Program Description:

Physical Therapy in a Heart Failure Clinic

Ann Knocke, MS, PT, CCS
Newton Wellesley Hospital, Physical Therapy Department, Wellesley, MA

ABSTRACT
Aerobic exercise and resistance training have been proven
to be beneficial for patients with heart failure. Current
reimbursement guidelines exclude these patients from our
traditional cardiac rehabilitation program, so at Newton
Wellesley Hospital a clinic model was developed for the
disease management and exercise of heart failure patients.
Key Words: heart failure, physical therapy, exercise
INTRODUCTION
Newton Wellesley Hospital (NWH) is a 289 bed
teaching hospital located about 15 miles west of Boston,
Massachusetts. Our Cardiovascular Health Center offers
6 Phase II cardiac rehabilitation classes, serving patients
after myocardial infarction, coronary bypass surgery,
valve surgery, and angina. In addition, we run a disease
management program for patients with heart failure (HF).
Referrals come from inpatient admissions for acute onset HF
and referrals from cardiologists and primary care physicians.
This HF clinic is a nurse practitioner (NP) based clinic that
offers disease management, education, exercise, and long
term follow-up. There are dieticians and physical therapists
involved in the education and exercise components of the
program. The program uses a multidisciplinary model,
which affords us the opportunity to incorporate each team
members expertise into a comprehensive patient care plan
that positively impacts outcomes.
The CHF program began in 1996 by a NP and a physical
therapist. The practitioners recognized the exclusion of HF
patients from traditional cardiac rehabilitation programs
and a more flexible, fluid, clinic model was developed. At
the beginning of the program there were only 5 patients
enrolled at a time, building gradually, with an estimated
500 patients participating to date. The current enrollment
includes 64 patients for the exercise class, which is offered
twice per week. Patients range in age from 52-92 years,
33 males and 31 females. The diagnosis of diastolic HF
accounts for approximately 70% of the current group of
patients, with the remainder diagnosed with systolic HF.
At NWH we have an identify and connect program that
Address correspondence to: Ann Knocke MS, PT, CCS,
Newton-Wellesley Hospital, Washington Street, Newton, MA Ph: (617) 243-6172 (aknocke@partners.org).

46

alerts the NPs to any patient admitted with a diagnosis

of HF. Based on their status and preference, patients are
enrolled to nursing only visits or nursing visits with exercise.
Patients are also referred by their cardiologist directly to the
clinic from NWH and outlying hospitals.
Upon entrance into the program patients undergo an
evaluation by the NP, assessing current physical status and
medical regiment, with particular attention to signs and
symptoms of HF and weight gain. Brain naturetic peptide
(BNP) level is followed closely, as well as renal function, in
the titration and selection of medications. At each visit the
patients are reassessed by an NP, or nurse, for vital signs,
weight, breath sounds, edema, and symptoms. If a patient
has gained more than 3 pounds (1.4 kg) since the prior
sessions, the patient is not permitted to exercise.
Prior to entering the exercise program, patients are
evaluated by a physical therapist. This evaluation includes
a musculoskeletal screening, 6 minute walk test with
telemetry monitoring, balance screening, and self-report of
prior and current exercise routines. Following the results of
the six-minute walk test (6MWT), a target heart rate range
is determined, at 50% to 70% of 220-age.1-4 Patients are
educated in the use of the Borg 6-20 rating of perceived
exertion scale, with instruction to work at a level of 11-13,
or moderate exercise.1-4
Exercise prescription is then determined, following the
American Heart Association and the American College of
Sports Medicine guidelines.5 Intensity is recommended
to be within the target heart rate range and/or perceived
exertion rating of 11-13 (moderate level). Duration is
targeted at 30 to 40 minutes of aerobic exercise, beginning
with the amount the patient is able to perform at the time.
Frequency is recommended to be 5 to 7 days per week.
Patients are monitored with telemetry for the first 3 exercise
sessions, and then continue without telemetry unless there
are rhythm or ectopy concerns. Patients are monitored
for heart rate and blood pressure throughout the exercise
sessions, and after 5 minutes of recovery. Oxygen saturation
is measured as well. The examination and management of
patients in the HF clinic is outlined in Figure 1.
Modes of exercise include treadmills, upright and
recumbent bikes, elliptical machines, and NuStep
machines. The NuStep is a seated stepping and upper
extremity exercise machine. It is well tolerated by patients
with common comorbidities such as back pain, balance
difficulties, and lower extremity weakness; this is one of
the preferred machines by our patients. Considerations

