Cardiopulmonary home exercise program

INTRODUCTION

Global life expectancy has increased, accompanied by a rising prevalence of chronic disease. Consequently, a growing number of individuals are living longer with conditions such as chronic heart failure, chronic obstructive pulmonary disease (COPD), hypertension, and diabetes mellitus. Chronic heart failure and COPD commonly coexist, with reported prevalence estimates ranging from 20% to 32%.¹ Both populations are at significant risk of morbidity and mortality. Evidence indicates that each group develops alterations in skeletal muscle that contribute to reduced functional capacity.² The precise events and mechanisms underlying skeletal muscle atrophy remain incompletely understood; however, muscle disuse, chronic low-grade systemic inflammation, and elevated oxidative stress are thought to be key contributing factors.³

Cardiac and pulmonary rehabilitation have been shown to be beneficial for patients with chronic heart and lung disease. In their paper, “Benefits of Cardiac Rehabilitation,” Damluji et al. describe the origins of cardiac rehabilitation in the 1960s in the United States and Canada, where it was initially implemented as an inpatient program aimed at early mobilization following myocardial infarction.⁴ Over time, cardiac rehabilitation evolved into a predominantly outpatient model. A substantial body of evidence has since documented its clinical benefits.⁵ For patients with chronic lung disease, pulmonary rehabilitation is an evidence-based intervention that has been shown to improve symptoms, enhance functional capacity, and reduce hospital admissions.⁶ Despite the well-established benefits of both cardiac and pulmonary rehabilitation programs, they are underused. The reasons for this are multifactorial, and include barriers such as transportation difficulties, a limited number of available programs, and low referral rates. In their review of access to pulmonary rehabilitation, Malla et al. report that in the United States there is approximately one pulmonary rehabilitation center for every 6,030 individuals with chronic obstructive pulmonary disease.⁷ Several studies have investigated whether home-based programs provide benefits comparable to those delivered in center-based settings. In a comprehensive Cochrane Database review, Anderson et al. concluded that home- and center-based cardiac rehabilitation are similarly effective for patients following myocardial infarction or with heart failure.⁸ In addition, Bernocchi et al. evaluated the efficacy of an integrated, home-based telerehabilitation program in patients with both COPD and chronic heart failure, concluding that this approach is both feasible and effective.⁹ In this paper, we outline the implementation of a home-based exercise program.

BENEFITS OF CARDIOPULMONARY EXERCISE

There is a large benefit to exercise in individuals who have cardiopulmonary disease. It has been shown that exercise can “improve efficiency of the heart and lung function, speed up blood circulation, increase oxygen supply to the whole body, and improve elasticity of blood vessels. In addition, exercise can lower blood lipids and prevent arteriosclerosis and thrombosis.”¹⁰ It is important for health care providers to be aware of these benefits and to educate their patients on the benefits of exercise.

SAFETY CONSIDERATIONS

Multiple safety considerations should be considered when someone with a diagnosis of cardiopulmonary disease is exercising. A pulse oximeter can be used to intermittently check heart rate and oxygen saturation during exercise. Symptoms should be monitored throughout exercise, and exercise should be terminated when the following signs or symptoms occur: chest pain, hypertension (>250 mmHg systolic and >120 mmHg diastolic); fall in blood pressure >20 mmHg, O₂ saturation less than or equal to 80 percent, sudden pallor, loss of coordination, dizziness or faintness, signs of respiratory failure, mental confusion.¹¹ Patients should also have assistance from other individuals (friends, family, caregivers) as needed for balance or functional mobility. Assistive devices, counters, and chairs should be used as needed for safety to avoid falls during exercises.

