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How to do: Telerehabilitation
in heart failure patients
Department of Cardiac Rehabilitation and Noninvasive Electrocardiology, Abstract
According to the present guidelines for heart failure patients, regular exercise training hasobtained the class of recommendation I, level of evidence A. Despite the benefits of cardiacrehabilitation, many heart failure patients are inactive. Common patient’s rejection of existingforms of rehabilitation and limitations resulting from the disease itself hinder the outpatientcardiac rehabilitation. That is why home telerehabilitation seems to be the optimal form ofphysical activity for heart failure patients. (Cardiol J 2012; 19, 3: 243–248) Key words: telerehabilitation, heart failure
sions [4–9]. In order to fulfill these two tasks, symp-toms (fatigue, dyspnea, chest pain) and parameters Thanks to the progress in various scientific (electrocardiogram [ECG], heart rate, arrhythmias, fields, medicine is capable of saving more and more ischemia, blood pressure, body mass, saturation, lives. Yet, paradoxically, this situation generates an medication taken, etc.) need to be monitored. These increasing number of patients with heart failure procedures should render home telerehabilitation (HF). Heart failure is a crucial problem in modern cardiology. Statistics show that more than 10 and Despite the fact that telemedicine is highly ap- 4 million people suffer from HF in Europe and in plicable and effective, there are very few papers the USA, respectively. According to the present dedicated to the study of TR in HF patients [9–16].
guidelines for HF patients, regular exercise train- Until recently only a couple of home rehabilitation ing has obtained the class of recommendation I, le- monitoring models have been presented. From the vel of evidence A [1]. The problem medicine needs simplest (1) heart rate monitoring [10] and (2) tran- to deal with is the provision of cardiac rehabilita- stelephonic electrocardiografic monitoring [11], tion (CR) to all HF patients and thus complying with through more advanced (3) tele-ECG-monitoring via a remote device [12] and (4) real-time ECG and Despite the benefits of CR, many HF patients voice transtelephonic monitoring [13]. It seems the are inactive [2, 3]. Common patient’s rejection of last two are the most useful and reliable.
existing forms of rehabilitation and limitations re-sulting from the disease itself hinder the outpatient Model of telerehabilitation
CR. That is why home telemonitored CR seems tobe the optimal form of physical activity. Telemedi- There are no guidelines about TR in HF pa- cine can be most useful in performing exercise tients. On the basis of research data and our expe- training for two reasons: it can control the stability rience the following model of TR for HF patients of clinical status and help supervise training ses- Address for correspondence: Ewa Piotrowicz, MD, PhD, Department of Cardiac Rehabilitation and NoninvasiveElectrocardiology, Institute of Cardiology, ul. Alpejska 42, 04–628 Warszawa, Poland, fax: +48 22 343 4519,e-mail: Cardiology Journal 2012, Vol. 19, No. 3
Table 1. Responsibilities of telerehabilitation team members.
Physician’s responsibilities
Clinical assessment of patients before inclusion, during and after CR Planning exercise trainings and optimal workload Educating patients on their illness basics (how to self-evaluate worrying signs and symptoms and the levelof perceived exertion according to the Borg scale) Telephone consulting with patients, if need arises (nurses asses problems prior to physician’s counseling) Obtaining patients’ consent for CR (compelling patients to fill in and sign patient’s consent form) Nurse’s/an ECG technician’s responsibilities
Educating patients (*how to measure heart rate, blood pressure, and body weight, *how to operate thetele-monitoring equipment) Enlisting patients into the electronic telemonitoring database Programming the assigned exercise training in the telerehabilitation device Analysing ECG (subsequent to consulting the physician) Assessing patients perceived exertion in Borg’s scale Receiving telephone information from patients regarding potential problems and necessity to consult a physician 10. Ensuring that patients fill in the CR questionnaire 11. Registering, distributing and ensuring the return of CR devices 12. Ensuring patients sign the CR device lease form 13. Conducting antropometric measurements prior to and following the CR (weight, height, waist and hip circumference) Physiotherapist’s responsibilities
Planning exercise trainings and optimal workload — teaching how to perform the exercises prescribed and conducting educational training sessions — providing patients with a short lecture on the technicalities of exercise training — deciding whether patients are sufficiently trained and capable of safely conducting CR at home Assessing (daily) the correctness of the exercise training, reacting to improper/incorrect courseof exercise training Psychologist’s responsibilities
Providing psychological support. Each patient should receive psychological care that includes discussingand commenting the disease itself, its course, its treatment and patient’s rehabilitation acceptance. Thepatients should also be offered, if necessary, individual psychological support in the form of conversationsover the phone. Such conversations should be carried out regularly within the tele-monitoring programme Telerehabilitation medical
Telerehabilitation equipment
team and device
and infrastructure
Telerehabilitation is carried out by a medical Currently available monitoring systems include: team and advanced monitoring systems are used.
