Indian Journal of Physical Therapy and Research

: 2021  |  Volume : 3  |  Issue : 2  |  Page : 70--71

Raising the bar in heart failure rehabilitation

Konrad J Dias 
 Professor, Board certified Cardiovascular and Pulmonary Clinical Specialist; American Board of Physical Therapy Specialities, Maryville University of St. Louis, USA

Correspondence Address:
Dr. Konrad J Dias
Maryville University of St. Louis, Missouri

How to cite this article:
Dias KJ. Raising the bar in heart failure rehabilitation.Indian J Phys Ther Res 2021;3:70-71

How to cite this URL:
Dias KJ. Raising the bar in heart failure rehabilitation. Indian J Phys Ther Res [serial online] 2021 [cited 2022 May 17 ];3:70-71
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Heart failure (HF) is a major health concern in India and across the world. Over the past decade, this progressive and debilitating disease continues to dramatically increase in incidence and prevalence both in the developed and the developing world.[1] Advances in medical therapy and technology coupled with an increase in the prevalence of obesity, hypertension, and diabetes have collectively contributed to this disease increasing in epidemic proportions.[1]

Physiotherapy for patients with HF is an essential pillar for combating the HF epidemic in India and beyond. Despite its necessity, physiotherapy for these patients is challenging due to the deconditioning effects of HF on skeletal muscle function compounded by the complex pathophysiological and compensatory changes seen with HF.[2] In addition, patients with HF present with low levels of physical activity that have been associated with greater mortality.[3] With all these challenges in mind, it is imperative that physiotherapists are equipped with appropriate tools to help raise the bar in their overall clinical management and demonstrate to society the value we can offer to patients with this complex pathology.

 Heart Failure Clinical Practice Guideline

Rehabilitation guidance in the management of patients with HF continues to revolutionize in the 21st century. More recently, two seminal papers published in the Physical Therapy Journal collectively encapsulate the evidence related to HF rehabilitation research. The first of these is a comprehensive clinical practice guideline (CPG) paper published in 2020.[4] This practice guideline disseminates nine systematically developed statements that assist practitioners in making informed decisions in the management of patients with HF. These statements were derived through expert analysis of available data specifically considering the risks and benefits of each category of intervention. The nine key action statements provide physical therapists with contemporary evidence-based interventions to increase activity, participation, and reduce hospital readmissions in individuals with HF. The interventions delineated within the CPG include the effects of aerobic exercise, strength training, high intensity interval training, inspiratory muscle training, and the use of neuromuscular electrical stimulation in the holistic management of patients with HF. In addition, two algorithms presented in the paper guide clinical decision-making based on participation restrictions, activity limitations, and reduced endurance or exercise intolerance.

Although CPGs aim to provide a comprehensive report of best evidence for any given condition, the literature reports low utilization of CPG in clinical practice.[5] The reason for this is often because CPGs are typically based on a single condition, resulting in a mismatch between the phenotypic characteristics of subjects studied in clinical trials and the complex, multimorbid nature of patients typically see in clinical practice. This is certainly true for HF where patients often present with multiple comorbidities and risk factors that alter their overall prognosis. In light of this, a mismatch between subjects represented in clinical trials compared to patients commonly seen in clinical practice, a second knowledge translation paper published earlier this year, provides an outline for the utilization of the evidence in clinical practice to in an effort to maximize guideline directed care.[6]

 Heart Failure Knowledge Translation

The hallmark of the HF knowledge translation paper is that it provides physiotherapists with a framework to utilize research in the context of other knowledge and social norms to facilitate the application of the evidence in clinical practice. The authors propose a clinically oriented 5-step (Assessment, Behavior Modification, Cardiorespiratory fitness testing, Dosing, and Education) model to assist physical therapists in applying the evidence into patient/client management. The use of this systematic 5-step methodology has the power to enhance consistency in clinical practice. Hence, often, inconsistencies in practice, productivity standards, time constraints, knowledge deficits, biases developed over years of clinical practice, and other miscellaneous factors make it challenging for therapists to incorporate new evidence into practice. For this reason, an easy to use 5-step paradigm presented in this article has the potential to improve consistency in the use of evidence-based interventions provided by therapists in the management of patients with HF.

In this 5-step model, physiotherapists are encouraged to incorporate a formal assessment of stability, address behavior modification, test cardiorespiratory fitness, select and dose skilled interventions, and educate patients on disease management during any episode of care in the holistic management of patients with HF. In addition, several figures, tables, and appendices serve as essential tools for utilizing the evidence in clinical care. Two examples involve the use of a red, yellow, and green traffic light figure and an education checklist. The traffic light figure can be used to assist patients in recognizing relevant symptoms of decompensation and appropriate actions to take based on their symptomatology. The education checklist is a checklist of items that can be documented and discussed with the patient and family to maximize consistency and effectiveness of the education being provided to patients. Education in clinical care is essential as physiotherapists today are challenged to change a culture marked by incessant marketing of sugars, calorie-rich foods, individuals incorporating unhealthy choices, and patients not achieving adequate daily activity, all of which collectively contribute to the growing prevalence of HF.


I anticipate that through the use of these evidence-based resources, physiotherapist can raise the bar in clinical practice and provide value to patients, clients, and the health-care system in India and across the globe. With growing health-care costs and many medical therapies escalating in cost, many of which are unaffordable to patients, services provided by physiotherapists can be the best approach in the overall management and prognosis for this debilitating disease.


1Virani SS, Alonso A, Aparicio HJ, Benjamin EJ, Bittencourt MS, Callaway CW, et al. Heart disease and stroke statistics – 2021 update: A report from the American Heart Association. Circulation 2021;143:E254-743.
2Writing Committee Members; Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr., et al. 2013 ACCF/AHA guideline for the management of heart failure: A report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 2013;128:e240-327.
3Doukky R, Mangla A, Ibrahim Z, Poulin MF, Avery E, Collado FM, et al. Impact of physical inactivity on mortality in patients with heart failure. Am J Cardiol 2016;117:1135-43.
4Shoemaker MJ, Dias KJ, Lefebvre KM, Heick JD, Collins SM. Physical therapist clinical practice guideline for the management of individuals with heart failure. Phys Ther 2020;100:14-43.
5Zadro JR, O'Keeffe M, Allison JL, Lembke KA, Forbes JL, Maher CG. Effectiveness of implementation strategies to improve adherence of physical therapist treatment choices to clinical practice guidelines for musculoskeletal conditions: Systematic review. Phys Ther 2020;100:1516-41.
6Dias KJ, Shoemaker MJ, Lefebvre KM, Heick JD. A knowledge translation framework for optimizing physical therapy in patients with heart failure. Phys Ther 2021;101:pzab079.