Atlas›Domain IX · Biomedical, neuro & digital›Guide 075
Guide IX-075

Cardiac and pulmonary rehabilitation

A 22 · L 69 · M 924 interventions in the Trinity explorer
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[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: BACPR Standards and Core Components for Cardiovascular Disease Prevention and Rehabilitation, 3rd edition (2017), from a secondary copy [uncertain: secondary], with the current 4th edition (2023) as described on BACPR's own publications page; NICE NG185 Acute coronary syndromes (2020; section 1.8 cardiac rehabilitation recommendations dated 2007 and 2013), checked on NICE's site, and NICE quality standard QS99; AHA/AACVPR Core Components of Cardiac Rehabilitation Programs: 2024 Update (as summarised by the AHA); the Heart Manual (NHS Lothian programme and facilitator materials, editions current on the provider's site); ATS/ERS Statement on Key Concepts and Advances in Pulmonary Rehabilitation (Spruit et al., 2013); BTS Guideline on Pulmonary Rehabilitation in Adults (Bolton et al., 2013) and BTS Quality Standards for Pulmonary Rehabilitation (2026 edition, superseding 2014); Breathing, Thinking, Functioning model (Spathis et al., 2017).

Status of sources (October 2026). NICE NG185 section 1.8 is taken from NICE's recommendations page; the Cardiac Anxiety Questionnaire from the ZPID open test archive and a post-MI validation study. BACPR's current edition is the 4th (2023), which BACPR describes as having five core components and six standards, a greater emphasis on a person-centred approach and on patient choice of when, where and how the programme is delivered, and wider inclusion of patient groups; BACPR also publishes separate core competences for the psychosocial component (2025) and for the health behaviour change and education component [source: BACPR publications page]. Claims tagged "BACPR 2017" come from a secondary copy of the superseded 3rd edition, remain [uncertain: secondary] and may differ in the 2023 edition (the 2017 copy lists six core components, the 2023 edition five). HADS cut-offs are [uncertain]. Check local services against the 2023 edition and the 2025 psychosocial competences.

What it is. Cardiac rehabilitation (CR) and pulmonary rehabilitation (PR) are structured, multidisciplinary programmes, not a psychotherapy. NICE describes CR as a coordinated, structured programme that removes or reduces the underlying causes of cardiovascular disease and provides the best possible physical, mental and social conditions, with components of health education, lifestyle advice, stress management and physical exercise [source: NICE QS99, citing NG185 1.8.1, 1.8.19]. BACPR frames CR as biopsychosocial and lists six core components: health behaviour change and education; lifestyle risk factor management; psychosocial health; medical risk management; long-term strategies; audit and evaluation [uncertain: secondary, BACPR 2017]; the 2023 edition has five core components, whose names could not be checked here [source: BACPR publications page]. NICE says everyone after a myocardial infarction should be offered CR with an exercise component regardless of age, and that comprehensive CR should include health education and stress management [source: NICE NG185]. ATS/ERS define PR as "a comprehensive intervention based on a thorough patient assessment followed by patient-tailored therapies", including exercise training, education and behaviour change [source: ATS/ERS 2013].

How change happens (as the sources frame it). Supervised activity, education and risk-factor work reduce physical risk; education and behaviour change aim to "restore confidence and foster a greater sense of perceived personal control" [uncertain: secondary, BACPR 2017]; self-efficacy, collaborative self-management and health behaviour change maintain benefit [source: ATS/ERS 2013]. In chronic breathlessness, the Breathing, Thinking, Functioning model proposes that three vicious cycles (dysfunctional breathing, anxiety and fear, and activity avoidance leading to deconditioning) keep breathlessness worse than lung disease alone predicts, and that each can be turned into a "cycle of improvement" [source: Spathis et al. 2017].

Who delivers it and regulatory status. CR and PR are delivered by multidisciplinary teams rather than one registered profession. BACPR lists a senior clinician coordinator, a named lead for each core component, a physician with an interest in prevention and rehabilitation, and team members who may include a dietitian, exercise specialist, nurse specialist, occupational therapist, pharmacist, physiotherapist and practitioner psychologist [uncertain: secondary, BACPR 2017]. ATS/ERS list physicians, physiotherapists, respiratory therapists, nurses, psychologists, exercise physiologists, nutritionists, occupational therapists and social workers [source: ATS/ERS 2013]. In the US, CR has a physician medical director with day-to-day supervision by a physician or non-physician practitioner, and teams may include "behavioral health experts" [source: AHA 2024 update summary]. In the UK the individual professions are regulated by their own regulators (nurses by the NMC; physiotherapists, occupational therapists, dietitians and practitioner psychologists by the HCPC; pharmacists by the GPhC), while exercise professionals are not statutorily regulated [uncertain: not verified]. UK services submit data to the National Audit of Cardiac Rehabilitation (NACR) and take part in the National Certification Programme for CR [uncertain: secondary, BACPR 2017]; UK PR services are audited and accredited through national schemes (NRAP; PRSAS) [source: BTS QS 2026]. US programme certification by AACVPR and Medicare coverage rules exist [uncertain: not verified].

The psychotherapist's place. A psychotherapist may be inside the team (BACPR's "practitioner psychologist"; ATS/ERS's "psychologists") or outside it, treating a client who is referred to, attending or dropping out of a programme. Either way, the role is collaboration, referral and integrating psychological work with the programme; the exercise, medical and dietary content belongs to the team. This guide gives no exercise prescriptions, intensities or session schedules; any such question is routed to the programme team [synthesis].