A special remote device for tele-ECG-monito- A TR medical team should be composed of: a phy- red and supervised exercise training-TR set sician, a physiotherapist, a nurse, an ECG techni- (Pro Plus Company, Poland), which consists of: cian, and a psychologist. The responsibilities of TR EHO mini device, blood pressure measuring Ewa Piotrowicz, How to do: Telerehabilitation in heart failure patients
tained data are subsequently analyzed by themedical team and a medical report follows.
Telerehabilitation set
An EHO mini device adjusted to register 16- -seconds–5-minutes fragments of ECG recordingfrom three precordial leads and to transmit the datavia mobile phone network to the monitoring center(Fig. 2). An EHO mini device has training sessionspreprogrammed individually for each patient (definedexercise duration, breaks, timing of ECG recording).
The moments of automatic ECG registration are pre-set and coordinated with the exercise training. Theplanned training sessions are executed with the de-vice indicating what should be done with sound andlight signals. There are sound signals in the form ofbleeps and light signals from color emitting diodes.
Bleeps and green diode blinking mean the patientshould do exercise, another set of bleeps and reddiode blinking mean stop exercise. The timing ofautomatic ECG recordings corresponded to peakexercise.
An EHO mini device has a tele-event-Holter ECG feature as well. Tele-event-Holter ECG isa feature that enables a patient, whenever a worry-ing symptom occurs, to register and immediatelysend the ECG recording via mobile phone networkto the telemonitoring centre. The system works ina loop scheme, owing to which it is possible to ana- Figure 1 Telerehabilitation set — a manometer and
lyze the part of ECG recording which directly pre- a weighing machine, which both are compatible with ceded an event which made a patient press the sig- Patients are also able to make additional reg- istrations and send them at any time, for example, A data transmission set via a mobile phone.
when they felt unwell, if they experienced symp- A monitoring centre capable of receiving and toms like palpitations, chest pain, etc.
storing patients’ medical data (specialized har- Apart from the EHO mini device, the TR set dware and software are necessary). Thus ob- also includes a weighing machine and a manome- Figure 2. Electrocardiogram during telerehabilitation.
Cardiology Journal 2012, Vol. 19, No. 3
Table 2. The initial telerehabilitation phase — baseline clinical examination
Potential abnormality
Laboratory tests
Anemia (< 13 g/dL in men, < 12 g/dL in women) Hyperglycemia (> 6.5 mmol/L), diabetes control concentrations (natrium, potas-sium, magnesium), urinalysisThyroid tests Tools for diagnosis and management of heart failure Sinus tachycardia, sinus bradycardia, arrhythmias (atrial flutter/fibrillation;supraventricular, ventricular arrhythmias)’ conduction disturbances,ischemia, QRS duration-evaluation for CRT implantation Chest X-ray
Cardiomegaly, ventricular hypertrophy, normal pulmonary findings,pulmonary venous congestion, interstitial edema, pleural effusion, Kerley Blines, hyperlucent lung fields, pulmonary infection, pulmonary infiltration Echocardiography
Assessment of left ventricular function (global and focal), ejection fraction;end-diastolic/end-systolic diameter, left atrial size, valvular structure andfunction, mitral diastolic flow profile, pericardium, aortic outflow velocitytime integral, inferior vena cava. Evaluation for cardiosurgery, CRT Ambulatory ECG
Assessment of arrhythmias, conducted disturbances, silent ischemia monitoring (Holter ECG)
Monitoring ventricular rate control in patients with atrial fibrillationEvaluation of functioning of implantable devices (pacemakers, CRT)If necessary, referral for ablation supraventricular or ventricular arrhythmias Six-minute-walk test [25]
Assessment of submaximal functional capacity and evaluation of the responseto intervention Cardiopulmonary
Objective evaluation of exercise capacity and exertional symptoms, such as exercise test [26, 27]
dyspnea and fatigue. Presence of exercise-induced arrhythmias, conducteddisturbances, ischemia. Heart rate of onset of an arrhythmia, ischemiaAssessment of chronotropic response to exercise. Obtaining data necessaryto define the duration and frequency of exercise sessions and recommendedtraining workloads. Evaluation of the response to intervention BNP — B-type natriuretic peptide; NT-proBNP — N-terminal pro-BNP; CRT — cardiac resynchronization therapy ter, which both are compatible with the EHO mini Table 3. Education programme designed and
device and enable blood pressure results and body run by the telerehabilitation staff.
