The WHO definition of cardiac rehabilitation from 19681refers to a “process by which a person is restored to an optimal physical, medical, psy- chological, social, emotional, sexual, vocational and economic status.” Over the ensuing years this statement of intent has remained remarkably similar. The World Health Organization’s current definition addresses the cardiovascular status of the patient before, during, and after the event:
The rehabilitation of cardiac patients is the sum of activities required to influence favourably the underly- ing 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 society. Rehabilitation cannot be regarded as an isolated form of therapy but must be integrated within the entire treatment.2
Current cardiac rehabilitation programs strive to involve the patient’s family in the whole process, thereby deploying health promotion intervention in a wider section of the community.
Objectives of cardiac rehabilitation include:
• a significant improvement in the patient’s func- tional capacity
• psychological adaptations to the chronic disease process
• a foundation for long-term behavior and lifestyle changes to favorably influence the long- term prognosis
• maintenance of an independent lifestyle for as long as possible.
This was not always the case. Initially, the emphasis was put on physical training as the
mainstay of cardiac rehabilitation, primarily with the intent of improving symptoms and physical capacity.
Physical conditioning in reference to heart disease is actually far from new. Fully 200 years ago Heberden observed the beneficial effects in a patient he advised to saw wood for 30 minutes daily over a 6-month period. Although that was long before the first mention of acute myocardial infarction in the medical literature, no doubt some of Heberden’s patients had sustained an infarct as the condition is understood today.
The first person to introduce exercise systemat- ically into the therapy of cardiovascular disease was M. Oertel in 1875.3 He successfully treated a patient with overweight and shortness of breath with an increasing number of steps in a hilly terrain, the “Terrain-Kur,” which became popular in the ensuing years. Later he used an arm ergometer for this purpose. As early as 1875, Stokes recommended physical activity for the treatment of angina pectoris. This counsel was all but forgotten following Herrick’s original clinical description of acute myocardial infarction in 1912: the worry that physical exertion heightens the risk of ventricular aneurysm or rupture, or aggravates myocardial ischemia, kept patients vir- tually immobilized in bed for 6 or 8 weeks. On dis- charge, anything as strenuous as stair-climbing was forbidden for at least a year. A few patients returned to work many months after hospital dis- charge; for most, all chance of a normal life was past.
Credit is due to Samuel Levine for questioning the wisdom of enforced bedrest and inactivity for
1
From Exercise Training to Comprehensive Cardiac Rehabilitation
Peter Mathes
3
a prolonged period following the onset of infarction; his “armchair” method, recommended largely on an empiric basis to avoid thromboem- bolic or respiratory complications, has since been well supported and extended on both a clinical and research basis. When Leonard Goldwater and colleagues assessed their experience at the first cardiac work classification clinic in the US in the 1940s, it came as a surprise to many that fully 50–70% of patients could return to work, although not necessarily to the same job as before.
The first inpatient progressive physical activity program for patients with acute myocardial infarction was described by Newman et al. in 1952.4 Physical activity began during the second week of hospitalization and gradually increased until discharge at 6 weeks. During the 1950s, a concept of utilization of residual functional capacity and an occupational classification by energy expenditure was popular.5 Later in the decade, detailed physical activity programs for inpatients were formalized. This was promoted by Wilhelm Raab and P.D. White in the US, Beck- mann and Knipping in Germany, and Gottheiner in Israel.6 Beckmann started the first systematic inpatient training program for the prevention of cardiovascular disease.
In the 1960s, with the proliferation of coronary care units involving continuous electrocardio- graphic (ECG) monitoring, progressively earlier mobilization after acute myocardial infarction was practiced. It was realized that the belief that there would be measurable physical invalidism after a coronary event was largely unfounded.
Many patients with healed myocardial infarctions were found to have exercise capacities that were equal to those of presumably healthy, sedentary middle-aged men. Rehabilitation was dominated by exercise training and included some vocational readjustment. It was recognized that such mea- sures resulted in an earlier return to normal activ- ities as a result of improvements in both physical and psychological capabilities.7 Early mobiliza- tion helped reduce the fear of disability, although a restrictive attitude still hampered patient progress.8
During the 1970s, the multidimensional aspects of cardiac rehabilitation were acknowledged, and the team approach became popular.9Established methods were developed, which resulted in a
proliferation of hospital-based inpatient and outpatient programs.8 Guidelines for cardiac exercise programs were established by the American College of Sports Medicine10 and the American Heart Association.11During the 1970s, public awareness of the individual’s potential role in his or her own health destiny grew.
Rehabilitation and secondary prevention gained widespread support as an integral component of comprehensive coronary care.