EXERCISE RECOVERY MANAGEMENT

Individuals should ensure that O₂ saturation does not drop below 88 percent to prevent possible cell damage from hypoxia.¹⁶ The Rating of Perceived Exertion (RPE) scale, also known as the Borg Scale of Perceived Exertion, is used to understand how much effort patients perceive they are expending.¹⁵ The level of effort graded on the RPE 10-point scale should remain within goal levels. If the individual’s exertion is outside of appropriate levels, the individual should rest until O₂ saturation is >88 percent and RPE levels have returned to 3–4 for moderate intensity or 5–7 for vigorous intensity.^15,16 Techniques that have been used clinically for recovering O₂ saturation after physical activity include seated or standing rest. Pursed lip breathing and diaphragmatic breathing are also used for exercise recovery, which have been shown to increase O₂ saturation with COPD by enhancing alveolar ventilation and allowing for improved gas exchange.¹⁷

EXERCISE PARAMETERS

ENDURANCE TRAINING

Frequency & Duration: According to the AHA guidelines, it is recommended to complete 150-minutes of moderate intensity per week or 75-minutes of vigorous intensity per week of cardiovascular exercise. However, only 22.9 percent of American adults ages 18–64 meet these recommendations.¹² Therefore, it is advised that patients complete as much physical activity as possible, and that they feel is achievable for them. It may be helpful to begin with a small goal rather than asking them to complete 150-minutes per week.¹⁵

Intensity: Individuals should be educated on the 10-point RPE scale to ensure appropriate level of effort for exercise is completed. According to Mytinger et al., RPE of 11–14 is recommended on the –20 RPE scale, although using the 10-point RPE scale will likely be easier to understand and to explain.¹³ The individual can be advised to complete RPE of 3–4/10 for moderate intensity or 5–7/10 for vigorous intensity when using the 10-point RPE scale.¹⁵

STRENGTH TRAINING

Strength training should be performed 2 non-consecutive days per week using multiple muscle groups and progressing to 3 days per week as able. The 10-point RPE scale should be used for assessing intensity, and levels should remain at 3–4/10. The individual should begin with 1 set per exercise and progress to 3 sets with 10–15 repetitions per set as tolerated.¹⁵

EXERCISES IN ASSOCIATION WITH PATIENT FUNCTIONAL LEVEL

A wide variety of functional differences exist in the cardiopulmonary population. Some individuals can walk long distances without assistance, and some individuals may need assistance from others to get out of bed and/or require assistive devices (AD) for their mobility. The following section will cover cardiopulmonary exercise possibilities at all levels of mobility and function. Home exercise programs should be tailored to individuals and their functional levels by licensed clinicians.

Level 0: Bed-bound. Patients may have reduced mobility that prevents them from mobilizing out of bed without assistance and/or may have low O₂ saturation upon sitting that prevents progression to standing. Goal for these patients is assisting them to achieve an upright position as this is the best position for improved pulmonary function for patients with cardiopulmonary disease.¹⁴

• Safety: An additional person should be present for assistance if necessary, appropriate body mechanics and equipment should be used for safe transfers, and oxygen saturation should be monitored with pulse oximeter.
• Supine:
  • Can complete bridging, rolling, AROM/AAROM/PROM/RROM of all UE and LE joints into multiple planes of motion.
  • Can use isolated joint movements and progress to a combination of joint movements. Theraband can be added for further progression using resistance.
• Raising head of bed or propping patient to upright sitting with pillows. Can advance patient from reclined position (45 degrees) to upright sitting (90 degrees). If patients can tolerate 90 degrees of trunk elevation, they will likely tolerate sitting on edge of bed. Oxygen saturation should be closely monitored in each of these positions.
• Sitting on edge of a bed or in a chair: Patients who are bed-bound would benefit from upright sitting to improve cardiopulmonary function and for position changes for pressure relief. If patients are able to tolerate sitting edge of bed for 1- or 2-hours without reduced O₂ saturation; it would also be beneficial for them to be transferred using appropriate assistance or equipment to supportive chairs with backrests and armrests.
• Standing frame: For upright tolerance and pressure relief as well. Ensure O₂ saturation is adequate and recheck intermittently in transitioning from seated to full standing position. Blood pressure should be monitored as well to monitor for orthostatic hypotension. Ensure someone remains with the patient while in a standing frame to monitor tolerance and to assist in adjusting for comfort as needed.

Level I: Wheelchair to Standing. For patients who predominantly use wheelchairs for their mobility but can complete transfers or stand with or without additional assistance. For patients who may stand to complete Activities of Daily Living (ADL) but are unsafe or unable to walk.

