W8: Cardia Rehab Flashcards
What is cardiac rehabilitation? Why is this exercise useful?
Cardiac rehab is a coordination of several activities required to influence favorably the underlying cause of cardiovascular disease as well as provide improvements to the physical, mental and social conditions of the patient. The programme will attempt to get patients to resume optimal functioning in their community through improved health behaviour, to slow or reverse the progression of the disease.
Exercise if useful as clinical outcomes such as reduced depression and anxiety, increased physical capacity and QoL are observed. There are also a reduced healthcares usage. (Lewin et al., 1992; Dallal et al., 2007; taylor, 2007; Jolly, 2007, 2009; Henwood & Barnes, 2008)
What’s the evidence base behind cardiac rehab?
Evidence shows that following the Heart Manual programme produces beneficial effects such as reduced anxiety and depression, physical capacity and QoL. There was also a. decrease in healthcare admission, and outcomes are similar to a hospital based clinical practitioner.
THe good to knows:
Physiological: cholesterol, cardiac symptoms, Blood Pressure,
psychological: anxiety, depression, exercise, QoL, health perception
Social: knowledge, cost-effectiveness, hospital re-admission, GP visits, self-reported behaviour, programme adherence, smoking (Lewin et al., 1993; Dalal et al, 2007; Taylor et al., 2007; Jolly 2007, 2009; Henwood & Barnes, 2008)
What are the 6 core components for cardiovascular disease prevention and rehab
- Health behaviour change and rehabilitation
- Change in lifestyle risk management includes smoking cessation, physical activity and, diet
- psychosocial health
- Medical risk management
- Long term management
- Audit and evaluation
What are the programme components. for the heart manual?
The workbook, audio, training, and facilitation
What are the factors that might affect a person’s rehabilitation?
Age, gender, education levels, social influence, perceived beliefs (even cultural), physical environment (accessibility), co-existing physical illness, social deprivation, past family history lifestyle, media
What are the principles of building an intervention in the heart manual
A particular focus on individualism, quality. life and reducing psychosocial morbidity
Informed consent
early intervention
Personalised advice
intervention for patient and family
patients self-monitoring
pacing approach
pro-active follow-ups
What are the 5-steps of success in the heart manual
- Building a rapport
- thinking about the CHDs
- Understanding the risk factors
- Setting a goal
- Sum it up
Why might you need to change a patients beliefs about health in CHD, what might be the misconceptions? Where do they come from? and how would you intervene to change such beliefs. What are some concepts behind why a patient would construct such beliefs? How might you attempt to train the patient in coping and what sort of questions would you ask to help challenge the negative self-talk?
Patients beliefs are likely to change the symptoms and effectiveness of the rehabilitation programmer (Lewin, 1997). Beliefs about surgery also influenced the recovery process. (Juergens et al., 2010). It is also possible to change the functional outcome by changing health beliefs of MI patients (Petrie et al., 2002; Broadbent et al., 2009).
Some cardia misconceptions could be things such as “my chest pain must mean my heart is weakening”, or “stress at work caused this” etc.
These cardiac misconceptions can come from various areas such as a patients misinterpretation of what the doctor says or cardiac misconceptions from unqualified health workers (Angus et al., 2011). Some other areas may be from misinformed family members or peers.
In order to change beliefs it is important not to directly challenge their beliefs. Use socratic questions that lead patients to a different conclusion. It is also crucial to pick up on subtle comments as patients may not be aware of their misconceptions.
One explanation of the misguided beliefs could be through the Cognitive Behavioural Theory. This theory presents that ones beliefs are constructed through the interaction of thoughts, behaviours, emotions and physiology which are all influenced by environment. In order to reroute the person’s beliefs it is important to tackle these aspects with a focus on behaviour and thoughts (Beck, 1976). Some factor that could cause a patient to become anxious are CAD diagnosis, unfamiliar environment, confined areas, sex, starting exercise, chest sensations, being in hospital settings and returning to the situation of shock, and returning to activites such as work, marital strain/arguments.
There also exists a self-regulation theory in which helps us understand how patients perceives the illness. This can be split into two processes which are the cognitive and emotion. The cognitive illness representation from the understanding about the illness itself from education or their experience, and the emotional response is triggered from the illness representation. These two processes construct a coping behaviour within the patient (Levanthal, 1997).
Some strategies to cope against misconceptions are taking a deep breath, distracting strategies, planning for activities, relaxation, positive self-talk, challenging dysfunctional thoughts, and problem solving. Some questions that may be asked when the patient is having negative thoughts are “why do you think so?”, “What is the evidence?”, “what alternative views are t here?” , “Is my thinking distorted?”, and “what actions could I take?” I could also use a technique where I provide the patient with a negative self-talk diary to heighten the patients awareness of their thought process.
What is motivational interviewing and what might be the process of it? How would you assess a patients readiness for change? What kind of goals would you set
Motivational Interviewing is a clinical style of eliciting from patients their own good motivations for behavioural change for health. The 4 processes may be to first ask for permission, then elicit information from the participants by understanding the patients knowledge, and current daily behaviours. Then providing the patient with advice through an indirect way saying “What we tend to advice…” or “We recommend” etc.. Then finally summarise what you have talked on the day. Some skills for motivational interviewing is the used of OARS which are acronyms of Open ended - Always ask in an open ended way for patients to elaborate themselves, Affirmation -understand the patients efforts, Listen & reflect, and summarise.