Developments in Rehabilitation Care
Enormous changes in the rehabilitative approach to the care of patients with cardiovascular disease have occurred since the WHO Expert Committee on the Rehabilitation of Patients with Cardiovas- cular Disease was organized by WHO in 1963. At that time, rehabilitation was concerned predomi- nantly with individuals recovering from acute, essentially uncomplicated, myocardial infarction;
the rehabilitative interventions recommended for such patients were considered to encompass “the sum of activities required to ensure them the best possible physical, mental and social conditions so that they may, by their own efforts, resume and maintain as normal a place as possible in the community.” Now, however, rehabilitation is con- sidered to be an essential part of the care that should be available to all cardiac patients. Its goals are to improve functional capacity, alleviate or lessen activity-related symptoms, reduce unwar- ranted invalidism, and enable the cardiac patient to return to a useful and personally satisfying role in society.
Cardiovascular disease is the number one medical problem in the Western world. It is becoming an increasing problem in developing countries; rheumatic heart disease, hypertension, and cardiomyopathy are already prevalent, and coronary heart disease is assuming growing significance. Despite differences in patterns of cardiac disease between and within developing countries, current concepts of cardiac rehabilita- tive care can be applied even in societies with minimal medical personnel and equipment resources. Guidelines are essential for their appli- cation. Rehabilitative care should be incorporated into the existing healthcare system, and should
conform to cultural traditions and social norms.
Guidance is also needed on maintenance of cardiovascular health, particularly for societies undergoing social transition, with consequent changes in culture, foods, lifestyle, and economics.
Demographic factors have had a radical influence on the range of cardiac patients consid- ered eligible for exercise therapy during rehabili- tation. Among patients with coronary heart disease, it is not only those who have recovered from uncomplicated myocardial infarctions, but also patients with complications of the acute episode, those with angina pectoris of varying severity, and those who have undergone coronary artery bypass surgery and coronary angioplasty who are now considered candidates for rehabilita- tive care. The spectrum of coronary disease is extensive. At one end are the patients treated by acute myocardial reperfusion with coronary thrombolysis and/or early coronary angioplasty or coronary bypass surgery, who exhibit a lesser severity of disease, minimal residual symptoms, little functional impairment, and a characteristi- cally excellent prognosis. At the other end are patients who, having survived several acute infarc- tions and surgical procedures, often have severe end-stage coronary heart disease characterized by varying combinations of myocardial ischemia, ventricular dysfunction, and ventricular arrhyth- mias. For all these patients, one of the most significant advances has been the emergence of a variety of test procedures designed to identify both the risk of early recurrent coronary events and the long-term prognosis. These assessments are typically exercise-based, and are designed to distinguish patients who can perform reasonable levels of activity without adverse consequences (low-risk patients) from those with a very limited exercise capacity in whom there is early onset of myocardial ischemia, ventricular dysfunction, or serious arrhythmias. An intermediate-risk group can also be identified. This delineation can serve as a basis for recommending not only medical and surgical therapies but also exercise (including the need for and intensity and duration of professional supervision of exercise). It can also serve as a guide to the resumption of work and other pre-illness activities.12–14
At the extremes of the coronary risk profile, computation of morbidity and mortality is
unlikely to be a sensitive measure of the outcome of rehabilitative or other interventions. For very low-risk coronary patients, the morbidity and mortality are so low, at least in the short term, that any intervention is unlikely to affect the outcome.
On the other hand, the outlook in end-stage coronary disease is so uniformly poor that other measures are required to ascertain the benefits of any intervention. Prominent among these are likely to be quality of life measures, which are related to an individual patient’s perception of improvements in physical, social, and emotional status, and the value he or she places on such improvements.15,16
Other categories of patients now considered candidates for rehabilitation include those who have undergone cardiac valvular surgery, those (both adults and children) who have undergone surgical correction or amelioration of con- genital heart disease, those with cardiomyopathy and ventricular dysfunction of other etiology, those with implanted cardiac pacemakers and cardioverter-defibrillators, and individuals who are recovering form cardiac or cardiopulmonary transplantation.12,17
These categories include large numbers of elderly cardiac patients. In both developed and developing countries, the numbers of “frail elderly” – the oldest members of society – are increasing more rapidly than any other popula- tion group. For many elderly patients with car- diovascular disease, return to remunerative work is often not an appropriate outcome measure of rehabilitation: rather, the attainment and mainte- nance of an independent lifestyle is an outcome that is valued both personally and, given the high cost of institutional care, by society. Thus, small improvements in capacity for physical work may exert a major and favorable impact on the quality of life of elderly cardiac patients.14,18
Current Concepts
In addition to the more favorable functional status and prognosis in a variety of cardiovascular illnesses, which reflect improved medical and surgical therapies, changes in a number of aspects of rehabilitative care per se have substantially influenced its application.