2. Framework

The programmes are described as service pathways. Timings below are service standards the sources set, not instructions to clients. BACPR's 2023 edition sets six standards; the BACPR detail below comes from a secondary copy of the 2017 edition and is [uncertain: secondary].

Cardiac rehabilitation (BACPR 2017 standards; NICE) [source: NICE NG185; NICE QS99] [uncertain: secondary, BACPR 2017]

  1. Identification, referral and recruitment. Eligible patients are identified and referred promptly, ideally during the inpatient stay; NICE's quality statement is referral before discharge after myocardial infarction (MI), and NG185 says to begin CR as soon as possible after admission and before discharge, inviting the person to a session [source: NICE NG185; NICE QS99]. BACPR sets recruitment contact within days of referral. Moving on: the patient has been contacted and enrolment discussed.
  2. Initial assessment. NICE's quality statement is an assessment appointment within 10 days of discharge after MI, which may be an outpatient visit, home visit or telephone interview; NG185 says CR sessions should start within 10 days of discharge [source: NICE NG185]. BACPR's assessment covers demographics and social determinants, medical history, lifestyle risk factors, psychosocial health (anxiety and depression via HADS, quality of life, psychological stressors, illness perceptions and self-efficacy, social support, alcohol and substance misuse), medical risk management including medication adherence, formal exercise risk stratification, and a written care plan. Incomplete assessment should not delay the programme. Moving on: personalised goals agreed.
  3. Structured programme. An early programme with a defined pathway that meets individual goals, "aligned with patient preference and choice": centre-based, home-based, manual-based (e.g. the Heart Manual) or web-based. BACPR sets a minimum duration of documented contact with the team; exercise frequency is set by the team, not described here. NICE asks for a choice of venues (home, hospital, community) and times, including outside working hours, single-sex classes where demand is sufficient, reminders to people who do not start or continue, and not excluding people from the whole programme if they skip specific components [source: NICE NG185]. Moving on: programme goals reviewed.
  4. Final assessment. Reassessment repeats the initial components to show outcomes and identify unmet goals; a summary goes to the GP and referrer with a copy to the patient.
  5. Long-term strategies. Self-management skills, signposting to heart support groups, community exercise and other services; communication between primary and secondary care.
  6. Audit and certification. Data to NACR; national certification.

US model (AHA/AACVPR 2024 update). Programmes are mandated to include physician-prescribed exercise, cardiac risk factor modification and psychosocial assessment, with psychosocial management as a core component; delivery may be in-person, virtual (synchronous, real-time audio-visual) or remote (asynchronous), and new models must not change the core therapeutic content [source: AHA 2024 update summary].

The Heart Manual (home-based CR) [source: Heart Manual programme document; facilitator training slides]

  • Part 1: facts about the heart condition for early recovery. Part 2: a six-week weekly programme, each week with recovery information, a graded activity element and a focus on one risk factor, with records of activity, mood and symptoms. Part 3: facts and advice (recovery, medicines, investigations). Supported by relaxation audio (also in Punjabi, Urdu, Gujarati and Hindi), a Q&A audio and an exercise video.
  • Editions: post-MI and revascularisation (planned PCI or CABG).
  • A registered practitioner assesses suitability; trained facilitators provide an initial assessment and a small number of follow-up contacts (face to face, telephone or video), then a final assessment and onward referral. Facilitators must complete the Heart Manual training course. It is not suitable for everyone (e.g. unstable conditions, very poor prognosis, complex comorbidities, severe cognitive impairment).

Pulmonary rehabilitation (BTS; ATS/ERS) [source: BTS guideline 2013; BTS QS 2026; ATS/ERS 2013]

  1. Referral. Offered to people with symptomatic chronic respiratory disease; after hospitalisation for a COPD exacerbation, offered at discharge with enrolment within about a month. Anxiety and depression should not exclude referral. People who decline are re-offered PR.
  2. Assessment. A multisystem assessment including a validated exercise capacity measure; it can identify treatable traits including anxiety and depression and is an opportunity to detect depression and consider ongoing support.
  3. Programme. Directly supervised, centre-based PR is the primary UK offer, with an evidence-based alternative for those who decline or cannot attend; content is exercise training, a structured education programme and behaviour change. Duration and frequency are set by the BTS standard and the team, not described here.
  4. Discharge assessment. Exercise capacity, breathlessness, health-related quality of life, muscle strength and knowledge.
  5. Maintenance. A co-developed written maintenance plan; benefits decline over months without continued activity; repeat PR can be considered later.

Other conditions: BTS discusses PR for bronchiectasis and interstitial lung disease, and does not recommend routine referral for asthma.

Psychotherapy alongside the pathway [synthesis]

  • Before: address fears and beliefs that block uptake; liaise on referral.
  • During: screen and share results with consent; brief CBT-informed work on cardiac anxiety, breathlessness-related panic, low mood; support goals and adherence.
  • After: relapse prevention, maintenance, adjustment, continuing therapy for disorders that persist, liaison with GP.
  • Typical format: individual sessions or brief contacts, sometimes joining an education session; no session count is specified by the sources for psychological input [uncertain: not specified in the cited sources].

