II. Literature Review
A study by Ades et al (1997), concluded that after comparing other post MI treatment interventions, cardiac rehabilitation is more cost effective than thrombotic therapy, coronary by-pass surgery and cholesterol lowering drugs, though less cost-effective than smoking cessation programmes. In 1997, cost-effectiveness was determined to reflect the UK situation. The results suggested QALY of ₤6,900, and a cost per life year gained three times ₤15,700. Although, it has been proven cost-effective; there are still various factors that influence costs and cost-effectiveness such as the location, patient population and their compliance. Moreover, studies on cardiac rehabilitation program usually focus in two aspects these are the exercised based and influence on the psychological aspect of the patient.
A key concept for health status is health-related quality of life (HRQL). HRQL represents the functional effect of an illness and its consequent therapy, as perceived by the individual. At present, Health – Related Quality of Life (HRQL) is used as a primary outcome measure in rehabilitation programs (Wenger, et al, 1995). HQRL (DiMatteo, et al.) is recognized as an important dimension of patient care and treatment outcome. This increased recognition is due, in part, to our greater understanding of the role of psychosocial factors, such as depression in medical outcomes, including compliance with medical treatment and subsequent cardiac events (2000).
HRQL was measured with the SF-36 at baseline and at completion of the phase II cardiac rehabilitation program. The SF-36 consists of 36 items evaluating eight dimensions of physical and mental health, including physical functioning, physical role limitations, bodily pain, general health, vitality, social functioning, emotional role limitations, and mental health. Ware and colleagues, who developed the SF-36, refer to it as a measure of the physical and mental components of health status. They also state that the SF-36 is a measure of HRQL (2000). At 3 months post-surgery, however, patients who had undergone CABG had similar SF-36 scores to those who had PTCA. Likewise, Barnason et al. showed that CABG patients exceeded preoperative levels of HRQL at 3 months, and all domains of the SF-36 stabilized or gradually improved by 6 months and 12 months post surgery (2000). Interestingly, when these exercise programs are offered on an outpatient basis in hospitals, individuals have demonstrated a high level of compliance while making significant improvements in exercise tolerance and muscular strength (Delagardelle, et al. 1999)
In a study conducted by Brubaker and company in 2003, baseline demographics for individuals with CHF and post CABG completing the cardiac rehabilitation program in 2000 and 2001 (≥24sessions) were similar and are shown in Table 1. Cardiac Rehabilitation was well tolerated for both groups with no untoward events occurring during the 12-week program.
Table 1. Patient Characteristics
n
CHF
CABG
Male
56
52
Female
20
29
EF%
34±11§
57±10
Age (yrs.)
73±9
73±7
n Number of participants completing program (≥24 sessions in 12 – weeks)
* Ejection Fraction
§ Values in mean ± standard deviation
Pre-post changes for exercise tolerance and quality of life constructs within and between groups are shown in Table 2. Quality of life scores and exercise tolerance in both groups improved significantly statistically with the cardiac rehabilitation program explaining 62% of the variance (F(9,98)=17.9 p<0.001). There was no statistically significant interaction between the CHF and CABG groups (F(9,98)=1.47, p=0.17). In addition, exercise tolerance and the self-reported SF-36 physical functioning (PF) quality of life construct were significantly correlated for both CHF and CABG patients (r 2=0.34, p<0.01).
Table 2: Outcomes for QOL Constructs and Exercise Toleranceµ
Outcome
CHF
CABG
Mean ±SD
Mean ±SD
Pre – test 12-weeks
Pre – test 12-weeks
n =
56 56
52 52
Body Pain**
59±23 66±24
54±27 65±25
General Health**
49±1 58±23
63±18 64±17
Health Transition**
3.5±2 2.3±1.2
3.1±1.2 2.4±1.2
Mental Health**
69±17 77±17
71±17 76±18
Physical Functioning**
42±20 55±22
43±21 61±21
Role – Functioning Emotional**
42±44 67±39
45±43 69±40
Role – Functioning physical**
15±30 39±38
17±34 42 ±37
Social Functioning**
58±5 81±19
80±20 85±20
Vitality**
39±22 54±21
44±19 55±21
Exercise Tolerance**
163±61 251±70
208±62 309±90
µ For readability, all numbers rounded to nearest 1.0 except for Health Transition. n Number of patients completing program (≥24 sessions in 12- weeks). SD Standard Deviation. ¥ Exercise Tolerance Measured in seconds. Significant pre – post changes: **p≤.001.*p ≤.05. Denotes significance within – groups.
