorders (scientific evidence:
level B).
Effects of relaxation instruction
At present, more then twenty studies demonstrate
that relaxation therapy is effective in patients with
coronary heart disease. Most of these studies are
randomized clinical trials. About half of the research
is on the beneficial effects of supplementing
rehabilitation that involves exercise modules in
polyclinics.60,61 Research covers a large variety of
methods and there is a large variation in results. Table
17 outlines the results of these studies. The use of
relaxation therapy after exertion has received the
most research interest – resting cardiac oxygen
consumption is reduced by relaxation. This is
confirmation that relaxation increases physiological
aerobic capacity. For this reason, it is important that
all patients have the opportunity to learn relaxation
methods. It is possible that relaxation helps
physiological adaptations consolidate the effects of
training. In other words, relaxation therapy can lead

Table 17. Overview of the effects of relaxation therapy. The second and third columns give the number of studies
in which the improvement in the group receiving relaxation therapy was greater than or equal to, respectively,
that in the control group.(60,61)

Type of improvement Number of studies showing effects of relaxation therapy

Positive effects No effects

Changing from ergotrophic to trophotrophic situations – physiological:

• reduction in heart rate at rest 7 3
• systolic blood pressure reduction 5 5
• diastolic blood pressure reduction 6 3
• reduction in myocardial ischemia 3 0
• fewer arrhythmias 3 1
• reduction in respiratory rate 3 0

Changing from ergotrophic to trophotrophic situations – psychological:

• less fear 5 4
• increased well-being 3 1
• less depression 5 0

Coping adequately with stress in daily life:

• fewer cardiac complaints 3 0
• fewer physical complaints 3 1
• return to work and normal activities 5 0

Recurrent complaints and long-term risk factors

• fewer additional cardiac problems, such as infarction,
the need for a coronary artery bypass graft, or death 3 0
• less smoking 0 3

30 V-08/2003/US
 KNGF-guidelines for physical therapy in cardiac rehabilitation
to an increase training intensity. A few studies have
investigated myocardial ischemia, by looking at ST
depression and by using thallium scintigraphy, and
rhythm disorders. In these studies, positive effects
were also found.
It is more difficult to assess the effects of learning
how to deal with physical limitations and activity
limitations. It has been shown that learning to deal
with stress in daily life improves symptoms and
promotes recovery, in terms of returning to work and
to a normal activity level. The small amount of
research that has been carried out confirms that
positive effects exist. A few studies have
demonstrated positive effects on recurrent long-term
complaints but a negative effect on stopping
smoking. It is not yet clear which particular method
should be used to improve prognosis.
Implications for the guidelines
The role of physical therapists in cardiac
rehabilitation programs is to develop and implement
exercise programs for patients, to provide
information and advice, and to provide relaxation
instruction. Consultation with practitioners of other
disciplines is also important. Exercise program
priorities are set according to the patient’s wishes and
exercise capacity.24 Therapy may include:
• practicing skills that increase strength or aerobic
capacity through motor activities;
• increasing (total) aerobic capacity;
• increasing (local) strength;
• practicing specific functions and activities that
help the patient enjoy exercising;
• practicing specific exercises that help reduce the
effects of risk factors, such as hypertension,
hyperlipidemia, diabetes mellitus, obesity,
physical inactivity and emotional factors.
There follow detailed descriptions of how
information and advice, exercise programs, and
relaxation instruction are provided in practice.
Providing information and advice
Important components of rehabilitation are providing
appropriate information for cardiac patients and
helping to build trust in therapy.62–64 In providing
patient information, the goals may be: to provide
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information about the disorder and rehabilitation, to
influence compliance, and to help the patient adopt
an adequate way of coping with the condition, which
may involve dealing with fear. For more information,
see Supplement 1 on patient education.
Behavior-orientated principles
Today, increasing attention in physical therapy is
being paid to integrating physical, psychological and
external factors, such as pain, stress and fear. These
categories often overlap, however.65 For example, it
may possible to deal successfully with biomechanical
factors that cause symptoms while the patient’s daily
life limitations remain the same or even increase,
perhaps because of psychosocial factors. Behavior-
orientated principles can be applied in the
rehabilitation of patients who are not able to deal
adequately with the consequences of coronary heart
disease. In effect, these principles represent the
integration of behavioral science and rehabilitation.
In this approach, the focus is on the situation in
which the behavior appears, not on the under lying
pathology.65 Behavior-orientated rehabilitation also
involves:
• using tests to determine why the patient is
functionally limited and to identify the causes of
symptoms. Tests are repeated to help guide and
evaluate treatment;
• active patient participation;
• helping patients acquire adequate coping skills
during treatment that will enable them to deal
better with the condition (e.g., motor and
relaxation skills);
• using a time-dependent approach to treatment, in
which treatment follows a time line.
In behavior-oriented approaches to rehabilitation, it
is important to include the patient’s partner,
employer and occupational physician and the
practitioners of any other disciplines involved as
much as possible during rehabilitation.
Tailored exercise programs
Exercise programs can comprise exercises that focus
on improving performance or exercises that focus on
improving health, or both. Exercises that focus on
improving performance involve physical training,
increasing (total) aerobic capacity, strength training,
31
KNGF-guidelines for physical therapy in cardiac rehabilitation
and reducing the effects of risk factors. Exercises that
focus on improving health involve practicing specific
skills and activities and helping patients learn to
enjoy exercise. In the latter, training is less intense
than in physical training. Attention should always be
paid to encouraging patients to enjoy exercising.
If the aim of the exercise program is to increase
objective aerobic capacity, it is essential to adhere to
certain physiological training principles to help bring
about the desired physiological changes. These
physiological training principles have the following
characteristics:2
• specificity: the effects of training are highly
specific to the type of exercise used and to the way
training load is built up. This means that motor
performance must be developed in the context of
specific motor activities;
• progressive load build-up: the training load must
increase as the patient’s physical condition
improves;
• overloading: the training load should be the
minimum needed to produce the desired effect of
training (e.g., a physiological change);
• supercompensation: it is important that enough
rest is taken during recovery after training.
Insufficient rest limits physiological change and
‘supercompensation’, which form the basis of
effective training;66
• relationship between physical condition and
training load: as the patient’s physical condition
improves, the effect of constantly increasing the
training load is reduced;
• Reversibility: to sustain the effects of training, it is
essential that the patient enjoys exercising,
thereby ensuring its continuation.
In order to reduce subjective limitations on
movement, it is important that use is made of
behavior therapy and social learning theory during
treatment administration.67 For more information on
the principles of behavior therapy and social learning
theory, the Dutch reader is referred to the Cardiac
Rehabilitation Guidelines 1995/1996.2
Not only must a choice be made in deciding the
priorities of the exercise program, but also in selecting
the movements and training variables that are used.
32
Activities
Cardiac rehabilitation can involve a large range of
different activities, such as those necessary for
practicing basic skills and those involved in normal
daily life, sport and recreation. Use can also be made
of fitness and aerobics exercises, swimming, and
exercises in water. The activities chosen must have a
relationship with the patient’s normal daily activities
so that training can be as specific as possible. If the
aim of training is to improve the patient’s physical
condition, an ergometer should be used, and track-
and-field, sporting and recreational training should
be carried out. The use of an ergometer during
training is recommended when patients are at an
increased risk or when additional monitoring is
needed, such as ECG, or blood pressure or heart rate
measurement. If indicated by the rehabilitation team,
training should be monitored using an ECG or blood
pressure measurement, or both.
Training variables and training load
Training variables are items such as the intensity,
frequency and duration of training and the length of
the rest intervals. The way in which training load is
built up is also important. Training load is a function
of the magnitude of the load, and the duration and
frequency of its application. The duration of loading
depends strongly on the patient’s physical condition,
the goals of training, and training intensity. How
frequently the load is applied depends on the
patient’s physical condition and the magnitude of
previous loads.
The general indications of target values for training
variables given in the clinical practice guidelines are
derived from the multidisciplinary Cardiac
Rehabilitation Guidelines 1995/1996,2 the American
College of Sports Medicine guidelines,10,24,68 exercise
standards defined by the American Heart
Association,12 and the guidelines developed by the
American Association for Cardiovascular and
Pulmonary Rehabilitation.11 Table 18 summarizes the
training variable values recommended for patients
with cardiovascular problems by these different
guidelines. The American Heart Association and the
American Association for Cardiovascular and
Pulmonary Rehabilitation also quote minimum
values for training parameters whereas the American
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 KNGF-guidelines for physical therapy in cardiac rehabilitation