• Safety: Monitor O2 saturation, use AD as needed, use additional person for assistance as needed
• Seated exercises: AROM/AAROM/PROM/RROM of all upper and lower extremity (UE, LE) joints into multiple planes of motion. Can complete combination of motions of multiple joints into multiple planes for whole-body involvement and cardiopulmonary usage.
• More activity examples:
  • Wheelchair mobility: Use wheelchair with arms and legs to go forward and backward in figure 8 pattern; if there is limited space available can do this also in straight line.
  • Wheelchair Press ups: Ensure wheelchair is locked. Press through hands on armrests and feet on floor to lift bottom off of seat.
  • Sit to stand transfers: Standing and sitting from wheelchair with no upper extremity support, or with use of assistive device as necessary.
  • Pivot Transfers: Pivoting back and forth from wheelchair to standard chair; use assistive device or armrests as needed.

Level II: Standing to walking small distances (<50 ft). For patients who can stand and walk short distances with or without assistive device(s).

• Safety: Individuals should use balance support such as a counter, assistive device, or additional person for assistance; chairs can be placed behind them as well. Monitor oxygen saturation.
• Standing: AROM/AAROM/PROM/RROM of all UE and LE joints into multiple planes of motion. Can complete combination of motions of multiple joints into multiple planes for whole-body involvement and cardiopulmonary use.
• More Activity Examples: Sit to stands, walking, lateral steps, step taps

Level III: Walking Large Distances (>50 ft). For patients who are able to leave their houses and walk in the community with or without assistive device; patients who are relatively sedentary.

• Safety: Use AD as needed, monitor O₂ saturation
• Standing: AROM/AAROM/PROM/RROM of all UE and LE joints into multiple planes of motion. Can complete combination of motions of multiple joints into multiple planes for whole-body involvement and cardiopulmonary use.
• More activity examples: Squats, walking forward/backward, lateral walking, step ups

Level IV: Advanced. Individuals who exercise regularly or are independent, do not use an assistive device, and require no functional assistance. For this population it will be important for them to select what forms of physical activity they enjoy and would be willing to complete frequently.¹⁵ It is important to educate lifestyle changes that can be made so that they can maintain or improve their current functional status. This population should be encouraged to complete endurance activities for most days of the week for a total of 150 minutes of moderate intensity exercise or 75-minutes of vigorous exercise if possible, as well as strengthening exercises at least 2 days per week. If individuals are starting from sedentary lifestyles and beginning to exercise for the first time, they may be more compliant with the program starting with smaller amounts of activity in the beginning of the program and working up to a goal of meeting AHA guidelines as they progress.¹²

• Strengthening examples: lateral raises, rows, latissimus dorsi pull downs, chest press, bicep curls, triceps extensions, leg press, knee extension, knee flexion, heel raises, squats
• More activity examples: Stairs, burpees, treadmill or stationary bike, brisk outdoor walking, swimming, lunges, jumping jacks

DISCLOSURE STATEMENT

Home exercise programs should be developed by a licensed medical professional with consideration of the individual’s medical status. Clinical reasoning/judgment is essential to the formulation and execution of a home exercise program. The exercises listed are guidelines and are not the only exercises possible to complete. The authors of this article will not be held liable for any injuries obtained from using information from the above listed programs.

CONCLUSION

Overall, patients’ home exercise programs should be tailored toward their specific activity levels. The standard recommendations for improving cardiopulmonary fitness may be difficult for patients to achieve, and they should be advised to do as much physical activity as they can.¹⁵ Safety considerations are very important in the cardiopulmonary population, and vital signs/symptoms should always be monitored with exercise. There are many different levels of function across the cardiopulmonary population, and these levels should be considered when forming home exercise programs. A home exercise program can be generated for a patient in many ways; the ones provided in this article are examples of each mobility level category, but each program should be adjusted to the specific individual. The exercises listed underneath each category are not all inclusive.

