Holistic rehab programs address medical, physical, lifestyle and emotional needs.
In the past, cardiac rehabilitation was an exercise program for young, active heart attack survivors. However, today's cardiac rehabilitation programs benefit people of all ages and with many forms of disease.
The programs, which often take place at a hospital with a rehabilitation team, encompass a holistic approach that includes medical evaluation, physical activity, lifestyle education, and psychosocial support.
"As cardiac rehabilitation programs have grown, the most important change has been to look at the full spectrum of their heart problem, including what led to it," explains Kate Traynor, RN, MS who directs the Cardiovascular Disease Prevention Center at the Massachusetts General Hospital in Boston, a Harvard Medical School teaching hospital.
As such, patients learn to modify all of their heart disease risk factors, which may include high blood pressure, high cholesterol, smoking, obesity, or diabetes. Within that, they learn to eat healthfully, exercise safely, and to manage stress and depression.
In some centres, the mind/body connection is coming into sharper focus as well, with the addition of complementary therapies like yoga and meditation.
Helping patients understand the impact of their mood state on their actions is important, because depression and other factors can make it difficult to make the behavioural changes that can significantly lower their risk for recurrent heart attacks, cardiovascular complications, and sudden cardiac death. "Cardiac rehabilitation is not like an antibiotic that you take and then it's done - it's a lifestyle modification," says Traynor.
Physician-supervised cardiac rehabilitation is recommended for anyone who has congestive heart failure, coronary artery disease, peripheral artery disease, certain congenital heart diseases, cardiomyopathy, or cardiovascular disease, or who has recently suffered a heart attack, experienced angina (chest pain), or had coronary artery bypass surgery, valve repair or replacement, or angioplasty. Other candidates include patients with a pacemaker and heart transplant candidates or recipients.
Some patients are advised against undergoing cardiac rehabilitation, including those with severe residual angina, uncompensated heart failure, uncontrolled arrhythmias, severe ischemia, LV dysfunction, or arrhythmia during exercise testing.
Patients with poorly controlled hypertension or diabetes or ongoing fever, or who have hypertensive or any hypotensive systolic blood pressure response to exercise, are also contraindicated for the programs.
The programs can be especially helpful after a hospital discharge, as they allow patients to exercise with others and receive help making important changes in their daily living.
They have also been shown to safely improve exercise tolerance and psychosocial well-being. One study, published in the American Journal of Medicine in 2004, looked at nearly 50 trials and 9,000 patients and found that cardiac rehabilitation was associated with a lower risk of death (from any cause), lower cholesterol levels, and reduced triglyceride levels, as well as lower incidence of self-reported smoking.
Elderly patents that participate in cardiac rehabilitation programs may experience improved functional independence, prevent premature disability, and reduce the need for custodial care. Both the American Heart Association and American College of Cardiology recommend cardiac rehabilitation programs.
The phases of cardiac rehab
Cardiac rehabilitation services consist of three phases and periodic follow-up evaluations. The goal is to reduce the risk of a second heart attack, keep a patient's condition from worsening, and improve quality of life. The first phase begins while the patient is still in the hospital and the emphasis is on low-level exercise and education.
During this phase the cardiac rehabilitation team meets with the patient and family members to evaluate the patient's risk profile and habits, come up with an achievable plan, and provide education about heart disease and healthy lifestyle factors.
Members of the cardiac rehabilitation team may include a cardiac nurse, nurse educator, cardiologist, nutritionist, exercise specialists, physical therapists, occupational therapists, and social workers. Sometimes patient-volunteers share their experiences about living with heart disease as well.Massachusetts General Hospital offers patients two series of classes. A course on healthy eating teaches patients how to read food labels and choose heart-healthy foods from a restaurant menu, and provides advice on achieving and maintaining weight loss.
A series on heart disease explains the signs and symptoms of heart disease, medications, and exercise considerations, such as how to exercise safely, what footwear is best, and how to monitor oneself.
There are also three classes that teach stress management techniques, such as meditation, deep breathing, and yoga. "We try to expose them to a lot in the hopes that they'll find something they can use," Traynor says.
During the initial phase of cardiac rehabilitation, patients also begin doing assisted range-of-motion exercises. Low-risk patients may also start to sit up and perform personal hygiene activities, such as brushing their teeth and shaving.
Once out of critical care, patients begin to walk in their rooms and in the hallway. Discharge planning is begun, with an emphasis on risk factor modification and lifestyle changes.
Upon discharge, patients spend two to six weeks recovering at home. During this time, they do supervised low-level exercise and physical activity and learn about changes they need to make to their regular activities.
Team members continue to check the patient's medical status and recovery, and offer encouragement as the patient becomes stronger and healthier. The team also re-emphasizes risk reduction strategies.
The next phase of their cardiac rehabilitation program may last several months. During this phase, physician and cardiac rehabilitation staff members determine the appropriate level of exercise and the patient has exercise treatments three times a week at a rehabilitation facility.
The patient receives constant medical supervision, including exercise electrocardiograms (ECGs), as well as supervision by a nurse and exercise specialist. Dietitians, social workers, chaplains, pharmacists, physicians, and others may also be involved in the care, providing counseling and education about stress management, smoking cessation, nutrition, and weight loss.
The third phase of cardiac rehabilitation is a maintenance program. Patients continue to exercise three times a week, ideally engaging in the types of exercises they enjoy most, such as walking, bicycling, or jogging.
Medical supervision is often not necessary, and patients can take their classes in community gyms and other fitness facilities. This phase is designed to promote heart-healthy habits that last a lifetime.
Success in cardiac rehabilitation is not only beneficial to patients, but can be enormously satisfying to members of the health care team, concludes Traynor.
"It is gratifying to see people who come in frightened after being diagnosed with heart disease leave the program feeling so much better about themselves."
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