Table 18. Summary of training variable values recommended for patients with cardiovascular problems by
guidelines developed by different organizations.

American College of American Heart American Association for

Sports Association exercise Cardiovascular and
Medicine guidelines (10) standards (12) Pulmonary Rehabilitation
guidelines (11)

Aerobic Capacity training:

Frequency 3–5 times/week 3 times/week minimum 3–5 times/week

Intensity 55–90% of HR-max or 50%–75% of VO2-max or 50% VO2-max minimum

40–80% of VO2-max or HR-reserve
HR-reserve

Duration 20–60 minutes 20 minutes minimum 20–60 minutes

continuously

Method aerobic or intermittent healthy physical activity healthy physical activity

activities

Strength training:
Method minimum one set, 10–15
repetitions, large muscle
groups, start with low
resistance
one set, 10–15 repetitions, one set, 12–15 repetitions,
8–10 exercises, large 8–10 exercises, large
muscle groups muscle groups before
small muscle groups

Frequency 2–3 times/week 2–3 times/week 2–3 times/week

College of Sports Medicine gives a range of values.
The Cardiac Rehabilitation Guidelines 1995/19962
recommend that patients should train at 50–60% of
their reserve heart rate in the first half of movement
training modules and at 60–80% in the second half.
Static strength exercises are effective when training is
carried out at 30–40% of maximum voluntary muscle
strength. Optimal effects are achieved at 50–60% of
maximum. Above 70% of maximum, effectiveness
begins to level off.2
The training variable values recommended for
reducing the effects of specific risk factors are:24
• Hypertension: training intensity of 50–85% of HR-
max or 40–70% of VO2-max or 11–13 on the Borg
scale; training duration of 30–60 minutes; training
frequency of 3–7 days a week; strength training is
given with many repetitions and low resistance.
• Diabetes: training intensity of 50–90% of HR-max
or 50–85% of VO2-max (a lower intensity may be
necessitated by complications or chronic
diabetes); training duration of 20–60 minutes;
training frequency of 4–7 days a week.
• Obesity: training intensity of 50–70% of peak
VO2; training duration of 40–60 minutes (or two
20–30 minute sessions a day); training frequency
of 5 days a week; more important to build up
duration than intensity.
• Hyperlipidemia: 40–70% of peak VO2 or 11–16*
on the Borg scale; training duration of 40
minutes; training frequency of 1–2 sessions, 5–7
days a week; more important to build up duration
than intensity.