REFERENCES

1. Le Jemtel TH, Padeletti M, Jelic S. Diagnostic and therapeutic challenges in patients with coexistent chronic obstructive pulmonary disease and chronic heart failure. J Am Coll Cardiol. 2007;49(2):171–80. DOI: 10.1016/j.jacc.2006.08.046
2. Gosker HR, Wouters EF, van der Vusse GJ, et al. Skeletal muscle dysfunction in chronic obstructive pulmonary disease and chronic heart failure: underlying mechanisms and therapy perspectives. Am J Clin Nutr. 2000;71(5):1033–47. DOI: 10.1093/ajcn/71.5.1033
3. Jackman RW, Kandarian SC. The molecular basis of skeletal muscle atrophy. Am J Physiol Cell Physiol. 2004;287(4):C834–43. DOI: 10.1152/ajpcell.00579.2003
4. Damluji AA, Tomczak CR, Hiser S, et al. Benefits of Cardiac Rehabilitation: Mechanisms to Restore Function and Clinical Impact. Circ Res. 2025;137(2):255–72. DOI: 10.1161/CIRCRESAHA.125.325705
5. Kabboul NN, Tomlinson G, Francis TA, et al. Comparative Effectiveness of the Core Components of Cardiac Rehabilitation on Mortality and Morbidity: A Systematic Review and Network Meta-Analysis. J Clin Med. 2018;7(12). DOI: 10.3390/jcm7120514
6. McCarthy B, Casey D, Devane D, et al. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2015;2015(2):CD003793. DOI: 10.1002/14651858.CD003793.pub3
7. Malla G, Bodduluri S, Sthanam V, et al. Access to Pulmonary Rehabilitation among Medicare Beneficiaries with Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc. 2023;20(4):516–22. DOI: 10.1513/AnnalsATS.202204-318OC
8. Anderson L, Sharp GA, Norton RJ, et al. Home-based versus centre-based cardiac rehabilitation. Cochrane Database Syst Rev. 2017;6(6):CD007130. DOI: 10.1002/14651858.CD007130.pub4
9. Bernocchi P, Vitacca M, La Rovere MT, et al. Home-based telerehabilitation in older patients with chronic obstructive pulmonary disease and heart failure: a randomized controlled trial. Age Ageing. 2018;47(1):82–8. DOI: 10.1093/ageing/afx146
10. Luan X, Tian X, Zhang H, et al. Exercise as a prescription for patients with various diseases. J Sport Health Sci. 2019;8(5):422–41. DOI: 10.1016/j.jshs.2019.04.002
11. Albouaini K, Egred M, Alahmar A, et al. Cardiopulmonary exercise testing and its application. Postgrad Med J. 2007 Nov;83(985):675–82. DOI: 10.1136/hrt.2007.121558
12. Blackwell DL, Clarke TC. State Variation in Meeting the 2008 Federal Guidelines for Both Aerobic and Muscle-strengthening Activities Through Leisure-time Physical Activity Among Adults Aged 18–64: United States, 2010–2015. Natl Health Stat Report. 2018;(112):1–22.
13. Mytinger M, Nelson RK, Zuhl M. Exercise Prescription Guidelines for Cardiovascular Disease Patients in the Absence of a Baseline Stress Test. J Cardiovasc Dev Dis. 2020;7(2):15. DOI: 10.3390/jcdd7020015
14. Katz S, Arish N, Rokach A, et al. The effect of body position on pulmonary function: a systematic review. BMC Pulm Med. 2018;18(1):159. DOI: 10.1186/s12890-018-0723-4
15. Brown TM, Pack QR, Aberegg E, et al. Core Components of Cardiac Rehabilitation Programs: 2024 Update: A Scientific Statement From the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation. 2024;150(18):e328–e347. DOI: 10.1161/CIR.0000000000001289
16. O’Driscoll BR, Howard LS, Earis J, et al.; British Thoracic Society Emergency Oxygen Guideline Group; BTS Emergency Oxygen Guideline Development Group. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017;72(Suppl 1):ii1–ii90. DOI: 10.1136/thoraxjnl-2016-209729
17. Tonika Tohri, Metilda, Sindi Sugandi. The Effect of Pursed Lip Breathing and Diaphragmatic Breathing on Increasing Oxygen Saturation in COPD Patients. Journal of Nursing Practice. 2025;9(1):89–94. DOI: 10.30994/jnp.v9i1.965

Article citation: Neuber S, Buscemi D. Cardiopulmonary home exercise program. The Southwest Journal of Medicine. 2026;14(61):12–20
From: Department of Physical Therapy, University Medical Center, Lubbock, TX (SN) Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX (DB)
Conflicts of interest: none
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.