In this study, Exercise time was distributed between Trackmaster® treadmills, Schwinn® stationary bicycles, Monarch® upper body arm ergometers, Nautilus® resistance equipment, and hand weights. All subjects were encouraged to attend the 12 weekly education seminars taught by cardiac nurses, respiratory therapists, and exercise physiologists. The seminars covered topics such as coronary artery disease, dietary concerns, anatomy and physiology of the heart and lungs, home exercise, risk factors for heart disease, food label reading, stress management, diabetes, cholesterol, smoking cessation, and medications. Subjects had the opportunity to ask questions during and after class or in a one-on-one situation with a clinical staff member. This concludes that interventions must integrate on the wholistic approach of the individual namely: physical, mental, emotional and the social aspects. Trials have been established that psychological and educational interventions can reduce risk factors, improve psychosocial well-being and patient knowledge. On the other hand, in practice, the information provided is often inadequate, inconsistent and is frequently misunderstood by the patients.
However, focusing on the non-medical treatment such as walking exercises programmes wherein, walking exercise programmes (Hakim et al, 1998) have a positive effect on the distance that patients with intermittent claudication can walk. An improvement of 90 to 190% in walking distance can be expected. The patient should be advised to exercise daily and to maintain this training programme for at least 3 to 6 months. As well as reducing the complaints of the disease, the walking exercise programme has a longer-term effect of reducing mortality.
Cardiac Rehabilitation program is intended for patient with established heart to further reduce the risk or re-occurrence of myocardial infarction and the likes. It is further enhance with psychological and educational interventions. As noted in Effective Health Care Bulletin, exercise as sole intervention has a positive impact on the physical aspects of recovery at no additional risk to the patient (1998). Accordingly, many personsconsider exercise as being synonymous with vigorous physicalactivity, like jogging or running. However, walking especially brisk walking is the most common aerobic training modality utilizedin cardiac rehabilitation programs. A study conducted in 2002, suggest that physicians andallied health professionals can prescribe brisk walking on aflat surface to their cardiac patients with confidence thatthis intensity will achieve cardio – respiratory and health benefits.Furthermore, these results serve to discount the lingering notionthat cardiac patients need to participate in vigorous exercisesuch as jogging or running in order to benefit from an exercisetraining program. Although some studies suggest an even lowertraining threshold than the one used in the present study), especially in extremely deconditioned subjects. It is important not to do too much too quickly and build up on the level of activity gradually. In contrast, a systematic review conducted in 1995, which formed the basis of a US guideline on cardiac rehabilitation, provides detailed information on RCTs of exercise alone. Exercise was found to have a positive impact on patients’ physical ability to exercise, and on physiological measures of cardiac disease. There was not enough evidence to evaluate the effects of different intensities.
The second aspect of most research study is with regards to psychological outcomes; to quote Wegner, which in Cardiac rehabilitation should be emphasized that exercise has not found to do any harm to patients and no enough evidence was found to evaluate the effect of exercise alone on psychological or social outcomes, or return to work (1995). This issue was further supported by (Specchia, et al.) by their additional trials examining the effects of exercise alone. However (Singh, et al. 2006), contradicted that patients can get Psychological improvements include reduction of depression, anxiety, and stress. All these improvements enable acquisition and maintenance of functional independence and return to satisfactory and appropriate activity that benefits both the patient and society. As evidenced by the meta-analyses (Linden, et al. 2006) to support its conclusions regarding the effects of psychosocial interventions that includes patient education, counseling and behavioural interventions. These have been shown to affect risk factors including blood pressures and cholesterol levels. They also produce significant improvements in psychosocial well-being and in patient knowledge, especially concerning the benefits of activity. Increases in knowledge may not be sufficient to produce changes in behavior or lifestyle.
Overall, quality of life can be meaningfully assessed in most individual rehabilitation programs. That in particular would be in combined exercise and psychological intervention. Even as, some benefits from single modality interventions have been demonstrated, a combine approach of exercise appears to be more beneficial. However, what is lacking with the above studies is the motivation of patients to comply with the program. The patient’s beliefs, values, and judgments affect his or her perception of treatment. According to Pell, poor uptake rates relate mainly to either service or patient factors. Service factors such as availability and accessibility of the programme and patients perception of the strength of a physician recommendation to attend (1996). There are findings that confirm that adherence to the national guidelines is poor and that few physicians play an active part in rehabilitation programmes. There is little in the way of assessment (a prerequisite for a “menu driven” service) or audit; this is especially worrying as secondary prevention is an important goal of rehabilitation.
This research study aims to contribute optimal method of delivering the service. In particular, it is important to compare patient’s rate of speed before and after the duration of the program. In must be also noted the optimal mix of the components and the frequency of the programme. The view to be further tested is the need to maintain improvements in lifestyle and the problems with the continuing compliance, the importance of long-term maintenance of the patient in doing the said rehabilitation programme, regardless of gender. Proper selection of patients is of paramount importance before beginning phase exercise programs. Patients with certain characteristics are at a higher risk, and therefore, require all attempts at correction of the high-risk condition prior to exercise training.
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