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KNGF-guidelines for physical therapy in cardiac rehabilitation
Calculating the intensity of aerobic capacity
exercises
The intensity of individual exercises can be calculated
using information from a maximum or symptom-
limited aerobic capacity test. The reserve heart rate
(HR-reserve), which equals maximum heart rate
minus resting heart rate, is used during training when
VO2-max is unknown. The Karvonen formula is used
to derive the heart rate target during training, as
follows:2,69
heart rate during training = heart rate in the resting
state + (X/100 x HR-reserve),
where X = target percentage VO2-max.
Calculating the intensity of strength exercises
Using the pyramid diagram shown in Figure 2, an
estimate of maximum muscle strength can be made
without having to determine directly the maximum
weight a patient can pick up only once. The patient
should choose a weight that he or she can lift about
10 times and it should then be determined how
many times he or she can repeatedly lift the weight
in practice. The total number of repetitions the
patient can make is related to a percentage on Figure
2. The weight, in kg, is multiplied by the percentage
to obtain an estimate of maximum muscle strength.
Figure 2. Pyramid diagram relating the number of
times a patient can repeatedly lift a specified weight to
maximum muscle strength.70
Continuous training and intermittent training
In continuous training, the patient exercises at a
34
specified training load for a relatively long period of
time without stopping. There are two levels of
intensity: extensive continuous training, which is
characterized by a relatively long duration and
relatively low intensity, and intensive continuous
training, which is characterized by a relatively short
duration and relatively high intensity. The minimum
training duration required for training to have a
central effect on maximum aerobic capacity is 20–30
minutes. Therefore, to achieve an effect, it is
necessary, first, to build up to the minimum training
duration and, then, to increase training intensity. As
the patient’s physical condition improves, the focus
of the exercise program changes from extensive
continuous training to intensive continuous training.
If the patient is severely overweight, or suffers from
extreme hypertension, diabetes mellitus or
hypercholesterolemia, the total training duration can
be increased while the intensity is kept at a low level.
In this way, the main focus of training is on
metabolizing fat.52
In intermittent training, periods of intensive training
are alternated with periods of rest or less intensive
training. By choosing the right duration and intensity
of intermittent training, it is possible to influence
different metabolic systems, such as alactic anaerobic,
lactic anaerobic or aerobic metabolism.2 Intermittent
training enables patients to prepare themselves for
the desired training intensity and duration.
Intermittent training is particularly recommended for
patients with peripheral arterial disease and
intermittent claudication.24
Effects of medication on heart rate, blood pressure, ECG
and exercise capacity
Supplement 4 summarizes the effects of different
medications on heart rate, blood pressure, the ECG
and exercise capacity.10
Beta-blockers52 affect both heart rate and contraction
force. They are administered for high blood pressure,
angina pectoris and certain rhythm disorders. Beta-
blockers can be used effectively on a long-term basis.
They influence exercise capacity, reduce symptom
duration and affect heart rate. In patients taking beta-
blockers, heart rate increases in parallel with
increasing load and VO2-max even though the
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 KNGF-guidelines for physical therapy in cardiac rehabilitation
medication significantly reduces the maximum heart
rate. The magnitude of the reduction in maximum
heart rate depends on the dose and type of beta-
blocker. The nature of beta-blocker administration
determines the relationship between exercise load
and heart rate. Therefore, the dose, intake time and
type of beta-blocker must be the same for all tests
carried out during the rehabilitation program. A
change in one of these three parameters can lead to a
change in heart rate during exercise. In order to
provide effective maximum aerobic training for
patients taking beta-blockers, the heart rate must be
relatively high during training, in terms of percentage
maximum heart rate. It is advisable to keep training
intensity at a level at which the heart rate is 70–90%
of the maximum measured while the patient is taking
the beta-blocker. The results of training are usually
good in patients using beta-blockers. However, those
who take beta-blockers because of hypertension have
poorer results.24 The results of training in patients
taking other forms of medication, such as ACE
inhibitors, calcium antagonists and diuretics, are also
good.71
Relaxation instruction
It is recommended that every cardiac patient learns
about or experiences relaxation exercises.2 The aims
of these exercises are: to enable patients to learn
about their physical limits, to improve aerobic
capacity, to help patients regain an emotional
balance, and to help them find a practical way of
dealing with heart disease. There are many ways in
which relaxation instruction can contribute to
cardiac rehabilitation. Being able to relax has a
positive effect on recovery and can enable patients to
exercise without stress. Becoming aware of stress and
learning to sense the position of one’s body in space
enables patients to understand their physical
limitations. The sense of inner peace that comes
about during relaxation can reduce feelings of fear
and depression. Moreover, learning to deal with stress
in daily life improves social functioning. Together
these factors influence psychological balance and
help patients find a practical way of dealing with
heart disease. There are even positive effects over the
long term.
During exercise, patients are given information about
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and an explanation of stress and relaxation, and how
to incorporated relaxation into an exercise program.
If instructing the patient in a group does not have the
required effect, the patient can be given individual
relaxation instruction. Individual sessions are
recommended for patients who are likely to be
receptive to relaxation therapy and who are willing to
accept change, and for those who did not receive
enough information during relaxation instruction to
enable it to be effective. For all these patients, it is
important that attention is paid to the existence of
any underlying psychological factors. If any are
present, patients should be referred for guided
conversation therapy.72 For more information on
relaxation instruction, Dutch readers should refer to
the Cardiac Rehabilitation Guidelines 1995/19962
and the published conclusions of a workshop entitled
“Relaxation instruction in cardiac rehabilitation”.72
Evaluation
In addition to carrying out continuous evaluation
during treatment, thorough evaluations should take
place every four weeks during treatment and at the
end of therapy. The choice of evaluation instrument
made by the physical therapist depends on the
specific goals of therapy. Table 19 describes the
desired end result for each goal along with the
recommended means of reliably evaluating the
achievement of these goals. In the final evaluation, it
is determined whether: (a) the patient has achieved
the specified goals; (b) the patient has partially
achieved the specified goals and it is expected that he
or she will achieve the treatment subgoals by
independently continuing treatment activities at
home; or (c) the patient has not achieved the
specified goals but is thought to have reached his or
her maximum capacity. In the last case, the patient is
sent back to the rehabilitation team. A description of
the measuring instruments used is given in
Supplement 2. The first evaluation should be carried
out after four to six group relaxation sessions. The
flow chart in Figure 3 provides an explanation of the
processes involved in evaluating relaxation therapy.
35
KNGF-guidelines for physical therapy in cardiac rehabilitation
Table 19. Physical therapy goals and measuring instruments used for evaluating the achievement of these goals.
Goal End result
1. Learn about physical Patient knows own
limits physical limits and
activity levels achievable
2. Learn to cope with Patient can cope with
physical limitations physical limitations
3. Optimize aerobic Aerobic capacity is
capacity level optimum for the patient
4. Make a diagnosis There is insight into the
patient’s capabilities
5. Overcoming fear of Patient is no longer
reduced aerobic capacity afraid to perform
physical activities
6. Developing an active Patient has an active
lifestyle lifestyle
7. Attaining knowledge Patient has knowledge
about secondary about secondary
prevention prevention
8. Learning to relax Patient has knowledge a-
bout relaxation and can use
this information to relax
36
Measuring instruments When used in the program
• the top five problem Beginning and end
areas are identified
and scored using a
questionnaire (visual
analogue scales could
also be used)
• activity problems are
identified and scored
using the fear,
dyspnea and/or
angina pectoris scale
• Borg scale scores on
exhaustion, chest
pain and shortness of
breath are obtained
• if necessary, heart rate
and blood pressure
are monitored
• questionnaire (as in Beginning and every four
goals 1 and 2) weeks
• ergometer
• MET’s units, specific
activity scale, six-
minute walking test
• all instruments used Continuous monitoring
in evaluating goal 3 during rehabilitation
• scoring before, during
and after movement
activities, Borg scale
score (see goals 1 and 2)
• history-taking and Beginning and end
observation
• history-taking Beginning and end
• start of rehabilitation
phase III activities
• risk factor checklist Beginning and end
• questionnaire During and at the end
• flow chart
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 GROEPSMODULE (4-6 KEER)

How many instructions are having an effect?