Cardiopulmonary Physical Therapy Journal

Vol 23 v No 3 v September 2012

Nursingcheck in
Weight
Heartrate
Bloodpressure
Lungandheartsounds
Legedema

CliniclevelII:
Twiceweeklynursing
assessment,exercisesession
withphysicaltherapists

ExerciseSession

6months

5minwarmup

CliniclevelI:
Maintainance:

Onceweeklynursing
assessment,exercisesession
withphysicaltherapists

Physicaltherapistassessment
andexercisesession

3months

3months

2030minaerobicexs
5mincooldown
strengthtraining

CheckoutbyPT

Figure 2. The 3 phases of the heart failure clinic.

5minseatedrest

Figure 2. The 3 phases of the heart failure clinic.

HRandBP
Bloodsugar

Figure 1. Examination and management of patients in the heart failure clinic.

Figure 1. Examination and management of patients in the

heart failure clinic.
are taken into account for orthopedic impairments, pain,
balance abnormalities, and personal preferences. Patients
are encouraged to experiment with various machines
for variety and carryover to health clubs or senior center
exercise rooms, as well as for determining the best machine
to purchase for home.6,7 When appropriate, patients
are referred for individual physical therapy services, for
example balance training, which can be coordinated on
the same visit day as the clinic.
Exercise is progressed as tolerated, with very
deconditioned patients beginning with 5 minutes of exercise,
followed by a rest period, continuing in intervals. More
fit individuals begin with 30 minutes continuous exercise
the first session, with warm-up and cool-down as well.
Light resistance exercise is added when appropriate, taught
individually with an emphasis on simple exercises that can
be reproduced at home. Stretching is recommended and
instructed for the working muscle groups. The HF program
runs for 12 months throughout which patients can move
from one phase to another if their medical status changes
(Figure 2).
The diagnosis of HF is not recognized by Medicare as
a Cardiac Rehabilitation diagnosis; thus, patients are billed
only for the nursing visits. One of the primary goals of the
program is to prevent readmissions for HF. Our 30 day all
cause readmission rate at NWH was recently estimated at
15% with 7.5% for acute HF. National estimates in the
same time period were 24% all cause and 17% acute HF
readmissions. As health policy evolves and reimbursement
may be spread over the course of an illness, rather than
service based, this model may prove to be very cost effective
for HF patients.
SUMMARY
In summary, we have developed a disease management
program that incorporates physical therapist directed
exercise training for our HF patients. This allows us to serve
this population despite their falling outside the traditional
cardiac rehabilitation model. Our patients benefit from
the more frequent nursing assessments, training effects,

Vol 23 v No 3 v September 2012

and social interactions that the clinic provides. As one

patient reported, The program has increased my mobility,
endurance, capacity, and tolerance. It has taught me how
to care for myself.
REFERENCES
1. Bartlo P. Evidence-based application of aerobic and
resistance training in patients with congestive heart
failure. J Cardiopulm Rehabil Prev. 2007;27:368-375.
2. Mandic S, Tymchak W, Kim D, et al. Effects of aerobic or
aerobic and resistance training on cardiorespiratory and
skeletal muscle function in heart failure; a randomized
controlled pilot trial. Clin Rehabil. 2009;23(3):207-216.
1
3. A rslan S, Erol MK, Gundogdu
F, et al. Prognostic value
of a 6-minute walk test in stable outpatients with heart
failure. Tex Heart Inst J. 2007;34(2)166-169.
4. Haass, M, Zugck, C, Kubler, W. The 6 minute walking test:
a cost-effective alternative to spiro-ergometry in patients
with chronic heart failure? Z Kardiol. 2000;89(2):72-80.
5. American College of Sports Medicine. ACSMs Guidelines
for Exercise Testing and Prescription. Lippincott Williams
& Wilkins; 2010.
6. Bresnick B. Encouraging exercise in older adults with
congestive heart failure. Geriatr Nurs. 2004;25(4):204211.
7. Parish TR, Kosma M, Welsch MA. Exercise training for
the patient with heart failure: Is your patient ready?
Cardiopulm Phys Ther J. 2007;18(3):12-20.

Erratum
The complete radiograph from Sobush et al (June 2012 issue) was
inadvertently cut off. The full image is reprinted here.

Figure 1. Representative PA and lateral plain-film radiographs.

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