Rehabilitation of the coronary patient: status 1986

Exercise therapy after coronary artery bypass graft surgery: a randomized comparison of a high and low frequency exercise therapy program

BACKGROUND

Postoperative exercise therapy aims at recovering, as soon as possible, independence in the basic physical activities; but the type, intensity, and therefore the costs of the programs, vary widely. The aim of this study was to compare the effectiveness of a low frequency (once daily, not in the weekend) program with a high frequency (twice daily, including the weekend) one and to assess whether the latter would yield sufficient benefit for the patient to justify higher costs in material and personnel (physiotherapists) after uncomplicated coronary artery bypass graft (CABG) surgery.

METHODS

Two-hundred and forty-six patients were randomly allocated to either a low or high frequency exercise program. Endpoints were the functional level as measured by the achievement of five activity milestones, the patient's independence (functional independence measures [FIM]) as assessed by a structured interview, the amount of daily physical activity (activity monitor), and patient satisfaction (questionnaire). Except for patient satisfaction, all measurements were done in the first week after surgery.

RESULTS

Patients with the high frequency exercise program achieved functional milestones faster than patients with the low frequency exercise program (p = 0.007). The frequency of the exercise program had no influence on functional independence as measured with the FIM or quantity of physical activity. The satisfaction degree was greater in the high frequency group (p = 0.032), although the low frequency group was not dissatisfied.

CONCLUSIONS

A high frequency exercise program leads to earlier performance of functional milestones and yields more satisfaction after uncomplicated CABG surgery and this should lead to an earlier discharge. On the other hand, if the shortage of physiotherapists remains unchanged or even increases, the low frequency program also yields excellent functional results, albeit at the cost of a somewhat longer hospital stay: but it would allow a sensible redistribution of the physiotherapists activity towards complicated and, therefore, more demanding patients.

A practical guide to exercise training for heart failure patients

BACKGROUND

Exercise training has been shown to improve exercise capacity in patients with heart failure. We sought to examine the optimal strategy of exercise training for patients with heart failure.

METHODS

Review of the published data on the characteristics of the training program, with comparison of physiologic markers of exercise capacity in heart failure patients and healthy individuals and comparison of the change in these characteristics after an exercise training program.

RESULTS

Many factors, including the duration, supervision, and venue of exercise training; the volume of working muscle; the delivery mode (eg, continuous vs. intermittent exercise), training intensity; and the concurrent effects of medical treatments may influence the results of exercise training in heart failure. Starting in an individually prescribed and safely monitored hospital-based program, followed by progression to an ongoing and progressive home program of exercise appears to be the best solution to the barriers of anxiety, adherence, and "ease of access" encountered by the heart failure patient.

CONCLUSIONS

Various exercise training programs have been shown to improve exercise capacity and symptom status in heart failure, but these improvements may only be preserved with an ongoing maintenance program.

Changes in exercise capacity and lipids after clinic versus home-based aerobic training in coronary artery bypass graft surgery patients

PURPOSE

Despite the documented benefits of participating in rehabilitation programs, access to cardiac rehabilitation is limited for a large number of people with coronary artery disease (CAD). There is potential to increase participation in exercise training if home-based exercise were a viable option.

METHODS

We conducted a retrospective database review of 1,042 patients who took part in exercise rehabilitation following coronary artery bypass graft surgery (CABGS) between 1992 and 1998. Of these, 713 patients took part in supervised exercise, and 329 were in an unsupervised, home-based group. All exercise protocols were based upon American College of Sports Medicine guidelines, and patients in both groups received exercise prescriptions that were similar in intensity, frequency, and duration.

RESULTS

There were no differences between groups at baseline. Following 6 months of exercise training, there were substantial improvements in peak VO2, peak workload, and peak MET levels in both the supervised and unsupervised groups (P < 0.0001). Patients in the supervised group had significant improvements in both LDL and HDL-cholesterol, whereas the home-based group showed improvement in HDL-cholesterol only. When analyzed by sex, men performed better than women for all measures of exercise capacity; however, women in both groups showed approximate 20% improvements (P < 0.05) in exercise capacity as well as improvements in HDL-cholesterol.

CONCLUSION

Stable post CABGS patients who receive a detailed exercise prescription to follow at home do as well as those in supervised rehabilitation.

Effects of Orem-based nursing intervention on nutritional self-care of myocardial infarction patients

The purpose of the study was to investigate the effect of nursing care based on Orem's nursing theory on nutritional self-care of myocardial infarction patients. Self-efficacy was explored as a disposition which may motivate behavioral change. One hundred and four subjects were randomly assigned to treatment or control groups. The nursing intervention, which took place during the first 6 weeks following hospital discharge, was effective in supporting healthy low-fat eating behavior. Nursing care influenced patients' self-care agency but lacked impact on self-efficacy for healthy eating.