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most a few all

is there a significant process? no/unclear

yes
* DEFINING THE PROBLEM

is there a problem with stress?

limited conditions or limitations?

is there an effect on the problem?

is another course of
satisfactory none or not enough* referral
sufficient action necessary?
yes

continue, in an individual or group form inappropriate time? delay

stop stop
yes

how well-motivated is
the patient?
Figure 3. Flow chart explaining the process of evaluating relaxation instruction throughout therapy.

sufficiently insufficiently

individual relaxation no relaxation

instruction

37
KNGF-guidelines for physical therapy in cardiac rehabilitation
KNGF-guidelines for physical therapy in cardiac rehabilitation
Ending therapy and reporting
The rehabilitation team is informed about the
treatment process and about treatment results during
and at the end of treatment. In addition, advice is
given on aftercare. It is decided in consultation with
the rehabilitation team whether rehabilitation should
continue or end. For more information on reporting,
the Dutch reader is referred to KNGF guidelines on
reporting.73
Aftercare
During rehabilitation, the patient must receive
information that encourages the continuation of
rehabilitation activities after discharge. For example,
information can be given on walking, cycling, or
joining a gym. It is important that patients choose
exercises that they enjoy and can continue for a long
time. Patients and their partners can be referred to
local heart patient clubs (e.g. Heart-in-Movement and
Heart Care Federation clubs in the Netherlands) and
to heart rehabilitation programs such as Corefit.
Corefit is a fitness program in the Netherlands in
which patients can work on their physical condition.
CORE stands for Cardiopulmonary, Osteoporosis,
Recreation and Education.74
Legal significance of the guidelines
These guidelines are not statutory regulations. They
provide knowledge and make recommendations
based on the results of scientific research, which
healthcare workers must take fully into account if
high-quality care is to be provided. Since the
recommendations mainly refer to the average patient,
healthcare workers must use their professional
judgement to decide when to deviate from the
guidelines if that is required in a particular patient’s
situation. Whenever there is a deviation from
guideline recommendations, it must be justified and
documented.4,5 Responsibility, therefore, resides with
the individual physical therapist.8
Guideline revisions
These KNGF guidelines are the first such clinical
guidelines to be developed for diagnosis, treatment
and prevention in patients requiring cardiac
rehabilitation. Subsequent developments that could
lead to improvements in the application of physical
38
therapy in this group of patients may have an impact
on the knowledge contained in these guidelines. The
prescribed method for developing and implementing
guidelines in general proposes that all guidelines
should be revised a maximum of three to five years
after the original publication.4,5 This means that the
KNGF, together with the working group, will decide
whether these guidelines are still accurate by 2006 at
the latest. If necessary, a new working group will be
set up to revise the guidelines. These guidelines will
no longer be valid if there are new developments that
necessitate a revision.
Before any revision is carried out, the recommended
method of guideline development and
implementation should also be updated on the basis
of any new knowledge and to take into account any
cooperative agreements made between the different
groups of guideline developers working in the
Netherlands. The details of any consensus reached by
Evidence-Based Guidelines Meetings (i.e., the EBRO
platform), which are organized under the auspices of
the (Dutch) Collaborating Center for Quality
Assurance in Healthcare (CBO), will also be taken into
account in any updated version of the method of
guideline development and implementation. For
example, the stipulation that uniform and
transparent methods are necessary for determining
the amount of evidence needed and for deriving
practice recommendations would constitute an
important improvement.
External financing
The production of these guidelines was subsidized by
the (Dutch) Ministry of Public Healthcare, Welfare
and Sport (VWS) within the framework of a program
entitled “A quality support policy for allied health
professions (OKPZ)”. The interests of the subsidizing
body have not influenced the content of the
guidelines nor the resulting recommendations.
Acknowledgments
For their help in producing these KNGF guidelines,
special words of gratitude are in order to members of
the secondary working group: ELD Angenot PhD
(rehabilitation physician, Amsterdam Rehabilitation
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 KNGF-guidelines for physical therapy in cardiac rehabilitation

Center), M Berkhuysen PhD (movement scientist), J

van Dixhoorn PhD (physician, Amersfoort and
Haarlem), T van Elderen PhD (psychologist,
Rijksuniversiteit Leiden), AM Erdman PhD
(psychologist, Rotterdam University Hospital), HACM
Kruijssen PhD (cardiologist, NVCC) and A Vermeulen
PhD (cardiologist, NVCC). Also words of gratitude are
in order to the referents: GE Bekkering MSc (NPi),
ATM Bernards MSc (NPi), YF Heerkens PhD (NPi), HJ
Lasonder-Veldhuizen MSc (KNGF) and ALJ Verhoeven
MSc (KNGF). Last but not least, thanks to Ms JA Smit
for her secretarial work.

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KNGF-guidelines for physical therapy in cardiac rehabilitation
Supplement 1: Patient education plan
The patient education plan forms part of the overall
physical therapy treatment plan. The development of
the patient education plan starts, during history-
taking, with carrying out an analysis of the patient’s
need for education. How much knowledge does the
patient presently have about his or her condition and
its treatment? Are the patient’s coping strategies
effective? Does the patient know how to improve
these strategies? What do the patient and his or her
partner expect from treatment? Attention must be
paid to every area of difficulty. This approach also
provides information about the reasons for any lack
of trust in therapy.
Dekkers75 divided patient education into four
categories: information, instruction, education and
guidance. This division is hierarchical in that the
provision of information requires least involvement
by the physical therapist whereas giving guidance
requires most.
1. Information: providing factual information about
the condition, its treatment, and patient self-care.
2. Instruction: providing guidelines or instructions
that enable patients themselves to have a positive
influence on treatment.
3. Education: providing information about and an
explanation of the condition and its treatment so
that patients have some background information
about the condition, understand the implications
of the condition, and gain knowledge about the
nature of the condition. The result should be the
achievement of sense of control and the
development of a sense of independence.
4. Guidance: providing emotional support so that
patients can cope with their disorders.
In practice, these four categories overlap. However, it
is important that activities are split into the four
categories during patient education to make sure
goals are understood. The practical characteristics of
activities carried out in the four categories are
different, in terms of the time required, and the
educational aids and skills employed. Education is
more didactic and involves more sophisticated
educational aids than providing information. When a
patient shows signs of denial or non-acceptance of
40
the condition, current patient expectations become
important in providing guidance. It is recommended
that this type of situation is discussed by the
rehabilitation team as a whole.
Steps in the patient education plan
Van der Burgt and Verhulst76 provide an overview of
the different educational models used in different
healthcare sectors, which they have adapted for
specific use in paramedical healthcare. The authors
integrate the Attitude, Social Influence and Personal
Efficacy model77 with van Hoenen et al.’s78 Education
Ladder Model. The Attitude, Social Influence and
Personal Efficacy model is based on the assumption
that the patient’s willingness to change current
behavior is determined by a combination of attitude
(i.e., how the person himself or herself views the
behavioral changes), social influence (i.e., how others
view the behavioral changes), and the patient’s
perception of his or her own efficacy (i.e., whether
the patient expects the changes to be effective or
not). According to van Hoenen et al., the Education
Ladder Model comprises the following steps: being
open, understanding, wanting, and doing. For
application in paramedical healthcare practice, van
der Burgt and Verhulst added two more steps: being
able, and keeping on doing. An additional step was
added, in which the patient’s individual
characteristics were determined. Van der Burgt and
Verhulst approach patient education as a process in
which behavioral change is the final step. This final
step is not attainable if the other steps have not been
completed first. In total, six steps have to be
completed, as shown in Table 20.
It is important that attention is paid to any
difficulties the patient may have during each step in
the process. This approach provides information
about the reasons for any lack of trust in therapy.
Scientific research shows that most information is
provided during the second treatment session. In
patient education, it is important that information is
given in a balanced way throughout all treatment
sessions. This enables attention to be given
systematically to all aspects of patient education
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 KNGF-guidelines for physical therapy in cardiac rehabilitation

Table 20. The six steps in patient education, as suggested by van der Burgt en Verhulst.(76)

1. Being open
The physical therapist adapts the methods used to suit the perceptions, expectations, questions and
concerns of the patient. Important questions are: What are the patient’s main concerns? Which concerns
limit the patient’s ability to be open to new information and to behavioral change?