3. Guiding principles

  • Biopsychosocial, multidisciplinary care [uncertain: secondary, BACPR 2017]: psychological work is one component of a team programme; coordinate through the named lead, do not run a parallel programme.
  • Screen everyone [uncertain: secondary, BACPR 2017]: psychological distress, quality of life, stressors, illness perceptions, self-efficacy, social support and alcohol or substance use are assessed for all patients, not only those who look distressed.
  • Matched levels of psychological care [uncertain: secondary, BACPR 2017]: normal distress after a cardiac event is managed by the CR team; clinical anxiety or depression linked to the event is managed in-service if trained psychological practitioners are on the team; otherwise, and for problems unrelated to the event or severe and enduring mental illness, refer to trained psychological practitioners and inform the GP.
  • Anxiety and depression are not exclusions [source: BTS 2013; NICE NG185]: low mood is a reason to support attendance, not to defer it; NICE lists people with mental health conditions among groups less likely to attend for whom CR must be made equally accessible.
  • Stress management yes, complex therapy not routinely [source: NICE NG185]: NICE says to offer stress management within comprehensive CR and not to routinely offer complex psychological interventions such as CBT as part of it; treatment of a diagnosed anxiety or depressive disorder follows that disorder's own care pathway [synthesis].
  • Equal, culturally sensitive access [source: NICE NG185]: CR is delivered in a non-judgemental, respectful and culturally sensitive way, with attention to groups less likely to attend and to wider economic, welfare, housing and social needs.
  • Discursive, not didactic education [source: ATS/ERS 2013] [uncertain: secondary, BACPR 2017]: tailor to learning needs and build self-efficacy; lecturing alone is insufficient.
  • Evidence-based behaviour change techniques [uncertain: secondary, BACPR 2017]: goal setting, pacing, problem solving, motivational interviewing and relapse prevention are named; use them explicitly.
  • Address misconceptions and illness perceptions [source: NICE NG185; Heart Manual training] [uncertain: secondary, BACPR 2017]: beliefs that increase disability or distress are treated as targets; NICE asks staff to establish health beliefs and illness perceptions before giving lifestyle advice.
  • Choice and preference [source: ATS/ERS 2013; NICE NG185] [uncertain: secondary, BACPR 2017]: a menu of venues, times and formats improves uptake; help the client choose rather than persuade.
  • Involve a supporter if the client wishes, avoid overprotection [source: NICE NG185; Heart Manual training; Spathis et al. 2017] [uncertain: secondary, BACPR 2017]: partners and family are invited in, but overprotection and carers doing what the patient can still do maintain disability.
  • Collaborative self-management [source: ATS/ERS 2013]: the client learns goal setting, problem solving, decision-making and following an agreed action plan with clinicians.
  • Target the dominant cycle [source: Spathis et al. 2017]: in breathlessness, one or two cycles usually predominate; aim at those for early wins.
  • Stay in scope [synthesis]: never advise on exercise amounts, medicines, symptoms or devices; route to the team, prescriber or emergency services.
  • Name what is new and what is persistent [synthesis]: separate adjustment to the event from pre-existing mental disorders, which may need their own treatment pathway.

4. Intervention inventory

Part A describes how the programmes are delivered, at a descriptive level, so the therapist can talk accurately with clients and teams. Part B gives the psychotherapist's own interventions. Example language is illustrative throughout.

A1. Comprehensive cardiac rehabilitation (team-delivered)

  • Purpose: secondary prevention and recovery after MI, revascularisation, or with stable angina or heart failure [source: NICE QS99] [uncertain: secondary, BACPR 2017].
  • Steps (as delivered by the team): referral, ideally before discharge; early assessment (outpatient, home or telephone); a written care plan; a programme combining health behaviour change and education, lifestyle risk factor management (physical activity and exercise, healthy eating and body composition, tobacco cessation), psychosocial health and medical risk management; final assessment; long-term plan to GP [uncertain: secondary, BACPR 2017]. Education topics named by BACPR include the condition, physical activity, diet, tobacco, medicines, psychological self-management, sexual activity, surgery and devices, and CPR. Exercise content is prescribed and risk-stratified by the team.
  • Example language: "Rehab isn't only exercise. It also covers how you're coping, what you understand about your heart, and stress. I'd like to work alongside your rehab team on the coping part." (illustrative)
  • Watch for: clients who think rehab is "just a gym" or only for the very fit; clients told nothing about it before discharge. Any question about how much activity is safe goes to the team [synthesis].

A2. The Heart Manual (facilitated home-based CR)

  • Purpose: a home-based, facilitated self-management programme used alongside or instead of centre-based CR [source: Heart Manual programme document]. NICE says a validated home-based programme such as the Heart Manual, with education, exercise and stress management and follow-up by a trained facilitator, can be used [source: NICE NG185].
  • Steps (as delivered): a registered practitioner assesses suitability; the patient works through a six-week weekly programme with records of activity, mood and symptoms, plus relaxation audio; a trained facilitator makes an initial contact and a small number of follow-up contacts, then a final assessment and onward referral. Facilitators address misconceptions, "feeling anxious and down", "tension and worry", goal setting and pacing, and family involvement; the manual includes worry and mood checks and anti-stress questionnaires [source: Heart Manual programme document; training slides]. Facilitators must be trained by the Heart Manual Department; non-registered staff may deliver parts under supervision.
  • Example language: "Your Heart Manual has a weekly section on worry and stress, and a relaxation recording. Shall we look at what you've tried from it so far and fit our sessions around that?" (illustrative)
  • Watch for: the manual being used without facilitator contact; low literacy, language or cognitive barriers; denial or rejection of the manual, which the training names as a facilitator issue [source: training slides]. A psychotherapist who is not a trained facilitator supports, rather than delivers, the programme [synthesis].