Social network and social support predict improvement of physical working capacity in rehabilitation of patients with first myocardial infarction

A cohort of 50 patients under 70 years of age who had suffered their first myocardial infarction (MI) entered an exercise-based rehabilitation programme. An extensive personal interview concerning psychosocial factors, including social network and social support, as well as an assessment of an array of clinical and laboratory variables was made before the patients were discharged from the hospital. A follow-up 6 months later of the 40 patients that completed the programme showed that material social support and social anchorage at baseline predicted improvement in physical working capacity, independently from age, gender and important clinical variables. The authors conclude that psychosocial factors could be predictors of equal importance as many of the standard risk factors and clinical assessments in the rehabilitation of a majority of post-MI patients. It is suggested that training programmes should provide opportunities for involvement of the patients' social network, in order to benefit from optimal social support during the rehabilitation process.

Cardiovascular rehabilitation: status, 1990

Cardiovascular rehabilitation is defined as the process of development and maintenance of a desirable level of physical, social, and psychologic functioning after the onset of a cardiovascular illness. Patient education, counseling, nutritional guidance, and exercise training play prominent roles in the process of rehabilitation. Benefits from cardiac rehabilitation include improved exercise capacity and decreased symptoms of angina pectoris, dyspnea, claudication, and fatigue. Recent pooled data regarding exercise training after myocardial infarction demonstrated a 20 to 25% reduction in mortality and major cardiac events. Exercise training may result in an improvement in systemic oxygen transport, a reduction in the myocardial oxygen requirement for a given amount of external work, and a decrease in the extent of myocardial ischemia during physical activity. The efficacy of modification of risk factors in reducing the progression of coronary artery disease and future morbidity and mortality has been established. Herein we review the history, current practice and results, and future challenges of cardiovascular rehabilitation.

Myocardial infarction and patients' wives

When a patient has a myocardial infarction (MI), all aspects of marital function are affected. Soon after the MI, patients' wives experience psychological distress that decreases with time. Illness behaviors among the MI patients' wives increase, and aggressive and sexual impulses are often inhibited. Many families experience changes in members' work status after the husband has an MI, and wives are faced with increased chores. Marital interaction also changes. Dysfunctional marital relationships are associated with a poor psychosocial outcome. Additionally, spousal factors such as dependency are also likely to affect patients. Intervention strategies are best directed to wives at risk for problems.

Success and failure of exercise training after myocardial infarction: is the outcome predictable?

One hundred fifty-six patients underwent a 5 week daily exercise training program after recovery from acute myocardial infarction. Outcome was assessed on the basis of exercise testing, integrating the measurements into a single outcome measure consisting of three categories (positive, n = 79; negative, n = 42; no change, n = 35). This composite criterion served as the end point for determining the predictability of a positive (training success) and negative (training failure) outcome. With use of logistic regression analysis, the baseline variables of clinical information, exercise data and psychosocial variables were able to identify patients with training success, as well as patients with failure (correct classification rates 81% and 85%, respectively). The characteristics of patients for whom training was beneficial differed from those of patients with a negative outcome. Work status before infarction was the single most important predictor of success, but it did not determine failure. Psychologic variables (type A behavior, well-being, depression) were important for predicting failure, but not for predicting success. Cardiac state and physical fitness largely determined training success. It is concluded that the physical benefit of exercise training in patients after myocardial infarction is highly predictable. Validation will make it possible to optimally apply exercise training as a therapeutic modality in these patients.

Effects of cardiac rehabilitation after coronary artery bypass grafting on readmissions, return to work, and physical fitness. A case-control study

In a case-control study 49 consecutive post-coronary artery bypass grafting (CABG) patients (10 f, 39 m) participating in a comprehensive rehabilitation programme were compared with 98 individually matched double control patients, receiving standard care. The rehabilitation programme, starting 6 weeks after surgery, consisted of follow-up at a coronary clinic, repeated health education, and physical training in out-patient groups. During the first year after CABG, fewer study group patients were readmitted to hospital (14% vs 32%, p less than 0.01) and on fewer occasions (1.1 vs 2.9, p less than 0.05). Fewer patients used anxiolytic drugs (0% vs 15%, p less than 0.01). At the one year post-CABG exercise test we found in the study group a tendency to a greater increase in work capacity, as compared with the values obtained at the preoperative exercise test (33 vs 25 W ns). There were no differences in the rates of returning to work (59% vs 64%). In a long-term follow-up study (av. 38 months post-CABG) the patients were asked to fill in a questionnaire evaluating perceived physical work capacity and training habits. The study group patients rated their physical work capacity higher, and more patients had continued with regular physical training (66% vs 46%, p = 0.05). There were fewer patients using anxiolytic drugs (9% vs 30%, p less than 0.01). Although the programme did not influence the return to work we conclude that it improved the quality of life of our patients as it entailed fewer readmissions and reduced the use of anxiolytic medication; in addition it promoted physical fitness and training habits.

ECG Monitoring in Cardiac Rehabilitation: Is It Needed?

In brief: The need for expert supervision in cardiac rehabilitation exercise programs is generally accepted, but the use of ECG monitoring as a safety measure in such programs is controversial. No randomized controlled studies of monitoring vs supervision alone have been performed. Consequently, there is no uniform approach to the role of ECG monitoring in cardiac exercise programs. In addition, considerable expense for labor and equipment would be required to monitor all participants continuously for the duration of a program, which typically lasts 12 weeks. The data indicate that administrators of such a program would spend approximately $1 million on ECG monitoring over eight years in the hope of preventing one serious cardiac event.