2. Understanding
Information must be presented in such a way that the patient will understand it and remember it. It is
important: not to provide too much information at one time; to decide which information is needed first
and what can be saved for later; to repeat the message (in another form, if necessary); and to use educational
aids, such as leaflets and videos. The physical therapist should monitor whether or not the patient has
understood the information provided.

3. Wanting
The physical therapist should determine what motivates the patient to act. Here it is important: to
determine how significant performing the exercises is to the patient; to find out whether individuals in the
patient’s environment encourage or discourage the patient; and to determine whether the patient feels that
he or she can influence the situation. The physical therapist offers support and provides information about
different options and alternatives. Achievable goals are set.

4. Being able
The patient must be able to perform the desired behavior. Functional skills must be practiced. It is important
that the physical therapist determines which practical problems the patient expects and decides how they
will be overcome.

5. Doing
This step covers the actual performance of the new behavior. The physical therapist makes a clear, concrete
and realistic agreement with the patient and sets concrete goals. If possible, positive feedback is given.

6. Keeping on doing
The patient must to continue to perform the learned behavior after treatment has ended. During therapy,
the physical therapist will discuss with the patient whether continuation is possible. It is important to know
what the possibilities are, what encourages the patient, and whether there are any short-term or long-term
gains. The physical therapist should determine what helps the patient get back on track after a ‘dip’ in
motivation.

without the patient receiving too much information situation.

at one time.79
During each step in patient education, it is important
that certain characteristics of the patient (i.e., personal
factors) are taken into consideration, such as:
• Locus of control: the degree of influence the
patient believes he or she has over the situation.
• Attribution: the factors that the patient believes
are having an influence on his or her life
• Coping: how the patient reacts to important
incidents in his or her life.
• Emotional state: the patient’s current emotional
state may temporarily prevent him or her being
open to new information. Emotional state may
also determine the way the patient deals with the
situation.
A professional approach to providing patient

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KNGF-guidelines for physical therapy in cardiac rehabilitation

education involves understanding all factors that can

have a positive or negative influence on bringing
about the desired behavioral change.

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 KNGF-guidelines for physical therapy in cardiac rehabilitation

Supplement 2: Measuring instruments

I. Checklist of influenceable risk factors
Use of this risk factor checklist makes it possible to
identify risk factors that the patient can influence,
such as:

physical inactivity;

smoking;

obesity;

hypertension;

lipid disorders, such as hypercholesterolemia and
hyperlipidemia;

diabetes mellitus;

depression;

long-lasting stress.
Non-influenceable risk factors include hereditary
tendencies, age and sex.
II. Visual analogue scale for assessing activity level
Patients can use visual analogue scales to identify the
nature of the activities that have been most
problematic during the previous few weeks and to
estimate their duration and severity. The visual
analogue scale is a line measuring 0–100 mm. Visual
analogue scales can be used to evaluate a variety of
abstract concepts. Usually they are used for
measuring pain, but they can also be used to
determine the patient’s activity level.80,81 The visual
analogue scale provides a valid, reliable and
responsive way of measuring pain and the level of
activities of daily living. In practice, it can be
administered quickly.82,83 The Disability Rating
Index80 and the Verbal Rating Scale are similar
measuring instruments.
III. ‘Patient-specific complaint’ questionnaire81
This instrument can be used to determine the
patient’s functional status. In practice, the patient
selects between three and five of the most important
symptoms affecting physical activity. The
questionnaire is also used, for example, by patients
with rheumatism. To date, there is no information on
the reliability of this measurement method. However,
the questionnaire has been found to be responsive in
patients with back complaints.
IV. Dyspnea scale10
This instrument enables the observed level of
dyspnea to be estimated. Use of the New York Heart
Association (NYHA) cardiology scale is recommended
for quantifying the severity of dyspnea.85
V. Angina pectoris scale10

Table 21. Example of the visual analogue scale as used for assessing activity level.

(To be filled in by the physical therapist)

Patient code :

Physical Therapist :

Date :

The aim of this scale is to obtain knowledge about how the patient performs various activities. After each
question, the patient must draw a vertical line on the horizontal line. If the vertical line is placed to the far
left, the patient has no difficulty in performing the activity. If placed to the far right, the patient has a lot of
difficulty. All questions must be answered.(86)

Climbing stairs (for example):

No difficulty whatsoever impossible

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KNGF-guidelines for physical therapy in cardiac rehabilitation

Table 22. Dyspnea scale.

Level Description

+1 Mild, noticed by the patient but not others

+2 Mild, minor problems, noticed by observers
+3 Moderate problems, it is possible to continue activity
+4 Serious problems, patient must stop activity

Reproduced with permission from the American College of Sports Medicine. Source: American College of Sports Medicine guidelines for exercise

testing and prescription. Philadelphia, Baltimore: Lippincott William & Wilkins; ©2000.