First, there is evidence that patients classified by stratification procedures as being at low risk can safely exercise without medical supervision and safely and promptly return to pre-illness activities, including remunerative work. Further, it is now accepted that exercise training of lower intensity can produce improvements in functional capacity comparable to those produced by higher-intensity exercise. The lower-intensity exercise is character- ized by greater safety, which is particularly impor- tant if exercise sessions are unsupervised; it causes less discomfort and is more enjoyable, and thus makes adherence to the recommended exercise regime more likely. Among patients who can safely perform modest levels of dynamic exercise, the relative safety and substantial value of low- intensity isometric or resistive (strength training) exercise have also been identified.26That patients receiving all types of antianginal drugs can benefit from exercise training has been extensively docu- mented. Cardiac enlargement and compensated heart failure are no longer considered contraindi- cations to physical activity, and rehabilitation has improved functional status. Another important observation is the lack of correlation between the extent of ventricular dysfunction and physical work capacity.19–21
Greater attention is now being devoted to the educational and counseling components of reha- bilitative care, with new techniques being applied in these areas as well. Prominent among these is the behavioral approach to reducing coronary risk; this comprises not only transmission of information, but also practical training in the skills needed for adoption of a healthy lifestyle, and provision of opportunity to practice and rein- force these skills. To achieve successful lifestyle changes, patients must actively participate in the management of their disease. Evidence that favor- able modification of coronary risk factors can not only limit progression of the disease but even induce regression of the underlying atherosclero- sis has encouraged efforts of this area. This is par- ticularly true for individuals with accelerated atherosclerosis, manifest as myocardial infarction or a requirement for myocardial revascularization procedures. The importance of the family – and often the workplace – in encouraging and rein- forcing efforts to reduce coronary risk is increas- ingly acknowledged. It is thus essential that
healthcare professionals at all levels are trained to be effective teachers to their patients.15,22
Perception of health status is recognized as having an influence on clinical outcomes; for example, the perceived ability to exercise corre- lates better with resumption of work than do objective measurements of exercise capacity during formal testing. There is also substantial correlation between perception of health status and return to usual family and community activ- ities, and recreational and occupational pursuits.
Importantly, this perception can be favorably altered by education and counseling.23,24
Psychological problems, predominantly anxiety and depression, are recognized as greater obsta- cles to the resumption of pre-illness activities by coronary patients than physical incapacity. Return to work is increasingly viewed as an outcome measure that is economically, physically, and socially relevant to a wide variety of coronary patients, but one that may relate poorly to restora- tion of functional capacity. Total restoration of functional status, occupational as well as physical, remains a challenge to be met.
Practice Worldwide
Different programs and approaches have been developed in different areas of the world, all aiming at a similar outcome, utilizing a variety of different ways.
The Anglo-Saxon countries have largely pre- ferred a primarily ambulatory approach, favoring long-term exercise-based rehabilitation pro- grams, to which educational, psychological, and social components are being added in a stepwise fashion (R. Mulcahy16).
Countries with a long-standing spa tradition such as Germany, Austria, some eastern European countries and some of the southern European countries including Italy have adopted an inpa- tient, residential rehabilitation center approach, with a rather short duration (up to 4 weeks), con- sisting of intense, gradually increasing exercise programs, where educational, psychological and social components are begun during the very first days of the program.
In Germany, the initial, primarily exercise oriented-rehabilitation programs were begun
by Oertel,3 followed by Peter Beckmann.6 Patients were put together in groups of similar physical fitness, and the goal to be achieved was to make a proper mountain climbing tour at the end of this rehabilitation period. Koenig and Halhuber added psychological counseling and social support as essential components.16 In the days of a booming economy with the ever-present need for a large workforce, such rehabilitation centers proliferated within Germany and neighboring countries. Now that the economy is lagging, the number of centers is declining, being replaced in a less comprehensive way by ambulatory programs.16,25
Rehabilitative interventions are increasingly undertaken in children and young adults with a variety of cardiovascular disorders. The growing quantity of information about appropriate interventions in these age groups warrants wider dissemination. Medical and surgical treatments have significantly improved life expectancy in children with cardiovascular disease; subsequent comprehensive rehabilitation will thus have long-term economic and social benefits.25 Surgical treatment is available for over 95% of congenital cardiac lesions, yet post- operative results after successful surgery show that these children fail to achieve the same func- tional capacity as their healthy peers. Children with cardiac disease require significantly dif- ferent physical activities from adults, and the educational and counseling requirements for both the children and their families are also different. Comprehensive cardiac rehabilitation for children is cost-effective and prudent, benefiting individual patients and the society in which they live. Moreover, a large percentage of cardiac patients in developing countries are chil- dren and adolescents. Specific attention should therefore be directed to disseminating rehabilita- tive guidelines and promulgating the implemen- tation of appropriate programs for this section of the population.
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