Clinical practice guidelines for physical therapy in cardiac rehabilitation

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1 Clinical practice guidelines for physical therapy in cardiac rehabilitation EMHM Vogels, I RJJ Bertram, II JJJ Graus, III HJM Hendriks, IV R van Hulst, V HJ Hulzebos, VI H Koers, VII T Jongert, VIII F Nusman, IX RHJ Peters, X B Smit, XI S van der Voort. XII Introduction These clinical guidelines describe the application of physical therapy in cardiac rehabilitation. They were developed by the Royal Dutch Society for Physical Therapy (KNGF) and follow up the Cardiac Rehabilitation Guidelines 1995/1996 produced by the Dutch Cardiology Association and the Dutch Heart Foundation. In essence, the guidelines provide a summary of the information contained in the second section of this document, entitled Review of the evidence, in which the choices made in deriving guideline recommendations are presented separately. The guidelines and the review of the evidence can be read individually. An explanation of the abbreviations used and the definitions of some important terms and concepts are given in an appended list of abbreviations and definitions and a glossary. These KNGF guidelines on physical therapy in cardiac rehabilitation are for the use of physical therapists who work with cardiac patients in rehabilitation phases I and II. The (Dutch) physical therapists involved will have also knowledge of the multidisciplinary Cardiac Rehabilitation Guidelines 1995/1996 and of a supplementary publication entitled Physical therapy in cardiac rehabilitation. Considerations of treatment quality in cardiac rehabilitation are discussed below in the review of the evidence. Cardiac rehabilitation phases: Phase I: during hospital admission; Phase II: in the polyclinic rehabilitation setting (both clinical and polyclinic patients); Phase III: post-rehabilitation and aftercare phases. These clinical guidelines describe the goals of treatment and the end criteria in phase I and the diagnostic and therapeutic processes in phase II. Aftercare, which comprises phase III, is not covered by the guidelines. Defining cardiac rehabilitation These KNGF clinical guidelines have been devised for the implementation of physical therapy in patients who have had an (acute) myocardial infarction, or who have undergone a coronary artery bypass operation, percutaneous transluminal coronary angioplasty, a heart valve operation, or operative correction of a congenital heart disorder. I II III IV V VI VII VIII IX X XI XII Lisette Vogels, MSc, physical therapist / social scientist, Department of Research and Development, Dutch Institute of Allied Health Professions, Amersfoort, The Netherlands Rob Bertram, physical therapist, rehabilitation center Beatrixoord, Haren, The Netherlands Jean Graus, physical therapist, rehabilitation center Hoensbroek, The Netherlands Erik Hendriks, PhD, physical therapist / clinical epidemiologist and guidelines coordinator, Department of Research and Development, Dutch Institute of Allied Health Professions, Amersfoort, The Netherlands Rob van Hulst, physical therapist, Deventer Hospital, Deventer, The Netherlands Erik Hulzebos, MSc, physical therapist / human movement scientist, University Medical Center Utrecht, Utrecht, The Netherlands Hessel Koers, physical therapist / manual therapist, Groene Hart Hospital, Gouda, The Netherlands Tinus Jongert, MSc, exercise physiologist, TNO-PG, Leiden, The Netherlands Frank Nusman, physical therapist, Isala Klinieken, Zwolle, The Netherlands Roelof Peters, physical therapist, Sint Antonius Hospital, Nieuwegein, The Netherlands Bart Smit, physical therapist, Sint Lucas Andreas Hospital, Amsterdam, The Netherlands Simon van der Voort, physical therapist, Zonnestraal, Hilversum, The Netherlands 1