VI. Borg scale
The Borg scale is a subjective index that is used to
assess the patient’s degree of exhaustion or reaction
to participating in activities. Use of the Borg scale
helps patients learn how to match their daily
activities to their current exercise capacity.85
practice, the patient indicates the level of exhaustion
and the extent of any dyspnea or chest pain
experienced during activity on a scale from 6 to 20.
Patients quickly learn how to apply the Borg scale to
their daily activities. For example, the patient can
learn how to exert himself or herself up to a certain
level during the performance of normal daily
activities or while participating in a sport.2
scale score can be used in combination with heart
rate measurements made while resting, at maximum
exertion, and during recovery to provide feedback to
the patient on normal and abnormal symptoms.
VII. Six-minute walking test
Scientific research has been carried out on the use of
the six-minute walking test in patients with chronic
heart failure. The research shows that this test is safe
and applicable in these patients.88 Heijblom et al.89
concluded from their research that the six-minute
walking test provides reliable results in patients with
chronic heart failure and that the results correlate
In with cardiac information.
VIII. The MET Method
The MET’s method can be used to estimate aerobic
capacity levels and makes it possible to evaluate the
metabolic demands of motor activities without
having to take into account the individual’s body
size. One MET’S unit is equal to the basic metabolic
The Borg level of the particular individual while resting. The
number of MET’s units needed to perform a specific
motor activity depends on the ratio of the amount of
energy used during the activity and that used in
resting state. The numbers of MET’s units needed to
perform a large range of activities have been
determined.90 For more details, see Supplement 3.
The energy used by the patient in resting state
corresponds to an oxygen uptake, or VO2, of 3.5 ml

Table 23. Angina pectoris scale

Level Description

1+ Light, hardly noticeable

2+ Moderate, uncomfortable
3+ Serious, very unpleasant
4+ Most horrific pain ever felt

Reproduced with permission from the American College of Sports Medicine. Source: American College of Sports Medicine guidelines for exercise

testing and prescription. Philadelphia, Baltimore: Lippincott William & Wilkins; ©2000.

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 KNGF-guidelines for physical therapy in cardiac rehabilitation

Table 24. Borg scale for estimating aerobic capacity on the basis of subjective observation. Sources: Borg (85,86)
and Pollock and Wilmore.(87)

Borg scale score Scale A (15 points) Scale B (15 points)

6 no feeling of exertion
7 extremely light extremely light
8
9 very light very light
10
11 fairly light light
12
13 fairly heavy fairly heavy
14
15 heavy heavy
16
17 very heavy very heavy
18
19 extremely heavy extremely heavy
20 maximum exertion

per kg per minute. By using the MET’s method, the
physical therapist can correct differences between the
patient’s actual and desired performance by using an
appropriate rehabilitation program.
• It must be remembered that the patient’s ability to
perform an activity not only depends on his or
her aerobic capacity level, but also on his or her
fears, movement efficiency, and motor behavior,
which are all equally important.
• The number of MET’s units quoted for each
activity is an average. It is important to take
different levels of skill into consideration. For
more information, see the Cardiac Rehabilitation
Guidelines 1995/1996.2
IX. The specific-activity scale91
X. Evaluating relaxation instruction2
It is of the utmost importance not only that the
patient receives relaxation instruction but also that
the effects of relaxation instruction on daily life are
evaluated. To date, no reliable measurement
instruments are available. Measurement methods 1
and 2a shown below are highly recommended. The
third measurement method requires more time but
results in more detailed information.
Three measuring instruments for evaluating
relaxation instruction:
In this method, the patient is asked to score the result

Method 1: Therapist’s opinion.

Does the therapist have the impression that the patient has learned how to relax?

1 = yes, clearly: The patient can demonstrate the ability to carry out the instructions and, after doing so,
feels a positive benefit.
2 = not clearly: The patient can scarcely, or not at all, demonstrate the ability to carry out the instructions
and no change is experienced.
3 = no: The patient does not carry out the instructions and either no change or an unpleasant
change is experienced.

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KNGF-guidelines for physical therapy in cardiac rehabilitation

Figure 4: The Specific Activity

1. Can you walk down a single flight of stairs (i.e. more than eight steps) without stopping?

YES NO

3a. Can you shower without having

2a. Can you carry something in your to stop?
arms while walking downstairs?
NO YES
Or can you:
Or can you: • make up a bed?
• work in the garden? • hang up the laundry?
• dance (e.g., foxtrot)? • walk at 4 km/h?
• walk at 6.4 km/h on a level • take part in golf or bowling?
surface? • mow the lawn?

YES NO

2b. Can you carry a 12-kg weight up

the stairs?

Or can you: 3b. Do you have to stop to rest while

• carry heavy objects (> 40 kg)? getting dressed and undressed?
• shovel snow or rake the garden?
• take part in an active recreation NO Or do you have symptoms while:
such as skiing, squash, basketball, • eating or standing?
soccer or handball? • sitting down or lying?
• can you jog at 9 km/h?

YES NO YES

(CLASS 1) (CLASS 2) (CLASS 3) (CLASS 4)

Figure reproduced with permission from Circulation.(91) Source: Goldman L et al. Comparative reproducibility and validity of systems assessing

cardiovascular functional class: advantages of a new specific-activity scale. Circulation 1981;64(6):1227-34. Copyright 2000.

46 V-08/2003/US
 KNGF-guidelines for physical therapy in cardiac rehabilitation

Method 2: Patient self-assessment.

2a. Questions asked at the end of treatment.

1a. Have you found an exercise method that you can use yourself at home and is it one you practice
repeatedly?
2 = yes (completely adequate)
1 = yes (somewhat adequate)
0 = no

1b. If yes, which exercises do you prefer?

2a. Do the relaxation exercises you practice at home have an effect?

2 = yes (definitely)
1 = yes (to some extent)
0 = no

2b. Which effects do you notice?

3. Do you expect to continue relaxation exercises in the future?

2 = yes, certainly
1 = yes, perhaps
0 = no

A total score of 5 or 6 points indicates that relaxation exercises have had a positive influence; a total score of
0 or 1 indicates that there has been no effect.

Additional questions:

4. Do you feel the need to continue with relaxation exercises?

yes, certainly

yes, perhaps

no

5. If yes, what type of instruction would you prefer?

group

individual

2b. Matrix method.

of following each relaxation instruction on a matrix.91 The matrix can be filled in before the exercise is
completed, as suggested in the Cardiac Rehabilitation Guidelines 1995/1996.2 Each instruction can be repeated
four times, after each of which the patient scores the result on the following dimensions: (C) completion, (F)
feeling, and (A) appreciation, as explained below. The higher the percentage of instructions that receive three
pluses, the better the patient’s ability to relax.

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KNGF-guidelines for physical therapy in cardiac rehabilitation

Instruction C F A C F A C F A C F A

C (completion) F (feeling) A (appreciation)

+ completed; easy, good + clear experience + positive, felt good
0 completed; unclear 0 vague experience 0 mixed feelings
- not completed - no experience - negative, felt bad

Method 3: Questionnaire on applying relaxation instruction.

This method was developed by van Dixhoorn to assess cardiac patients.92 The Dutch questionnaire evaluates
exercise frequency, relaxation while resting and during activities, and the positive and negative effects of
conscious relaxation. Scores on all these factors have a high level of reliability.93

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 KNGF-guidelines for physical therapy in cardiac rehabilitation

Supplement 3: Metabolic equivalence of professional,

leisure and sporting activities

Table 25. Metabolic equivalence of a range of professional, leisure and sporting activities.

