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The primary aim of rehabilitation of patients with physical conditions such as skeletal, spinal, or brain injuries, or following a cardiac event such as a myocardial infarction, is to enable the patient to return to as near their level of pre-morbid functioning as their physical condition allows. Since much heart disease is a product of an unhealthy life-style, an important secondary aim in cardiac rehabilitation is to enable the patient to change their behavior to reduce the risk of further arterial damage and recurrent cardiac events.
Cardiovascular disease is a major problem in most industrialized countries. Currently in the UK approximately 300,000 people per year have myocardial infarction, of whom 50 percent survive for at least 28 days. There are also large numbers with the disabling symptoms of coronary disease such as the 1.4 million individuals in Britain with angina. While there has been progress in the prevention of coronary artery disease in most counties with a high incidence of heart disease, an aging population and advances in medical treatments mean the number of people with coronary disease and its consequences is in fact increasing. A sizeable proportion of these people would beneﬁt from cardiac rehabilitation. While prolonged inpatient rehabilitation—often in sanatoriums in country environments thought to be healthy—has been common in some countries for many years, the development of intensive outpatient programs is a product of the last quarter of the twentieth century. Founded with great enthusiasm, the early results from cardiac rehabilitation programs were disappointing but developments in therapeutic and data analytic techniques have led to a much more positive picture emerging since the mid-1990s. Many now hold that that comprehensive cardiac rehabilitation can improve the quality of life and physical health of patients with coronary heart disease and most sophisticated systems of healthcare aim to oﬀer rehabilitation to patients suﬀering the eﬀects of cardiovascular disease.
1. Main Features Of Cardiac Rehabilitation
The main group of patients who receive cardiac rehabilitation comprises survivors of acute myocardial infarction, although patients who have undergone coronary bypass surgery or angioplasty may also receive it. Since the latter are often elective procedures, rather than the unpredicted disaster of a heart attack, the patients’ problems may diﬀer and less is known about the most appropriate forms of rehabilitation for them. The ﬁrst cardiac rehabilitation programs were primarily based around exercise regimes and this remains the core of many programs. However with the increasing understanding of the psychological eﬀects of myocardial infarction and the psychological and behavioral determinants of coronary heart disease (Krantz and Lundgren 1998), programs have widened to include many psychosocial components. There is no agreed standard program of cardiac rehabilitation, and programs vary widely in practice, but a modal program would be oﬀered in an outpatient setting, starting six to eight weeks after discharge from hospital, would run for two or three months and would include regular exercise, an educational component about life-style change, and some procedures—such as relaxation training—to reduce distress. Exercise is usually conducted in specialist hospital gymnasiums, often with careful monitoring of the heart rate to diminish the risk to the patient. Rehabilitation programs are usually oﬀered to middle-aged patients but might not be oﬀered to the elderly, although they are the main suﬀerers from heart disease. Uptake of rehabilitation can be poor, especially in older patients. Such rehabilitation programs are expensive and diﬃcult to deliver to the inﬁrm, the socially disadvantaged, or those who live far from a specialist centre. Fortunately, eﬀective versions of some aspects of rehabilitation can also be delivered by manual and supplementary telephone contact (Lewin et al. 1992), or by brief educational or counselling interventions while the patient is still in hospital (Johnston et al. 1999).
2. The Eﬀects Of Cardiac Rehabilitation
2.1 Psychosocial Outcomes
It would appear self-evident that patients will be distressed immediately after an unexpected, painful, and life-threatening event such as an acute myocardial infarction, and that this distress will continue for some time. While this is true of perhaps 15 to 30 percent of patients, a number of studies have shown that anxiety and depression are only slightly raised in most patients while still in hospital, but rise several weeks later and may remain elevated for at least a year (Johnston et al. 1999). Perhaps as signiﬁcant is the ﬁnding that anxiety and depression are very high in the patients’ partners while the patients are in hospital and these remain high—higher than that of the patients—for at least the subsequent year. There are many studies using rehabilitative techniques designed to reduce the distress associated with an infarction. Issues covered in such interventions will typically include an explanation of the attack and the healing process, including medical treatments and investigations, information on resumption of activities, and material on the emotional eﬀects of a heart attack and the management of stress. Many recent studies of such interventions are positive and until recently there was a clear consensus, which had been conﬁrmed by meta-analysis (Linden et al. 1996), that anxiety and distress could be reduced by appropriate rehabilitation programs, including programs that focused primarily on exercise (Kugler et al. 1994). However, an analysis by Dusseldorp et al. (1999) failed to conﬁrm this ﬁnding. This is almost certainly because of the inclusion of two major studies with substantial samples that failed to ﬁnd a reliable eﬀect of psychosocial rehabilitation on distress (Jones and West 1996, Frasure-Smith et al. 1997). These studies are aberrant, and while their impressive size (which came about because they were primarily designed to detect eﬀects on reinfarction rate) means that they have a substantial eﬀect on summary analyses, few in the ﬁeld accept that distress cannot be reduced after a myocardial infarction. Other studies have shown highly signiﬁcant eﬀects of simple interventions (Lewin et al. 1992, Johnston et al. 1999) on distress and on the resumption of the normal activities of daily life. Johnston et al. also showed that anxiety and depression was greatly reduced in the partners of patients if they were included in the rehabilitation program.
