CARDIAC REHABILITATION


CARDIAC REHABILITATION

The WHO defines cardiac rehabilitation as:

The rehabilitation of cardiac patients is the sum of activities required to influence favourably the underlying cause of the disease, as well as the best possible physical, mental and social conditions, so that they may, by their own efforts, preserve or resume when lost, as normal a place as possible in the community. Rehabilitation cannot be regarded as an isolated form of therapy, but must be integrated with the whole treatment, of which it forms only one facet.
(WHO 1993)

Cardiac rehabilitation is a comprehensive intervention that offers education, exercise and psychosocial support for patients with CHD and their families and is delivered by many specialist health professionals. Cardiac rehabilitation can promote recovery, enable patients to achieve and maintain better health, and reduce the risk of death in people who have heart disease.

COMPONENTS OF CARDIAC REHABILITATION

·         Risk factor assessment and modification.
·         Education.
·         Exercise.
·         Psychosocial support.

Operation and delivery

It transpires that cardiac rehabilitation is really a continuum of care from the time the patient is admitted until discharge and extends to outpatient care, as well as longterm follow-up in the community. Patient care is shared with the cardiology team, of which cardiac rehabilitation forms an essential part. Cardiology management includes patient assessment and risk stratification (predicting the likelihood of recurrence of cardiac events and disease prognosis). The patient also undergoes diagnostic tests and drug therapy, and may need revascularisation, such as angioplasty or a bypass grafting as appropriate. Traditionally, cardiac rehabilitation is divided into four phases, progressing from the acute hospital admission stage to long-term maintenance of lifestyle change.
Phase I: inpatient period.
Phase II: early post-discharge period.
Phase III: supervised outpatient programme, including structured exercise.
Phase IV: long-term follow-up/maintenance in primary care.

Phase I: Inpatient period
Cardiac rehabilitation is offered as soon as it is practical as an integral part of care to someone who is admitted (or who is planned to be admitted) to hospital with CHD.
It includes:

·         assessment of physical, psychological and social needs;
·         negotiation of a written informal plan for meeting these identified needs;
·         initial advice on lifestyle, e.g. smoking cessation, physical activity (including sexual activity), diet, alcohol consumption and employment;
·         mobilisation;
·         education about prescribed medication, its benefitsand possible side effects;
·         involvement of relevant informal carer;
·         provision of locally written information about cardiac rehabilitation;
·         discharge planning.

Phase II: Early post-discharge period

This service shows variation in different regions and can vary from as little as a telephone helpline to group sessions or individual appointments The National Service Framework recommendation includes:
·         comprehensive assessment of cardiac risk, including physical, psychological and social needs for cardiac rehabilitation, and a review of the initial plan to meet these needs;
·         provision of lifestyle advice and psychological interventions according to the agreed plan by the multi-disciplinary team;
·         maintaining involvement of relevant informal carer;
·         home visits, if appropriate.

Phase III: Supervised outpatient programme, including structured exercise

Traditionally, this phase is well set up in the form of an outpatient hospital-based programme, although more services are now shifted into primary care. It includes:
·         risk stratification and identification of the high-, medium- and low-risk patient for exercise;
·         individualised progressive exercise prescription and supervised exercise sessions which vary from 4–12 weeks in different regions;
·         re-evaluation of risk factors for CHD and health promotion advice and education
·         psychosocial interventions, such as stress management, counselling and vocational guidance.

Phase IV: Long-term follow-up/maintenance in primary care

This phase is now well set up in many districts, with emphasis on provision of exercise sessions available in community or leisure centres. Specialist training to exercise CHD patients in the community is available to the exercise instructors by the British Association for Cardiovascular Prevention and Rehabilitation (BACPR).

Phase IV includes:

·         long-term maintenance of individual goals;
·         professional monitoring of clinical status and follow-up of general progress;
·         ongoing psychosocial support and support groups.

Cardiac rehabilitation team

The cardiac rehabilitation package individualised for each patient requires expertise and skills from a multidisciplinary collaborative team of professionals The team includes a cardiologist and staff from nursing, physiotherapy, dietetics, pharmacy, occupational therapy and psychology with training in cardiac rehabilitation. Continuation of care in the community involves the primary healthcare team that is the general practitioner and cardiac nurse, phase IV exercise specialist and a link from a local cardiac patient support group



The role of the physiotherapist

Physiotherapists have the knowledge, assessment skills and clinical reasoning, combined with evidence-based approach to treatment, to undertake the rehabilitation management of patients with multi-pathology problems. Physiotherapists are also trained to run group sessions and classes. Hence, the role of the physiotherapist within the multi-disciplinary team should focus on exercise prescription, training and education in phases I–III. The modification in exercise prescription needs to be discussed with medical and nursing team members. In a group setting where exercise is delivered to CHD patients, teamwork and liaison with other team members who are aware of patients’ clinical and psychosocial issues is essential.

Reference:

·        Tidys Physiotherapy, (15th)

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