A3. Pulmonary rehabilitation (team-delivered)

  • Purpose: for people with symptomatic chronic respiratory disease, especially COPD, including after an exacerbation; BTS recommends PR for COPD partly "with a view to improving psychological wellbeing" [source: BTS 2013].
  • Steps (as delivered): multisystem assessment; supervised exercise training prescribed by the team after an exercise assessment; a structured education programme aimed at self-management, decision-making and self-efficacy; behaviour change support; collaborative self-management including action plans for exacerbations; discharge assessment; written maintenance plan [source: ATS/ERS 2013; BTS 2013; BTS QS 2026]. Advance care planning can be discussed within PR [source: ATS/ERS 2013].
  • Example language: "PR is designed for people who get breathless. The team expects you to be breathless during it and will set things at your level, so you don't have to be fit to start." (illustrative)
  • Watch for: fear of breathlessness keeping the client away; dislike of groups and transport problems, which BTS names as dropout reasons [source: BTS 2013]. Never advise on exercise or oxygen use [synthesis].

A4. Alternative and remote delivery

  • Purpose: to widen access for people who cannot or will not attend a centre [source: BTS QS 2026; AHA 2024 update summary] [uncertain: secondary, BACPR 2017].
  • Steps (as described): CR may be centre-, home-, manual- or web-based; US models include virtual (synchronous) and remote (asynchronous) sessions that keep the same core content; UK PR offers an evidence-based alternative to people who decline or cannot attend centre-based PR; ATS/ERS describe home-based PR as comparable when appropriately resourced and telehealth evidence as limited [source: as cited].
  • Example language: "If the group sessions feel impossible right now, there may be a home or online version. Would it help to ask the team what they offer?" (illustrative)
  • Watch for: choosing home options mainly to avoid feared situations (e.g. social anxiety, fear of collapsing in public); this can be fine, but note it and work on the fear [synthesis].

B1. Psychosocial screening and sharing results

  • Purpose: BACPR expects every patient to be screened for psychological distress (HADS, available through NACR), quality of life (Dartmouth COOP; Minnesota Living With Heart Failure questionnaire), stressors, illness perceptions and self-efficacy, social support, alcohol and substance misuse, and sexual health [uncertain: secondary, BACPR 2017]. Heart Manual remote assessment materials list HADS and PHQ-9 among validated tools [source: training slides]. In PR, HADS is among the measures BTS names [source: BTS 2013]. Where heart-focused anxiety is suspected, the Cardiac Anxiety Questionnaire (Eifert et al., 2000) measures fear, avoidance and heart-focused attention; its German 17-item version (HAF-17, Hoyer and Eifert, 2009) is free in the ZPID open test archive under a non-commercial licence, and a post-MI validation found three factors (fear/worry, avoidance, attention) after dropping three items [source: ZPID PsychArchives HAF entry; BMC Med Res Methodol CAQ table]. Using it in CR is this guide's suggestion [synthesis].
  • Steps: (1) Check which measures the team already uses and when (initial and final assessment), to avoid duplication. (2) With consent, administer licensed instruments under the service's licence; HADS is a licensed questionnaire, so do not copy items. (3) Score and interpret using the instrument's own manual and local pathway thresholds; the authors' published score bands (Zigmond and Snaith, 1983) are in the licensed manual and [uncertain]; do not apply remembered cut-offs. (4) Ask directly about suicidal thoughts when depression scores or presentation suggest it; questionnaires do not replace this [synthesis]. (5) Feed back to the client in plain words and, with consent, to the named psychosocial lead. (6) Repeat at the end to show change.
  • Example language: "Lots of people feel low or on edge after a heart attack. This short questionnaire helps us see whether that's part of normal recovery or something we should give extra help with." (illustrative)
  • Watch for: physical symptoms inflating scores (fatigue, breathlessness, poor sleep) [synthesis]; clients minimising distress to look "a good patient"; scores improving while avoidance persists. Working: the client understands the result and agrees a next step.

B2. Matching the level of care and referring

  • Purpose: apply BACPR's levels: normal emotional distress managed by the CR team; clinical anxiety or depression linked to the event managed in-service if trained psychological practitioners are on the team; otherwise, and for problems unrelated to the event or severe and enduring mental illness, refer to trained psychological practitioners and inform the GP; alcohol or substance misuse referred to an appropriate resource; longstanding or complex sexual problems referred onward [uncertain: secondary, BACPR 2017].
  • Steps: (1) Formulate: adjustment to the event, a clinical disorder triggered by it, or a pre-existing or unrelated disorder. (2) Decide who holds it: team, in-service psychology, primary care psychological therapy or secondary mental health care. (3) Make the referral with consent and a short summary (scores, risk, cardiac or respiratory context, programme status). (4) Tell the GP. (5) Agree who follows up and how the rehab team hears back.
  • Example language: "What you're describing sounds bigger than the usual shake-up after a heart attack, and it was there before. I'd like to get you proper treatment for it, and I'll let your GP and the rehab team know, if that's OK." (illustrative)
  • Watch for: referrals that bounce because the cardiac context makes services hesitant; clients lost between services after the programme ends [synthesis].

