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for a patient or may result in an unstable physiologic response.

Unstable responses provide some indication that the patient is nOt able

to meet physiologic demands owing to the pathologic process for the

level of work that the patient is performing. In this siruation, the physical

therapist needs to consider the patient'S response to other activities and

determine whether these activities create a stable response. If it is stable,

can the patient function independently doing that level of work?

For example, some patients may be stable walking 10 ft to the

bathroom at one time, yet this activity may require maximal exertion

for the patient and therefore should be considered too much for the

patient to continue to do independently throughout the day.

If the patient'S response is nOt stable, then the therapist should try to

discern why it is not stable, along with finding out if anything can be

CARDIAC SYSTEM 63

Table 1-2 1 . Indications of Patient Instability

Relative Indications

Absolute Indications That the

That the Patient Is Unstable and

Patient Is Unstable and Treatment

Treatment Should Be

Should Be Withheld

Modified or Withheld

Decompensated congestive heart failure Resting heart rate > 100 bpm

Second-degree heart block coupled with

Hypertensive resting BP (syscolic

premature ventricular contractions

> 160 mm Hg, diascolic >90 mm

(PVCS) of ventricular tachycardia at rcst

Hg)

Third-degree heart block

Hypotensive resting BP (systolic

More than 1 0 pves per min at rest

<80 mm Hg)

Multifocal PVCs

Myocardial infarction or exten

Unstable angina pectoris with recent

sion of infarction within the prechanges in symptoms (less than 24 hrs)

vious 2 days

and electrocardiographic changes asso

Ventricular eccopy at rest

ciated with ischemia/injury

Atrial fibrillation with rapid ven

Dissecting aorric aneurysm

tricular response at rest (HR

New onset (less than 24 hrs) of atrial

> 100 bpm)

fibrillation with rapid ventricular

Uncontrolled metabolic diseases

response at rest (HR > 100 bpm)

Psychosis or other unstable psycho

Chest pain with new ST segment

logical condition

changes on ECG

BP = blood pressure; ECG = electrocardiogram; HR = heart rate.

Sources: Data from LP Cahalin. Heart failure. Phys Ther 1 996;76:520; MH Ellestad.

Stress Testing: Principles and Practice (4th cd) Philadelphia: FA Davis, 1 996; and NK

Wegener. Rehabilitation of the Patient with Coronary Heart Disease. In RC Schlant,

RW Alexander (cds), Hurst's the Heart (8th cd). New York: McGraw-Hili, 1994;1 227.

done to make the patient stable (i.e., medical treatment may stabilize

this response). Additionally, the therapist should find the level of function that a patient could perform with a stable response. However, at times, patients will not be able to be stabilized to perform activity. In

these cases, physical therapists need to determine whether a conditioning program would allow the patient to meer the necessary energy demands without becoming unstable. Proceeding with therapy at a

lower level of activity is based on the premise that conditioning will

improve the patient'S response. The cardiac system suppOrts the body in

its attempt to provide enough energy to perform work. Often, becoming stronger-increased peripheral muscle strength and endurancewill reduce the demands on the heart at a certain absolute activity