Power Metabolic Daily activities Professional Leisure activities Leisure and

(watt) equivalen activities sporting activities
ce (MET’s
units)

0 1 sitting quietly, eating sleeping

1.5 1.5 washing, shaving, watching TV, playing standing up for 15

dressing, washing cards, sewing minutes
dishes, writing

20 2 driving a car, light office work playing music (e.g., light cycling,
cooking, brushing (e.g., typing), piano or guitar), walking at 2.5 km/h
hair, moping the handicraft light wood work,
floor, dusting fishing, playing
billiards

40 3 making beds, radio, TV or car bowling, playing golf cycling at 8 km/h,

hoovering, ironing, repair, working as a (using golf cart), walking at 3–4
waxing furniture, bank teller, light painting, flying in an km/h, light
grocery shopping, welding, working as airplane, washing gymnastics
gardening a doorman, light the car, archery
janitorial work,
operating machinery,
working as a
seamstress or
shoemaker

60 4 showering, washing factory work (< 20 slow dancing, cycling at 10 km/h,

windows, scrubbing kg), screwing in horseback riding walking at 5 km/h,
floors, walking down screws, electrician’s (horse walking) playing volleyball,
stairs, mowing lawns work, bricklaying, table tennis,
(electric mower), painting, driving a badminton or golf,
weeding, trimming light truck, garage swimming (breast
plants, sexual work stroke)
activities (own
partner)

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KNGF-guidelines for physical therapy in cardiac rehabilitation

80-90 5 grocery shopping heavy office work, dancing, fishing in cycling at 12 km/h,
with a heavy bag, wall-papering, using fast-flowing water, walking at 5.5 km/h,
sexual activities (new a wheelbarrow, hunting, playing golf horseback riding
partner), digging in making footpaths, (carrying own bag) (trotting), playing
the garden, mowing mixed labor tennis doubles,
the lawn (non- involving digging, la- playing badminton,
electrical mower) ying stones or land- rowing
scaping, feeding
animals

110 6 walking up stairs, digging, plowing by horseback riding walking at 6.5km/h,

digging holes hand, using a (galloping), low- playing tennis
manual screwdriver, impact aerobics singles, canoeing,
transporting a load skiing, ice skating,
of 20–29 kg, mixed playing basketball or
construction non-competitive
activities, mining, soccer
mechanical work

140 7 shoveling powdery sawing wood, fast dancing (e.g., cycling at 15 km/h,
snow, chopping railroad work, swing) walking at 7.5 km/h,
wood, walking in transporting a load walking up gentle
gentle hills while of 30–38 kg hills, fencing, skiing
carrying less than 5 at 4–9 km/h
kg

160-170 8 shoveling wet snow, sawing by hand, high-impact aerobics cycling at 19 km/h,
cutting down trees, heavy digging using jogging at 8 km/h,
scrubbing floors, a pick-axe, moving cross-country skiing
hillwalking with a 40-kg weights, on the level, swim-
10-kg weight cleaning out stables ming (front crawl) at
35 m/min,
horseback riding
(racing), playing
hockey

190–200 9 hillwalking with a working in high- cross-country skipping at a rate of

10–20 kg weight at temperature ovens, running 70–80/min,
one’s own tempo garden construction swimming (front
work, throwing hay crawl) at a fast pace
bails

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 KNGF-guidelines for physical therapy in cardiac rehabilitation

220 10 carrying a weight of working in high- cycling at 23 km/h,

more than 30 kg, temperature ovens, playing squash,
hillwalking with a 8- heavy steel work hand-ball or paddle
kg weight at 6 km/h ball, rowing,
skipping at a rate of
125/min, high-
jumping, swim-ming
(back stroke) at a
very fast pace

240 11 judo skipping at a rate of

145/min, running at
10 km/h

260–270 12 carrying a weight of rugby cycling at 25 km/h,

up to 50 kg running at 12 km/h,
swimming at 3 km/h
(i.e., 1 km in 20
minutes)

290 13 running at 15 km/h

300-340 14-15 running at 17 km/h

>350 >16 carrying 10 kg up a cutting wood at a competitive sports,

16% slope at 6 km/h high tempo using an cycle-racing,
axe running at 18 km/h,
using barbells
weighing more than
13 kg

Table reproduced with permission from Bohn Stafleu Van Loghum. Source: Vanhees L. Cardiac rehabilitation. In: Physical Therapy/Kinesiology
Therapy Year book 1999. Den Dekker J, Aufdemkampe G, van Ham I, Smits-Engelsman BCM, Vaes P (editors). Houten, the Netherlands: Bohn
Stafleu Van Loghum; 1999:66-95. © 2000.

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 Supplement 4: Effects of medications on heart rate,
blood pressure, ECG responses and exercise capacity
Medications Heart Rate Blood Pressure ECG Exercise Capacity

ß-Blockers (including ↓ (R and E) ↓ (R and E) ↓ HR (R) ↑ in patients with angina;

carvedilol, labetalol) ↓ ischemia (E) ↓ or ↔ in patients without
angina

II. Nitrates ↑ (R) ↓ (R) ↑ HR (R) ↑ in patients with angina;

↑ or ↔ (E) ↓ or ↔ (E) ↑ or ↔ HR (E) ↔ in patients without angina
↓ ischemia (E) ↑ or ↔ in patients with con-
gestive heartfailure (CHF)

III. Calcium channel blockers

Amlodipine ↑ or ↔ HR (R and E)

}
Felodipine ↓ ischemia (E) ↑ in patients with angina’
Isradipine ↔ in patients without angina
Necardipine ↑ or ↔ (R and E)
Nifedipine
Nimodipine
Nisoldipine ↓ (R and E)
↓ HR (R and E)
Bepridil
Diltiazem
Verapamil } ↓ (R and E) ↓ ischemia (E)

IV. Digitalis ↓ in patients with ↔ (R and E) May produce nonspe- Improved only in patients with
atrial fibrillation cific ST-T wave atrial fibrillation or in
and possibly CHF change (R) patients with CHF
Not significantly altered May produce ST seg-
in patients with sinus ment depression (E)
rhythm

V. Diuretics ↔ (R and E) ↔ or ↓ (R and E) ↔ or PVCs (R) ↔,except possibly in patients

´ May cause PVCs and with CHF
“false positive” test
results if hypoka-
laemia occurs
May cause PVCs in hy-
pomangnesemia oc-
curs (E)

VI. Vasodilators, nonadren- ↑ or ↔ (R and E) ↓ (R and E) ↑ or ↔ HR (R and E) ↔,except ↑ or ↔ in patients

ergic with CHF
ACE inhibitors ↔ (R and E) ↓ (R and E) ↔ (R and E) ↔,except ↔ ↑ or ↔ in patients
with CHF