B3. Recognising when to suggest medical review

  • Purpose: keep physical safety with the medical team [synthesis].
  • Steps: (1) Know the client's crisis plan from the team (who to call, when to use emergency services). (2) If a client reports new, worsening or unexplained physical symptoms in session (chest pain, collapse, severe breathlessness, palpitations, signs of an exacerbation), do not interpret them as anxiety; follow the client's medical plan or call emergency services. (3) Pass on side-effect concerns or non-adherence to medicines to the team or prescriber with consent; never advise a change. (4) Record and inform the team.
  • Example language: "I can't tell whether that's your heart or anxiety, and it isn't my job to guess. Let's follow the plan your team gave you right now." (illustrative)
  • Watch for: colluding with the client's wish that "it's only nerves"; equally, reinforcing repeated checking once the team has assessed the symptom [synthesis].

B4. Exploring illness perceptions and misconceptions to support uptake

  • Purpose: BACPR asks teams to address misconceptions and illness perceptions that increase disability or distress; BTS advises that referral should explore the patient's understanding and address concerns, as lack of understanding of benefits may reduce uptake; Heart Manual facilitators "educate and address misconceptions" including about the cause of the condition [source: BTS 2013; training slides] [uncertain: secondary, BACPR 2017]. NICE asks staff to establish health beliefs and illness perceptions before giving lifestyle advice, to explain benefits, discuss barriers such as transport, and remind people who do not start or continue [source: NICE NG185]. ATS/ERS list perceived lack of benefit, disrupted routines, transport and timing among enrolment barriers [source: ATS/ERS 2013].
  • Steps: (1) Ask what the client thinks caused the event or illness, what it means for the future, how controllable it is and what rehab is for. (2) Note beliefs that predict avoidance (e.g. "exertion will cause another attack", "breathlessness damages my lungs", "rehab is for people worse off"). (3) Ask permission to share information; correct with team-sourced facts, not your own medical opinion. (4) Address practical barriers (transport, timing, work, caring) with the team's menu of options. (5) Summarise and let the client decide.
  • Example language: "What do you think brought this on? ... And what do you imagine would happen if you went to the first rehab session?" (illustrative)
  • Watch for: arguing, which hardens refusal; misconceptions you cannot answer (route them to the team). Working: the client can state a reason to attend in their own words.

B5. Motivational interviewing for uptake and behaviour change

  • Purpose: BACPR names motivational interviewing and relapse prevention among communication skills for CR staff; Heart Manual training uses importance and confidence scales and asks facilitators to consider readiness to change and build confidence [source: training slides] [uncertain: secondary, BACPR 2017].
  • Steps: (1) Ask open questions about what matters to the client (values, family, work, hobbies). (2) Use importance and confidence ratings (0 to 10) for one change at a time: attending rehab, stopping smoking, taking up the team's activity plan. (3) Explore why the score is not lower, and what would raise it a point. (4) Reflect change talk; roll with sustain talk. (5) Agree a small next step and who supports it.
  • Example language: "On a scale of 0 to 10, how important is it to you to get to the rehab sessions? ... You said 6, not 3. What makes it a 6?" (illustrative)
  • Watch for: high importance with low confidence, which points to fear or practical barriers rather than motivation; the therapist pushing a medical agenda. Working: rising confidence and specific plans.

B6. Goal setting, pacing and problem solving (supporting the team's plan)

  • Purpose: BACPR lists goal setting, pacing and problem solving with follow-up; Heart Manual training uses SMART goals and an effort scale with endpoints "Too Easy" and "Too Hard"; ATS/ERS describe goal setting, problem solving, decision-making and action plans as core self-management strategies [source: training slides; ATS/ERS 2013] [uncertain: secondary, BACPR 2017].
  • Steps: (1) Start from goals the client and team have agreed; the therapist does not set activity amounts. (2) Turn psychological goals into SMART form (e.g. "go to the shop alone once this week", "tell my partner when I'm worried rather than hiding it"). (3) Plan pacing of daily tasks across the day and week. (4) Anticipate obstacles; problem-solve: define, brainstorm, choose, try, review. (5) Review at the next contact.
  • Example language: "Your rehab team has your activity plan. My part is the worry that stops you doing it. Which bit of the week feels hardest to start?" (illustrative)
  • Watch for: boom-and-bust patterns; goals that are really the partner's; over-ambitious goals after a good week [synthesis].

B7. CBT-informed work on cardiac anxiety

  • Purpose: for heart-focused anxiety after a cardiac event: fear of another attack, body monitoring, avoidance of exertion or being alone, reassurance seeking. The cited sources name the targets (worry, tension, illness perceptions, stress management) but do not give a cardiac-anxiety protocol, so the steps below are standard CBT applied to this context [synthesis]. NICE says not to routinely offer complex psychological interventions such as CBT as part of CR, so this is individual work for clients whose heart-focused anxiety warrants it, alongside rather than instead of the programme's stress management [source: NICE NG185; synthesis on application]. The Cardiac Anxiety Questionnaire (Eifert et al., 2000) measures heart-focused fear, avoidance and attention and can track change (see B1) [source: ZPID PsychArchives HAF entry; BMC Med Res Methodol CAQ table].
  • Steps [synthesis]: (1) Confirm with the team that symptoms have been medically assessed and what activity is cleared. (2) Build a shared cycle: trigger (twinge, palpitation), catastrophic appraisal, anxiety and its bodily effects, safety behaviours (checking pulse, avoiding stairs, staying near hospital, asking for reassurance), short-term relief, longer-term restriction. (3) Psychoeducation on how anxiety produces chest and heart sensations, using team-approved information. (4) Cognitive work on specific predictions, weighing evidence the team has given. (5) Graded, team-cleared behavioural experiments, dropping safety behaviours step by step, within the activity limits the team has set. (6) Agree a rule for when a symptom does need medical help, so that the client is not left to judge alone. (7) Review progress against the programme's goals.
  • Example language: "Your team has checked your heart and cleared you to walk to the shop. Let's test your prediction that you'll collapse halfway, inside the limits they've given you, and see what happens." (illustrative)
  • Watch for: exposure that goes beyond what the team has cleared (never set exertion levels yourself); new symptoms during experiments (stop, follow the medical plan); reassurance seeking moving from partner to therapist. Working: less checking and avoidance, more of the programme completed.

