F-33 Cardiac rehabilitation
When I was a clinical medical student, frozen shoulder (shoulder-hand syndrome) was a recognised complication of myocardial infarction, occurring in 15% of survivors. The reason? Immobilisation and prolonged rest. Now, patients are asked to exercise and given much other advice. Cardiac rehabilitation started in the 1960s and has developed since into an effective, team-based, multi-modal intervention. The development of cardiac rehabilitation programmes from 1970 onwards is an example of parallel evolution; a similar change from focusing on a single aspect of the condition to a holistic approach encompassing social, emotional, lifestyle and other matters has occurred in most rehabilitation sub-specialities. Undoubtedly, there will be further changes, but the most significant challenge is to persuade funding organisations to fund it and patients to attend and use it. Second, because most cardiac conditions are associated with other vascular problems and other illnesses, and because the patients usually have chronic issues, cardiac rehabilitation needs to fuse with, for example, stroke rehabilitation and prosthetic rehabilitation. This page reviews its history and its main components.
Table of Contents
The competency.
A healthcare professional with rehabilitation expertise is “able to assess a patient with a cardiac disorder and advise on both the cardiac and general rehabilitation needed.” The behaviours, knowledge, and skills associated with this competency are available in a downloadable document that also provides some references.
Introduction
Cardiac rehabilitation’s unique challenge arises from the status bestowed upon the heart by most cultures. Moreover, most people understand that the heart keeps us alive like no other organ. Although Heberden described one patient “who improved by working in the woods half an hour per day.” after myocardial infarction, the initial scientific approach to heart disease was to rest because it was expected to reduce the strain on a weak heart. For example, “The nurse does not want to frighten the patient but she needs to help him understand that the work load of the heart must be reduced for a considerable period of time and that he must resume his previous activities very gradually.” [1959]
Rod Taylor and colleagues defined cardiac rehabilitation thus: “Cardiac rehabilitation is a complex, multicomponent intervention that includes exercise training and physical activity promotion, health education, cardiovascular risk management and psychological support, personalised to the individual needs of patients with heart disease.” This is similar to the definition of most rehabilitation services, such as that for pulmonary rehabilitation.
Cardiac rehabilitation draws on all rehabilitation skills and is essentially an educational and psychosocial activity, encouraging a healthy lifestyle: exercise, weight loss, and a reasonable diet. Services are inevitably closely involved in public health, and in the UK, Sports and Exercise Medicine training encompasses public health specifically, whereas Rehabilitation Medicine does not.
Cardiac rehabilitation: history
Once the nature of normal cardiac function and heart disease were understood, rest became the logical (but incorrect) recommended treatment. The logic is simple: The heart is a muscle; heart disease damages the heart muscle; the heart muscle takes time to regrow and will be vulnerable; therefore, rest until the muscle is back to normal. This is credible and influential logic, and until the 1950s, rest for up to one year was the standard recommendation.
From about 1960 onwards, cardiac rehabilitation evolved, and more details are given in three papers that discuss the history of cardiac rehabilitation. John Buckley describes “The changing landscape of cardiac rehabilitation; from early mobilisation and reduced mortality to chronic multi-morbidity management.” Julie Redfern and colleagues considered the “Historical Context of Cardiac Rehabilitation: Learning From the Past to Move to the Future.” Warner Mampuya overviews “Cardiac rehabilitation past, present, and future”.
The crucial first step was to convince professionals and patients that exercise was safe. The first move was from resting in bed to resting in an armchair, which started in the mid-1950s. By the mid-1960s, this progressed to trials of light exercise, and by the mid-1970s, cardiac rehabilitation based on structured exercise was accepted. One can see how difficult it is to question ‘accepted wisdom’, especially when it is supported by ‘common sense’ logic.
Cardiovascular rehabilitation increased its scope over the next few decades as the importance of other aspects became apparent. Thus, it now encompasses education of the patient and family on self-management and healthy behaviours, including:
- Reduction of harmful behaviours such as smoking
- Increasing exercise, daily activity, and fitness
- Improving diet to reduce weight and other risk items,
- Taking appropriate medications when needed, such as anti-hypertensive drugs.
Moreover, it involves broader matters such as:
- Improving psychological well-being and beliefs about cardiac disease
- Screening patients for additional treatable conditions
- Considering vocational and leisure activities
- Public health measures.