2.2 Risk Factor Reduction
A substantial proportion of heart disease is predicted by a few well-recognized and modiﬁable risk factors, all of which relate to some extent to behavior. These are elevated blood pressure, some lipids (including cholesterol), and cigarette smoking. Dusseldorp et al. (1999) have provided the most complete account of the eﬀects of psychoeducational programs on the reduction of these conventional risk factors. All were reliably reduced by the interventions.
As well as these well-accepted risk factors there are a number of psychological risk factors that, although not necessarily accepted by the whole medical community, have substantial epidemiological support. Currently the most prominent of these are Type A behavior and depression (see Krantz and Lundgren 1998), and there is increasing interest in social support. Type A behavior, a pattern of behavior characterized by competitiveness, time pressure, and hostility, has been recognized as a risk factor for myocardial infarction for some time. However, possibly because of continuing controversy over which component of this complex behavior pattern is actually harmful, there have been few studies that both modiﬁed the behavior and were large enough to detect any eﬀect on physical health. By far the largest of such studies is the Recurrent Coronary Prevention Project (Friedman et al. 1986) in which nearly 900 patients were randomized to either a prolonged program of Type A modiﬁcation using cognitive behavioral techniques or an alternative treatment emphasizing cardiological care and information. The behavioral intervention led to substantial reductions in Type A behavior and in recurrent myocardial infarction. There have been a number of successful small-scale replications of this study, but it does not seem to have been incorporated into clinical practice to a signiﬁcant extent. Future studies may concentrate more on hostility than the complete range of Type A behavior, since it is generally held that hostility is the component of Type A most reliably related to cardiovascular disease. Depression has emerged much more recently than Type A as a risk factor for heart disease (and indeed other physical conditions) and appears to be ﬁnding widespread acceptance. While studies are ongoing, there are no completed studies of the eﬀects of treating depression on recurrent heart disease. Frasure-Smith, one of the leading advocates of depression as a risk factor in recurrent heart disease, has described interventions for related states with disappointingly mixed eﬀects. In an early study she found that distress (which could include both anxiety and depression) could be successfully treated in patients after a myocardial infarction and that this was associated with reductions in morbidity and mortality over the subsequent seven years. However in a substantial replication (Frasure-Smith et al. 1997) she was unable to either reduce distress or aﬀect the recurrence rate.
3. Morbidity And Mortality
Few studies of rehabilitation have large enough samples to demonstrate reliable changes in morbidity or mortality, but meta-analytic techniques enable independent studies to be combined. Oldridge et al. (1988), in a highly inﬂuential analysis of exercise and life-style change programs, showed a reduction in mortality, but not reinfarction rate, following rehabilitation. Subsequent meta-analyses incorporating more studies of exercise have largely conﬁrmed these ﬁndings and also shown eﬀects on reinfarction, as have the meta-analyses of life-style change and stress management programs (Dusseldorp et al. 1999). They show that such programs were associated with a 34 percent reduction in mortality and a 29 percent reduction in reinfarction rate. The ﬁndings were most persuasive in studies in which there was evidence of change in life-style-related risk factors such as blood pressure, cholesterol, and cigarette smoking.
4. The Future
The outstanding issues for the future are eﬀectiveness, eﬃciency, and access. While it is clear that eﬀective programs exist, the results from ineﬀective trials are still reported and the critical components have yet to be isolated. In addition we can anticipate increasing eﬀorts to incorporate modiﬁcations of the newer psychological risk factors such as depression, hostility and, very probably, social support. Many programs are expensive to implement, they require gymnasiums, physiotherapists and other health professionals, and time—all scarce resources. Increasingly complex programs will have to be delivered in ever more eﬃcient ways. This will surely involve close targeting of interventions to patients’ particular problems and risks as well as more eﬃcient methods of delivery such as patient manuals, both printed and computerized, and the use of the internet. Perhaps the greatest advances need to be made in increasing access. In many counties with otherwise sophisticated healthcare systems, too few people are oﬀered cardiac rehabilitation, and many ﬁnd it diﬃcult to accept because of factors such as other commitments, poverty, and, no doubt, a failure to realize or accept the possible beneﬁts. In England and Wales 40 percent of centers restrict rehabilitation to those aged below 60, and when it is oﬀered to the elderly it is not geared to their special needs. The situation may be a little diﬀerent in the USA, where Richardson et al. (2000) report an increase in the uptake of rehabilitation in those aged 65 and over, from 28.3 percent in 1986 to 52.1 percent in 1996 for one particular service. Cardiac rehabilitation in the elderly appears to be safe and of value (Foreman and Farquhar 2000), but Oldridge (1998) has pointed to the lack of good, controlled studies. Most studies, like most rehabilitation programs, have focused on the middle-aged. We can expect to see in the near future a change in both access and a strengthening of the scientiﬁc basis of cardiac rehabilitation for the elderly.
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