Some methods used to assess readiness for change are measuring the patients confidence and how important they think the change is on a 10 point scale.
In being ready to make the changes it is important to create SMART goals. This being Specific, Measurable, Achievable, Realistic and Timely goals. It also becomes very important to pace the patient with gradual steps rather than starting of at high difficulties. In making sure that the patient is coherent and on the right track, patients should be able to create their own baselines and track progress perhaps using a goal setting chart in which each activity is recorded and the perceived difficulty of the task is rated every day.
What is the evidence behind exercise rehabilitation effects on cardiovascular diseases such as heart failure and coronary heart disease? Whats the suggested mechanism behind the improvements.
Some review articles suggest that exercise can actually reduce hospital re-admission rate, increase fitness and health-related QoL, and some mixed evidence behind all-caused mortality with one study suggesting there are improvements (Taylor et al., 2014) and one stating no change (Anderson et al., 2016).
Some of the suggested mechanism behind the cardiovascular changes are the decrease in heart rate, blood pressure, and blood clotting as well as the increased myocardial workload and an increase transport and uptake of oxygen, increase in glucose control, lean mass, and lipid control are understood to be the derived benefits. In addition, greater fitness levels, msucular strength, ability to perform daily activities of living, and a decreased rate of depression and anxiety are understood to be possible adaptations (Wise, 2010).
What is the typical flow of a cardiovascular rehabilitation assessment programme?
Firstly, pre-participation screening must take place in order to reduce risks of adverse events. Understanding the cardiovascular diseases that the patient has gone through and the possible risk factors must be taken into consideration at this stage. Then moving onto the baseline assessment phase, patients baseline values for BP, HR etc. must be taken into consideration. As well as the physiological considerations, baseline fitness levels must be assessed in order to be able to compare them in the future and also construct a training programme individualise to the patient. At this early-assessment phase, it is also important to discuss the patients preferences, provide options and prescribe exercise.
After these steps the actual programme would commence where strength training, aerobic training, and balance. training would take place at a span of around 8-12 weeks. These could take place at home or in a centre depending on the patients preference. Essentially at the end of the 8-12 weeks the patient will be reassessed and compare values to the baseline to see which areas have improved. At the re-evaluation stage it is important to advise patients to maintain the habitual training and exercise. There could also be referral to leisure services for ongoing engagement.
To further elaborate on what takes place in each stage, I will discuss the 3 stages in more detail. Firstly, in the early assessment phase the most important task to complete is screening the participants. At this phase performing tasks such as the ECHO, ECG or the exercise tolerance test, Cardiac MRI, diagnostic angiogram, and the thallium scan can be used. In these tests, some of the contraindications that must be considered are uncontrolled diabetes or high blood pressure, acute systemic illness, recent onset of a blood clog, Acute myocarditis , severe rejection, severely low or high HR, significant ischemia on resting ECG, significant low blood pressure with symptoms in changing positions, acute. inflammation of the veins. In these. cases, unless agreed with medical staff, should not be engaged in the rehabilitation programme. Furthermore to assess baseline values, physiotherapists and nurses must provide relevant medication and compliance from the patients, have a full cardiovascular risk profile of the patient and an understanding of other ongoing co-morbidities.
In assessing the patients preferences, the patients understandings and readiness must be assessed with health behaviour change interventions implemented when requires. These could include motivational interviews, creating SMART goals, evaluating the barriers, interests, self-confidence, and social support, relapsing prevention strategies and maintaining long-term physical activity, and providing informed choices regarding physical activity options.
With regards to understanding signs and symptoms of the patient, some symptoms to look out for are dizziness, angina, palpitations, shortness of breathing, fatigue, heart pain, increased heart rate, ankle swelling, weight increase of >2kg in 2-3 days and fluid in abdomen.
Some of the physical assessments that could be done are measuring heart rate, blood pressure, weight, and BMI.
At times glucose levels and oxygen levels could be measured as well.
In the assessment phase, performing a functional capacity test may be useful. These can be used to get patients to become familiar with RPE’s, to see the individual’s response to exercise, and to get a baseline measure of the patient. Some functional capacity tests that could be conducted are incremental shuttle walk test, the 6 minute walk test, and the Chester step test.
In providing the options for participants there are 2 main exercise programs that could be provided, One is the home-based exercise and the other is the centre-based exercise which include 1-2 times per week of a duration of 60 minutes. Evidence have shown that there are a few differences between the two exercise programs where home-based exercise program actually lead to a decrease in mortality, clinical events, CHD risk factors, and cost, and an increase in health-related QoL (Taylor et al., 2015). Furthermore, home-based exercise revealed a greater adherence compared to the centre-based. In conducting a home-based exercise programme, practitioners must make sure to demonstrate the correct technique, provide an RPE and heart rate monitor, remind patients to warm-up and cool down, and educate patients on the normal exercise response and over-exertional responses.
In a typical structure exercise programme, the time will be split into warm-up, conditioning, and cool down. These would typically be split into 15, 35, 10 minutes respectively. Exercises should be conducted at a intensity level of 40-70% of HRmax and at 11-14 rating of the RPE scale. Practitioners must make sure to keep track of the HR before, during and after the program, the RPE during the program, and the BP, Blood pressure and oxygen levels as required.