B8. Breathlessness-anxiety cycle (Breathing, Thinking, Functioning)

  • Purpose: in chronic respiratory (and other advanced cardio-respiratory) disease, the model links three cycles: Breathing (fast, upper-chest breathing raises work of breathing), Thinking (fear of breathlessness intensifies the sensation and can escalate to panic, and anxiety raises respiratory rate and tension), Functioning (avoiding activity leads to deconditioning, which worsens breathlessness) [source: Spathis et al. 2017]. Interventions are matched to the cycle they interrupt: breathing and relaxation techniques, handheld fans, CBT and activity management [source: Spathis et al. 2017].
  • Steps: (1) Draw the three cycles with the client using their own examples. (2) Identify the one or two that dominate; the authors suggest targeting these for early "quick wins" and challenging a specific misconception driving the dominant cycle [source: Spathis et al. 2017]. (3) For the Thinking cycle, the therapist's area: map panic sequences, catastrophic thoughts about suffocating or dying, and safety behaviours; use CBT for panic adapted to breathlessness [synthesis]. (4) For Breathing and Functioning cycles, link the client to the PR team or physiotherapist for breathing techniques, fan use and activity management, then support practice and adherence [synthesis]. (5) Frame change as reversing a vicious cycle into a cycle of improvement through small changes [source: Spathis et al. 2017]. (6) Involve carers who may be doing tasks the client can still do [source: Spathis et al. 2017].
  • Example language: "There seem to be three loops keeping your breathlessness worse than your lungs alone would. The worry loop is the one I can help with most; the physio can help with the breathing loop. Which loop feels biggest to you?" (illustrative)
  • Watch for: treating breathlessness as "only anxiety"; hyperventilation and genuine hypoxia look alike to a lay observer, so route medical questions to the team [synthesis]; carers' fear. Working: fewer panic episodes, less avoidance, more PR attendance.

B9. Relaxation and stress management

  • Purpose: NICE lists stress management as a CR programme component; BACPR wants patients to understand how "illness perceptions, stress awareness and improved stress management skills" affect health; the Heart Manual supplies relaxation audio and anti-stress questionnaires [source: NICE QS99; NICE NG185; Heart Manual programme document] [uncertain: secondary, BACPR 2017].
  • Steps: (1) Identify stressors (work, money, caring, the illness itself). (2) Link stress to symptoms and behaviour in a simple diary. (3) Practise relaxation, using the programme's own recording where the client has it, so practice is consistent [synthesis]. (4) Add problem solving and assertiveness for controllable stressors and acceptance-based coping for uncontrollable ones [synthesis]. (5) Review use.
  • Example language: "You've got a relaxation recording with your Heart Manual. Shall we try it here and talk about what you noticed?" (illustrative)
  • Watch for: relaxation-induced anxiety; relaxation used as a safety behaviour during panic; using stress management to avoid addressing a clinical depression [synthesis].

B10. Working with low mood and depression

  • Purpose: depression is associated with lower PR completion and with non-completion in ATS/ERS's barrier list; PR benefits for anxiety and depression are greatest in people with high baseline symptoms [source: BTS 2013; ATS/ERS 2013]. BACPR's levels decide whether depression is managed in-service or referred [uncertain: secondary, BACPR 2017]. Within CR itself NICE recommends stress management and says not to routinely offer complex psychological interventions such as CBT, so disorder-level treatment is a separate pathway [source: NICE NG185].
  • Steps [synthesis]: (1) Screen and assess severity and risk (B1, B13). (2) For mild, event-linked low mood: normalise, use activity scheduling and values-based goals that line up with the programme's activity plan, and use attendance as behavioural activation. (3) For moderate to severe or persistent depression: refer per B2; inform the GP; pass on that medication review may be needed without advising on medicines. (4) Address hopelessness about the illness and grief for lost roles.
  • Example language: "When mood is low, waiting to feel like going rarely works. Going to the session is often what lifts it a little. Could we plan the first one together?" (illustrative)
  • Watch for: missed sessions as an early sign of worsening mood; hopelessness, which raises suicide risk. Working: re-engagement and lifting mood scores.

B11. Pre-programme sessions to reduce dropout

  • Purpose: BTS reports an uncontrolled study in which a pre-PR group session using CBT techniques was followed by less dropout for non-illness reasons (low evidence level); ATS/ERS report a "group opt-in session" that improved uptake and graduation in an observational study [source: BTS 2013; ATS/ERS 2013].
  • Steps [synthesis]: (1) Offer with the team a short pre-programme session or a single individual session before starting. (2) Elicit expectations, fears and practical barriers. (3) Correct misconceptions with team information (B4). (4) Use importance and confidence ratings (B5). (5) Agree a plan for the first session, including how to cope with breathlessness or fear on the day.
  • Example language: "Before you start, let's talk about what you're expecting and what might get in the way, so the first session doesn't catch you off guard." (illustrative)
  • Watch for: the session becoming a lecture; too little evidence to promise a specific effect.

