There has been a dramatic development in medical and rehabilitative care for cardiac patient and family over the last 10-15 years. This article reviews the evolution of contemporary cardiac rehabilitation (CR) and the content of CR. The article also poses some questions and directions that CR may develop into 21st century.
THE EVOLUTION OF CARDIAC REHABILITATION
In the 1950s, CR consisted of extended periods of immobilisation, particularly post-myocardial infarction (MI), for up to 6 weeks. The theory at that time was that reduced workload on the myocardium would allow myocardial healing. Furthermore, patients were informed that return to work and normal activity would be unlikely.
The pioneering work of researchers (1952), was innovative and radical for that time. In 1952 they introduced “armchair management”, where cardiac patients could recover by sitting for a period of 7 days, rather than the traditional bed rest that lasted upto 6 weeks. This early study of a more active approach to recovery after a cardiac event included 81 (16% women) “post coronary thrombosis” patients aged between 42 and 80years. Researchers were primarily interested in minimising the problems of bed rest and long periods of inactivity. It became clear that when the patients in this study were mobilised out of bed, stood up and took up a few steps, their outcomes improved, or they at least had no more complications than before. Furthermore, the researchers claimed there were psychological benefits from early moblilisation, although they did not describe how these were measured.
Other clinicians in cardiac care at that time were becoming aware that extended immobility and bed rest were causing many psychologically harmful effects. Clinicians (1952) also encouraged an early “active” approach to rehabilitation and had patients sitting, walking and stair climbing by their 6th week post MI.
A further significant step was taken by in 1957. They advocated that not only was the traditional “passive bed rest approach detrimental to the rehabilitation of cardiac patients, but graded exercise should be included in the hospital phase along with early mobilisation. Although their early study was limited in that the exercise design was poorly described, their overall management post-event could be identified as one of the first comprehensive views of CR, as it included diet and stress management and other aspects of a holistic approach to a healthy life in their programme.
Once the misconception that inactivity was a requirement for recovery from a coronary event was dispelled in the 1950s, many researchers and clinicians started evaluating the effects of exercise for coronary heart disease (CHD) patients. This explosion of research was primarily driven by the growing evidence that habitual exercise provided not only a measure of primary prevention but also secondary prevention benefits to CHD patients in the year (1967), where evaluated the physiological outcomes of 67 post – MI patients enrolled in a structured cycling exercise programme. The programme involved exercising three times per week for 4months, training at a heart rate intensity of 150 beats/min. The researchers found a significant increase in work capacity and a significant reduction in the rate pressure product. In the 1960s, were to change significantly the established cautious attitude to CHD patients and exercise.
In the early 1970s there was a dramatic change in attitude towards individuals who had CHD, and post –MI patients in particular. World leaders in exercise – based CR at this time included habitual structured exercise was not only safe after a coronary event but also afforded many physiological and psychological benefits. Thus, there was, in a 20 year period, a move away from the passive, and what would now consider “dangerous”, bed rest for cardiac patients to an acceptance of early mobilisation and structured exercise as part of CR.
The Cardiac rehabilitation guidelines were published in the year 1995 as follows:
- Historical background
- Cardiac rehabilitation; programmes, content, management and administration
- Medical aspects of CR
- Exercise testing and prescription
- Enhancing exercise motivation and adherence in CR
- Psychological aspects of CR
- Dietary aspects of CR
- Funding issues in CR
The 1995 guidelines were a significant contribution to the expansion of effective and safe CR and continued to be highly relevant for practitioners into the early twenty-first century.
As in the 1995 guidelines, in the year 2000, researchers used the four phases of CR to describe the journey that cardiac patients should take through rehabilitation. Each phase gave clear guidelines on the intervention and care for that phase. Phase 3 included structured exercise sessions delivered to meet the assessment needs of individual patients. Gaman follows the guidelines for cardiac rehabilitation as provided by the researchers and tailored according to the needs of the individual
It is mentioned that exercise sessions may be structured in a variety of ways to meet the needs of individual patients. Typically they will be provided to groups, last at least 6wks, but normally 12wks or more and comprise at least 3 sessions per week with a minimum of 2 supervised exercise sessions (individual programmes often in a group environment) and 1 session of education and information for patients, partners, carers and families .
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