mass to be sent automatically to the monitoring fa- Patients and their partners ought to be taught: cility. Patients’ data are sent to the monitoring cen- — how to measure heart rate, blood pressure, tre instantly after being obtained by the EHO mini device. It is of utmost importance, since such a pro- — how to self-evaluate worrying signs and cedure hinders patients from manipulating their medical data (i.e. the patients have to take actual measurements and cannot simply enter whatever — how to self-evaluate the level of perceived data they wish thus providing the monitoring cen- exertion according to the Borg scale during ter with false information on their state of health).
EHO mini device, apart from storing and transmit- — how to operate a telerehabilitation set ting medical data to the monitoring centre, is also — how to give first aid in case of an emergency a mobile phone which allows patients to be in con-stant touch with the centre.
The initial telerehabilitation stage
Performing telerehabilitation
The goals of the initial stage are: a baseline Performing TR consists of two stages: an ini- clinical examination for reliable evaluation of clini- tial stage — conducted either at hospital sites or cal status and functional capacity (Table 2), educa- within outpatient programmes, and a basic stage — tion (Table 3), individual planning of exercise train- ing depending on patient’s exercise efficiency Ewa Piotrowicz, How to do: Telerehabilitation in heart failure patients
Table 4. Borg’s rating of perceived exertion scale.
the basal and peak heart rate during exercise test)and 10/20–14/20 of the Borg perceived exertion are Telemonitoring during training sessions
TR set is used to monitor and control training in anywhere the patient has elected to exercise. If the training session is completed uneventfully, the patient transmits ECG recording via a mobile phoneto the monitoring centre immediately after the endof every training session. The data are stored ina computer and are analyzed by TR team at the moni- achieved in tests, performing a few (3–6) monitored toring centre, and the safety, efficacy, and accura- cy of a particular patient rehabilitation programme Planning the exercise training. The chosen
workload should reflect individual effort tolerance Using the data on heart rate during exercise with regard to: perceived exertion according to the and the patient’s subjective evaluation of the per- Borg scale (Table 4) and the training heart rate range ceived exertion, consultants are able to adjust the established individually for each patient depending training workload appropriately or, if necessary, to on patient’s parameters (heart rate and physical ef- discontinue the session (physicians are those who fort) achieved in cardiopulmonary exercise tests.
Having accomplished the initial stage, patients Patients can also transmit an ECG recording at any moment, e.g. due to symptoms like palpita-tion, chest pain etc. (thanks to tele-event-Holter The basic telerehabilitation stage
ECG feature). The telephone contact is also usedfor psychological support.
The basic TR stage ought to consist of two parts performed prior to each training session:— first part — the training consent procedure re- There have been numerous papers published — second part — the training session.
recently indicating that cardiac disease patients, The first part — the training consent pro-
especially those with HF, benefit from home-based cedure. Each patient, before a training session,
CR. A mandatory element which makes this type should answer a series of questions regarding his of CR possible is its supervision by using telemed- or her present condition via mobile phone (factors icine. If this procedure is to be implemented, it is should include fatigue, dyspnoea, oedema, and necessary to know how to do it. That is why I be- medication(s) taken). Subsequently patients should lieve that this paper will be my humble contribu- transmit resting ECG, blood pressure and body tion to making the slogan ‘H H — Hospital-to- mass data to the monitoring centre. If no contrain- dications to training are identified, patients can re-ceive consent to start the training session.
Conflict of interest: none declared
The second part — the training session.
Exercise training should be performed in accor-dance with the published standards for HF patients References
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