B12. Involving partners and family; tackling overprotection

  • Purpose: BACPR invites a nominated supporter to take part and wants carers equipped to support long-term goals, and notes that social isolation is linked to higher cardiac mortality while overprotection can harm quality of life; NICE says to involve partners or carers if the person wishes [source: NICE NG185]; Heart Manual training names overprotection, family demands and relationship strain [source: training slides] [uncertain: secondary, BACPR 2017].
  • Steps [synthesis]: (1) With consent, invite the supporter to a joint session. (2) Ask each person what they fear and what they now do differently. (3) Identify overprotective patterns (doing tasks for the client, discouraging activity the team has cleared) and reassurance cycles. (4) Agree how the supporter can help the plan without policing it. (5) Offer the supporter their own support or referral if distressed.
  • Example language: "It makes sense you want to protect them. The team has cleared these activities. What would it be like for you to watch them do one without stepping in?" (illustrative)
  • Watch for: partner distress or trauma after witnessing the event; relationship conflict; isolation in clients without a supporter.

B13. Crisis and safety planning

  • Purpose: depression and adjustment after a serious cardiac or respiratory event can bring hopelessness and suicidal thinking; the cited programme sources do not set a suicide-risk procedure [synthesis].
  • Steps [synthesis]: (1) Ask directly about suicidal thoughts, plans and intent when mood is low. (2) Follow local risk procedures and current professional guidance. (3) Agree a written safety plan: warning signs, coping steps, people and services to contact, and making the environment safer, including safe storage of stockpiled medicines with the prescriber's or pharmacist's involvement. (4) Separate the medical emergency plan (symptoms) from the mental health crisis plan. (5) Inform the GP and team as procedures require.
  • Example language: "Some people after a heart attack feel they're a burden, or think about not being here. Have you had thoughts like that?" (illustrative)
  • Watch for: passive death wishes framed as "not bothering" with treatment; refusal of all care.

B14. Sexual health, work and practical concerns

  • Purpose: BACPR says vocational, financial and sexual health concerns should be addressed, patients should be able to raise sexual concerns, and longstanding or complex issues referred onward; NICE asks staff to raise sexual activity during CR and aftercare and to reassure people, and to consider physical and psychological status, the job and the work environment when advising on return to work; the medical advice itself comes from the team [source: NICE NG185]. ESC lists vocational advice as a core component [source: BMC comparison table] [uncertain: secondary, BACPR 2017].
  • Steps: (1) Ask about these areas routinely, giving permission to discuss them. (2) Explore anxiety about sex or returning to work. (3) Route medical questions (e.g. when sex or work is safe, medicines and erectile function) to the team; refer to sexual counselling or occupational support as available. (4) Work on the anxiety and relationship side.
  • Example language: "People often worry about sex or going back to work after this but don't like to ask. Is either on your mind?" (illustrative)
  • Watch for: embarrassment; financial strain driving premature return to work [synthesis].

B15. Alcohol and substance use

  • Purpose: BACPR includes alcohol and substance misuse in screening and refers to an appropriate resource; tobacco cessation and relapse prevention is a lifestyle component [uncertain: secondary, BACPR 2017]. Current smokers in PR attended and completed less often, yet many still benefited [source: BTS 2013].
  • Steps: (1) Ask non-judgementally; use the service's screening tool. (2) Use MI to explore change (B5). (3) Refer to alcohol, drug or stop-smoking services; tell the team. (4) Do not let smoking become a reason to exclude the client from rehab [synthesis].
  • Example language: "You don't have to have stopped smoking to come to rehab. Would you like to hear what help there is for stopping, when you're ready?" (illustrative)
  • Watch for: shame and concealment; drinking used to manage anxiety.

B16. Adherence and ambivalence conversations

  • Purpose: BACPR includes medication adherence in assessment and lists uptake and adherence as aims of the core components [uncertain: secondary, BACPR 2017].
  • Steps: (1) Explore attendance, home practice and medicine-taking without judgement. (2) Elicit beliefs and practical barriers (side effects, cost, forgetting, mood, fear). (3) Reflect ambivalence and support the client's own reasons. (4) Never advise starting, stopping or changing a medicine or the activity plan; encourage the client to raise it with the prescriber or team, and pass on concerns with consent [synthesis].
  • Example language: "It sounds like part of you wants to keep going with the tablets and part of you is worried about them. That's worth taking to your doctor. Would you like help working out what to ask?" (illustrative)
  • Watch for: silent stopping of medicines; the therapist being drawn into medical advice.

B17. Collaboration and information sharing

  • Purpose: BACPR requires a named lead for each core component, communication with the GP and wider team, and a summary to GP and referrer at the end [uncertain: secondary, BACPR 2017].
  • Steps [synthesis]: (1) Agree with the client what will be shared and with whom. (2) Identify the psychosocial lead and preferred route (MDT meeting, notes, letter). (3) Share screening results, risk, formulation summary and recommendations in brief, plain terms. (4) Ask the team for medical information needed for psychological work (what activity is cleared, what symptoms need action). (5) Close the loop at discharge.
  • Example language: "Is it OK if I tell the rehab nurse that the main thing holding you back is fear of being out alone? It'll help them plan with you." (illustrative)
  • Watch for: role confusion; duplicate questionnaires; confidentiality limits not explained.