Last, cardiac rehabilitation inevitably needs to consider other comorbidities needing rehabilitation input. Common examples include patients who have had a stroke or amputation of a leg because coronary artery disease is only one aspect of generalised vascular disease. Further, once patients with heart failure and other chronic cardiac conditions were found to benefit from cardiac rehabilitation, many older adults with co-existing conditions, such as osteoarthritis affecting mobility or Parkinson’s Disease, were seen.
The history of cardiac rehabilitation mirrors that of most other subspecialist rehabilitation areas. It was initially disease-focused but became involved in much broader areas of rehabilitation.
Integration with cardiology
Medical cardiologists (including cardiac surgeons) were active in developing cardiac rehabilitation services; Samuel Levine and Bernard Lown, two physicians, played a significant role in first questioning the need for bed rest. Cardiologists have remained active participants in cardiac rehabilitation, and the patient’s engagement in cardiac rehabilitation is influenced by the attitude of the doctor who sees them.
The continued involvement of medical professionals has led to a truly integrated and holistic service, at least where cardiology departments participate. This is reflected in descriptions of cardiac rehabilitation and its purpose. For example, Petr Winnige and colleagues discussed “Cardiac rehabilitation and its essential role in the secondary prevention of cardiovascular diseases.” Most descriptions include disease-specific management and the whole range of rehabilitation within a single service.
This arrangement benefits patients and reinforces the importance of exercise, lifestyle changes, and returning to functional activities. In practice, the service is likely to have two teams, one focused on person-centred rehabilitation and the other on person-centred disease management, with regular interactions between members of the two teams.
The main risk is that the service will overlook other conditions needing rehabilitation, and the patient will receive suboptimal rehabilitation for different conditions. The solution is for the cardiac rehabilitation service to be integrated into a regional rehabilitation network so that onward referral or joint working between services is easily achieved when needed.
Cardiac expertise
Patients with cardiac disorders may be seen in all rehabilitation services, and all rehabilitation professionals need to have sufficient expertise to initiate or support appropriate rehabilitation. Vital areas such as the need to exercise and lead a healthy lifestyle are common in all fields of rehabilitation.
The other crucial skill any rehabilitation professional must have is to discuss and acknowledge the cardiac condition and relate its rehabilitation to the overall problems the person has, explaining how the various conditions influence each other or not if that is the case. This is something that should occur for every patient who has two or more health conditions.
Anyone whose service mainly sees people with cardiac diseases will need additional expertise, most of which will be learned once in the service. The clinician will need to:
- Be familiar with cardiac conditions seen frequently,
- to answer any general concerns a patient may have and
- to recognise when the disease process may need additional investigation or treatment
- Know where and how to obtain additional information or information about rare conditions
- Be familiar with common condition-based pharmacological and surgical interventions,
- To respond to any patient concerns
- To be look out for common side effects or complications
The future
Interestingly, several recent overviews of cardiac rehabilitation have suggested that attention moves away from short-term rehabilitation and toward lifelong condition management.
For example, Julie Redfern and colleagues wrote, “Very few patients now need a period of “rehabilitation,” but rather life-long multifaceted prevention is needed to reduce the CVD burden.” Their first key recommendation is, “Implementation of lifelong preventive strategies, rather than time-limited programs, would optimize continuous management and care for patients.” In the same vein, John Buckley says. “Cardiac rehabilitation has evolved over three centuries from observed hypotheses in the eighteenth and nineteenth century, to an exercise-based programme in the mid twentieth century, and now to a multi-faceted, multi-morbidity chronic disease management programme.”
Attention may also move from the individual patient to the population who would benefit from rehabilitation. We already know that cardiac rehabilitation benefits patients and is cost-effective. Doubtless, further advances will increase effectiveness. However, the striking feature is that well under half of patients who could benefit take part. The research and clinical focus should move to ways of increasing population benefit.
Conclusion
Cardiac rehabilitation developed independently from other rehabilitation services and was firmly supported by the cardiology services because the need was apparent and medical services saw its potential value. The initial focus was on returning the heart to its usual function after function had been reduced by disease and damage. The importance of psychological factors, mood, and beliefs was recognised early, and the service rapidly became a multi-professional team that could help the person adapt across all domains. More recently, a further need has emerged; patients with other disabling disorders and cardiac rehabilitation services must integrate more closely into a broader rehabilitation network while maintaining their cardiac expertise and close link to medical and surgical services.