-Adrenergic blockers ↔ (R and E) ↓ (R and E) ↔ (R and E) ↔
Antiadrenergic agents ↓ or ↔ (R and E) ↓ (R and E) ↓ or ↔ HR (R and E) ↔
without selective blockade

VII. Antiarrhythmic agents All antiarrhythmic agents may cause new or worsened arrhtyhmias (proarrhythmic effect)
Class I
Quinidine ↑ or ↔ (R and E) ? or ↔ (R) ↑ or ↔ HR (R) may ↔
Disopyramide ↔ (E) May prolong QRS and
QT intervals (R)
Quinidine may result in
“false negative” test
results (E)
Procainamide ↔ (R and E) ↔ (R and E) May prolong QRS and ↔
QT intervals (R)
May result in “false
positive” test results
(E)

}
Phenytoin
Tocainide ↔ (R and E) ↔ (R and E) ↔ (R and E) ↔
Mexiletine
Flecainide
Moricizine ↔ (R and E) ↔ (R and E) May prolong QRS and ↔
QT intervals (R)
↔ (E)
Propafenone ↓ (R) ↔ (R and E) ↓ HR (R) ↔
↓ or ↔ (E) ↓ or ↔ HR (E)
Class II
ß-Blockers (see I.)
Class III
Amiodarone ↓ (R and E) ↔ (R and E) ↓ HR (R) ↔
↔ (E)
Class IV
Calcium Channel
Blockers (see III.)

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 KNGF-guidelines for physical therapy in cardiac rehabilitation

Medications Heart Rate Blood Pressure ECG Exercise Capacity

VIII. Bronchodilators ↔ (R and E) ↔ (R and E) ↔ (R and E) Bronchodilators ↑ exercise

capacity in patients limited
by Bronchospasm
Anticholinergic agents ↑ or ↔ (R and E) ↔ ↑ or ↔ HR
May produce PVC’s
(R and E)
Sympathomimetic agents ↑ or ↔ (R and E) ↑, ↔ or ↓ (R and E) ↑ or ↔ HR (R and E) ↔
Cromolyn sodium ↔ (R and E) ↔ (R and E) ↔ (R and E) ↔
Corticosteroids ↔ (R and E) ↔ (R and E) ↔ (R and E) ↔

IX. Hyperlipidemic agents Clofibrate may provoke arrhythmias, angina in patients with prior myo-
cardial infarction
Nicotinic agents may ↓ BP
All other hyperlipidemic agents have no effect on HR, BP, and ECG

X. Psychotropic medications
Minor tranquilizers May ↓ HR and BP by controlling anxiety: no other effects
Antidepressants ↑ or ↔ (R and E) ↓ or ↔ (R and E) Variable (R)
May result in ‘false positive’
test results (E)
Major tranquilizers ↑ or ↔ (R and E) ↓ or ↔ (R and E) Variable (R)
May result in ‘false positive’ or
‘false negative’ test results (E)
Lithium ↔ (R and E) ↔ (R and E) May result in T wave changes
and arrhythmias (R and E)

XI. Nicotine ↑ or ↔ (R and E) ↑ (R and E) ↑ or ↔ HR ↔, except ↓ or ↔ in

May provoke ischemia, patients with angina
Arrhythmias (R and E)

XII. Antihistamines ↔ (R and E) ↔ (R and E) ↔ (R and E) ↔

XIII. Cold medications with Effects similar to those described in sympathomimetic agents, ↔
Sympathomimetic agents although magnitude of effects is usually smaller

XIV. Thyroid medications ↑ (R and E) ↑ (R and E) ↑ HR ↔, unless angina worsened

May provoke arrhythmias
Only levothyroxine ↑ ischemia (R and E)

XV. Alcohol ↔ (R and E) Chronic use may May provoke ↔

have role in ↑ BP arrhythmias (R and E)
(R and E)

XVI. Hypoglycemic agents ↔ (R and E) ↔ (R and E) ↔ (R and E) ↔

Insulin and oral agents

XVII. Dipyridamole ↔ (R and E) ↔ (R and E) ↔ (R and E) ↔

XVIII. Anticoagulants ↔ (R and E) ↔ (R and E) ↔ (R and E) ↔

XIX. Antigout medications ↔ (R and E) ↔ (R and E) ↔ (R and E) ↔

XX. Antiplatelet medications ↔ (R and E) ↔ (R and E) ↔ (R and E) ↔

XXI. Pentoxyfiline ↔ (R and E) ↔ (R and E) ↔ (R and E) ↑ or ↔ in patients limited

by intermittent claudication

XXII. Caffeine Variable effects depending upon previous use

Variable effects on exercise capacity
May provoke arrhythmias

XXIII. Anorexiants/diet pills ↑ or ↔ (R and E) ↑ or ↔ (R and E) ↑ or ↔ (R and E)

Key: ↑ = increase; ↔ = no effect; ↓ = decrease; R = rest; E = exercise; HR = heart rate; PVC’s = premature ventricular contractions

* ß-Blockers with ISA lower resting HR only slightly.

+ May provide or delay myocardial ischemia.

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KNGF-guidelines for physical therapy in cardiac rehabilitation

List of abbreviations, glossary and definitions

Abbreviations
ECG electrocardiogram
HR-max maximum heart rate
HR-reserve heart rate reserve
ICIDH International Classification of Impairments, Disabilities and Handicaps
MET’s metabolic equivalent unit
VO2-max maximum oxygen uptake

Glossary
Activity Execution of a task or action by an individual
Borg scale Subjective scale that patients can use to indicate how they experience difference loads
Ergometer Standardized instrument for measuring work capacity
Functions Physiological functions of body systems (including psychological functions)
Impairment Problem with body function or structure, such as a significant deviation or loss
Limitation Difficulty in performing an activity; activities may be limited in nature, duration or
quality
Load The physical, mental or social demands on an individual
Load capacity The load an individual can handle
Muscular function Muscle strength, speed of movement, flexibility and coordination
Optimal functioning The level of functioning at which the patient can return to full participation in society
Participation Involvement in a life situation
Prevention The sum of all the measures taken to bring about behavioral change aimed at
preventing heart disease progression; in 1995, the (Dutch) Rehabilitation Commission
used the term secondary prevention, whereas epidemiologists refer to it as tertiary
prevention
Training Providing a physical exercise plan to force the body to adapt to a higher level of
functioning
Training capacity The individual’s scope for adapting his or her body to a higher level of functioning

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 KNGF-guidelines for physical therapy in cardiac rehabilitation
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