B18. Supporting advance care planning conversations

  • Purpose: ATS/ERS note that advance care planning, including end-of-life options and advance directives, can be discussed within PR [source: ATS/ERS 2013].
  • Steps [synthesis]: (1) Follow the client's readiness. (2) Explore values, fears and wishes. (3) Support the client to raise them with the medical team, who lead the formal process. (4) Attend to grief and anxiety the conversation stirs.
  • Example language: "Some people find it a relief to talk about what matters to them if things get worse. Is that something you'd want to think about, now or later?" (illustrative)
  • Watch for: forcing the topic; the client hearing it as a prognosis.

B19. Maintenance, setbacks and relapse prevention

  • Purpose: benefits decline without continued activity; BTS requires a co-developed written maintenance plan; BACPR emphasises long-term self-management and signposting; Heart Manual training asks facilitators to help patients maintain change and deal with setbacks [source: ATS/ERS 2013; BTS QS 2026; training slides] [uncertain: secondary, BACPR 2017].
  • Steps: (1) Before the programme ends, review gains and what helped. (2) Identify high-risk situations (exacerbations, readmission, anniversaries, life stress) [synthesis]. (3) Plan coping steps and early warning signs, alongside the team's maintenance plan. (4) Link to heart support groups or community services the team signposts [uncertain: secondary, BACPR 2017]. (5) Normalise setbacks and plan restarting.
  • Example language: "If you have a bad chest infection and stop for a few weeks, what would you want to remind yourself so you get going again?" (illustrative)
  • Watch for: loss of structure after the programme; return of avoidance after an exacerbation. BTS notes repeat PR may be considered later [source: BTS 2013].

B20. Psychotherapy after the programme ends

  • Purpose: to continue treatment for persisting anxiety, depression, trauma or adjustment problems, and support long-term change [synthesis].
  • Steps [synthesis]: (1) Use the final assessment results to decide whether further therapy is needed. (2) Continue or refer for disorder-specific psychological therapy. (3) Keep the GP informed. (4) Revisit the maintenance plan in sessions.
  • Example language: "Rehab has finished, but the panic hasn't gone completely. Let's keep working on it." (illustrative)
  • Watch for: trauma symptoms after a sudden cardiac event, ICD shocks or ICU stays, which may need trauma-focused treatment [synthesis].

5. Handling problems

Sources name barriers (transport, cost, dislike of groups, fear of exercise, comorbidities, depressive symptoms, smoking, lack of support, denial, overprotection) [source: ATS/ERS 2013; BTS 2013; Heart Manual training slides]; the responses below are largely [synthesis] unless tagged.

  • Declines rehab outright. Explore beliefs and barriers (B4), use importance and confidence ratings (B5), offer the team's alternative formats (A4). BTS requires re-offering PR to people who initially decline [source: BTS QS 2026]; for CR, NICE asks services to remind people who do not start or continue, by letter, phone or home visit [source: NICE NG185]. Respect the decision; leave the door open and tell the team. Example (illustrative): "It's your call. If you change your mind, the team can still take you later."
  • Denial or minimising ("I'm fine, it was a blip"). Named as a facilitator issue [source: Heart Manual training slides]. Do not confront; ask about the client's own goals and what would tell them they are not fine; use the final assessment as feedback. Watch for denial that protects against overwhelming fear.
  • Stuck: attending but not progressing. Re-formulate: check for an unrecognised dominant cycle (B8), hidden safety behaviours (B7), depression (B10) or a partner's overprotection (B12). Ask the team whether medical limits explain the plateau.
  • Overwhelm in session (panic, breathlessness, chest symptoms). Pause. If symptoms might be medical, follow the client's medical plan or call emergency services (B3). If assessed as panic, use the coping steps already practised with the team (e.g. breathing techniques taught by the physiotherapist) and slow the work. Reduce session demand afterwards.
  • Non-adherence to activity or medicines. Use B16. Never set or alter the plan; pass concerns to the team or prescriber with consent.
  • Health anxiety and repeated symptom checking. After medical assessment, agree with the team on limits to reassurance and a clear rule for when to seek help; work on checking as a safety behaviour (B7).
  • Rupture: "You think it's all in my head." Acknowledge; restate that symptoms are real and medically assessed, and that worry is one loop among several (B8). Repair by agreeing which part each professional holds.
  • Team tension (e.g. team sees client as "non-compliant"). Offer a formulation of the barrier; suggest small changes in approach (choice, timing, format) [source: NICE NG185 on choice of venues and times] [uncertain: secondary, BACPR 2017 on menu of options].
  • Cognitive impairment, language or literacy barriers. Programmes should consider cultural background and sensory or cognitive barriers [source: BTS 2013]; the Heart Manual has relaxation audio in several South Asian languages [source: Heart Manual programme document]. Use simpler materials, interpreters and carers; liaise on suitability.
  • Severe or pre-existing mental illness. Refer per BACPR levels and inform the GP [uncertain: secondary, BACPR 2017]; coordinate so that the client is not excluded from rehab.
  • Grief and loss of role (work, driving, independence). Name the losses; values-based goals; consider bereavement-style work for anticipated losses in progressive lung disease (B18).
  • Trauma after the event (intrusive memories of the arrest, ICU, ICD shocks). Assess for post-traumatic stress; refer or offer trauma-focused therapy; coordinate with the team on medical reassurance [uncertain: not covered in the cited sources].
  • Exacerbation or readmission mid-programme. Expect setback and loss of confidence; plan return with the team (B19); BTS notes repeat PR can be considered and that patients whose course was interrupted by an exacerbation may still benefit [source: BTS 2013].
  • Client asks the therapist about exercise amounts, symptoms or medicines. Decline to advise; help the client prepare questions for the team.

Sources

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