Pacemakers & Implantable Cardioverter Defibrillators

The devices

Cardiac implantable electronic devices fall into a few families, and the difference matters because it determines what the device will do during exercise.

Indications for pacing and resynchronisation, and for defibrillator implantation in primary and secondary prevention of sudden cardiac death, are set out in current European guidance.^1,2

The implant, and what can go wrong

A transvenous device is implanted through the subclavian or axillary vein with the generator in a subcutaneous or submuscular pocket below the clavicle, usually on the left. Complications occur in a small but clinically meaningful proportion of implants.³

• Pocket haematoma — common, particularly on anticoagulation. Swelling, bruising and pain; report expansion.
• Lead displacement — highest risk in the first weeks and the reason for arm restriction. Presents as loss of capture, hiccups from diaphragmatic stimulation, or recurrence of the original symptoms.
• Infection — pocket erythema, discharge, fever or systemic illness. Device infection is serious and usually requires system extraction.
• Twiddler's syndrome — lead dislodgement from the patient rotating the generator in its pocket.
• Venous thrombosis or subclavian stenosis — arm swelling on the implant side.

Arm restrictions — the balance

Most units restrict shoulder movement on the implant side for a period after transvenous implantation, commonly avoiding abduction and flexion beyond 90 degrees and heavy lifting for around four to six weeks, to let the leads fibrose into position.

The evidence base for the specific restriction is thin, and practice varies widely between centres. What is better established is the cost of over-restriction: prolonged immobilisation of the shoulder in an older population produces stiffness, and adhesive capsulitis after device implantation is a recognised and avoidable problem.

A workable approach

• Follow the implanting centre's protocol — it governs, and it varies.
• Do not immobilise. Movement below the restricted range, elbow, wrist and hand activity, and normal use of the arm for eating, dressing and light tasks should be encouraged from the outset.
• Sling use should be brief if used at all, and never continuous.
• Progress deliberately at the end of the restriction period. Patients often remain fearful well beyond the protocol window; range is regained by graded, reassured movement rather than by waiting.
• Screen the shoulder at follow-up. If range has not returned by six to eight weeks, treat it actively.

Exercise prescription with a defibrillator

Beyond that ceiling, prescription follows standard principles with a few additions:

• Perceived exertion alongside heart rate. Rate-responsive pacing, beta blockade and paced rhythms all distort the heart-rate response.
• Avoid abrupt high-intensity bursts early in a programme, which are the likeliest way to overshoot into a therapy zone.
• Upper-limb and contact activity guided by the implant-site restrictions, then unrestricted for most patients.
• Have a plan for a shock during exercise — stop, sit or lie down, and follow local escalation. Staff should know it before the patient starts.
• Anxiety is a genuine barrier. Fear of shock drives avoidance and deconditioning, and addressing it is part of the prescription.

Exercise-based cardiac rehabilitation in patients with an ICD improves exercise capacity without evidence of increased device therapy or adverse events in Cochrane review, and rehabilitation is recommended rather than avoided in this group.^4,5 The historical instinct to protect these patients from exertion is not supported.

Practical points that come up

• Driving is restricted after implantation and after any device therapy, with rules differing by licence class and jurisdiction. Direct the patient to the cardiology team and the licensing authority.
• Diathermy is contraindicated. Shortwave and microwave diathermy must not be used in a patient with an implanted device.
• Transcutaneous electrical nerve stimulation is generally avoided near the device and used elsewhere only with cardiology agreement.
• Magnetic resonance imaging is possible with modern conditional devices under a specific protocol — never assume, always check.
• Cardiac resynchronisation therapy patients are heart failure patients first; see Heart Failure and Cardiorespiratory Rehabilitation.
• New devices after other procedures are common — conduction disturbance after transcatheter aortic valve implantation and after cardiac surgery is a frequent route to a pacemaker.

Role of the physiotherapist

Protect the leads without immobilising the shoulder, and actively restore range at the end of the restriction period rather than waiting for a complaint. Establish the device type and, for a defibrillator, the programmed therapy zone before prescribing any exercise. Recognise post-implant pneumothorax, haematoma and infection. Address fear of shock directly, and get the patient into a rehabilitation programme rather than out of one.

References & evidence base

1. Glikson M, Nielsen JC, Kronborg MB, et al. 2021 ESC guidelines on cardiac pacing and cardiac resynchronization therapy. Eur Heart J 2021;42(35):3427–3520.
2. Zeppenfeld K, Tfelt-Hansen J, de Riva M, et al. 2022 ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J 2022;43(40):3997–4126.
3. Kirkfeldt RE, Johansen JB, Nohr EA, Jørgensen OD, Nielsen JC. Complications after cardiac implantable electronic device implantations: an analysis of a complete, nationwide cohort in Denmark. Eur Heart J 2014;35(18):1186–1194.
4. Isaksen K, Morken IM, Munk PS, Larsen AI. Exercise training and cardiac rehabilitation in patients with implantable cardioverter defibrillators: a review of current literature focusing on safety, effects of exercise training, and the psychological impact of programme participation. Eur J Prev Cardiol 2012;19(4):804–812.
5. Nielsen KM, Zwisler AD, Taylor RS, et al. Exercise-based cardiac rehabilitation for adult patients with an implantable cardioverter defibrillator. Cochrane Database Syst Rev 2019;(2):CD011828.

References are numbered in citation order (Vancouver/BMJ style) and were current at the time of writing. Guidelines are living documents — verify against the latest version before clinical use.