2 Table 1. Goals of therapy, end criteria and methods of evaluation applicable during the acute and mobilization phases of rehabilitation phase I. Acute phase Physical therapy goals End criteria Evaluation method Surgical treatment: Physical therapy: Monitoring mucus clearance Provide preoperative No objectively observed and ventilation pulmonary guidance; pulmonary problems. Monitor mucus clearance, ventilation and treatment Medical: (if necessary). Post-operative treatment: No excess mucus retention Non-surgical treatment: and no atelectasis; Monitor mucus clearance, Patient is hemodynamically ventilation and treatment stable; (if necessary). No severe rhythm disorders or conduction abnormalities. Non-surgical treatment: Patient is hemodynamically stable; Enzyme levels decreasing; No severe rhythm disorders or conduction abnormalities. Mobilization phase Physical therapy goals End criteria Evaluation method Surgical treatment and Physical therapy: History-taking 2 ; non-surgical treatment: Patient can function at the Risk factor checklist; Ensure patient can function intended level of activities of Objective determination of the at the intended level of daily living; patient s level of activities activities of daily living; Patient has moderate aerobic of daily living by evaluating Ensure patient has sufficient capacity ( 3 MET s 1 ); activities. information to start Patient has knowledge about phase II or to proceed heart disease and surgery and independently, which means can cope adequately with that the patient: the information; - can cope sensibly with Patient has knowledge the heart disease; of risk factors; - has knowledge about Patient can cope adequately the disease s nature, with symptoms. surgery and risk factors; and - can react adequately to any symptoms that might occur. 1 1 Metabolic Task Equivalent (MET s) = 3.5 ml of oxygen per kg per minute. Supplement 3 to the review of the evidence gives the metabolic equivalence (i.e., MET s values) of different activities. 2 Preferably using a structured questionnaire. 2

3 Risk factors and prognostic factors Coronary heart disease risk factors can be split into two groups: influenceable and non- influenceable risk factors. Influenceable factors include smoking, lipid imbalance (e.g., hypercholesterolemia and hyperlipidemia), hypertension, obesity, physical inactivity and diabetes mellitus. Non-influenceable factors include hereditary tendencies, age and sex. Prognostic factors that influence recovery after acute myocardial infarction include the residual function of the left ventricle and the size and location of the infarct. The patient s psychological condition, including factors such as exhaustion, fear and depression, and the presence of any co-morbid conditions, such as physical limitations or a cerebrovascular accident, can have a negative influence on recovery. applicable methods of evaluation in these two subphases are presented in Table 1. Rehabilitation phase II Before beginning rehabilitation in the polyclinic (i.e., rehabilitation phase II), all patients are screened by the rehabilitation team after physician referral. The referral documentation must include, as a minimum, the information listed in Table 2. The rehabilitation team consists, at a minimum, of a physician, a physical therapist, a social worker and a nurse. The physician in the team, who is usually a cardiologist, has the final responsibility for treatment. The exercise capacity of the patient are estimated by a cardiologist and are classified as either low, medium or high. Secondary or tertiary prevention Preventing the progression of coronary heart disease depends on modifying the above-mentioned risk factors. These risk factors include bio-psychosocial factors, which can limit adaptive potential and can, therefore, influence balance and ability to increase load capacity (see Glossary). Rehabilitation phase I Activities associated with cardiac rehabilitation during hospital admission take place in two parts: the acute phase and the mobilization phase. These phases occur after treatment, whether an operation was involved or whether treatment was conservative. The goals of physical therapy, the end criteria used for assessing the achievement of these goals, and the It is recommended that rehabilitation screening is carried out before, or shortly after, hospital discharge. Patients are screened by the rehabilitation team on the basis of questions posed in five areas of enquiry relating to the patient s physical, psychological and social functioning and to the presence of influenceable risky behavior (see Table 3). Physical therapy diagnosis forms part of the screening. Answers to questions in the five areas of enquiry are obtained by using objective measuring instruments, by clinical observation, and from the patient s testimony, which is supplemented by the use of a self-administered questionnaire, if necessary. The symptom-limited exercise test (ergometric) is an objective measuring instrument that can be used to Table 2. Minimum referral information given by the physician to the rehabilitation team. Medical diagnosis; Relevant cardiac information, as decided by the physician, including details of: - hemodynamic stability; - the location and extent of the infarction and the extent of any left ventricular dysfunction; - exercise testing results including ECG findings (e.g., the presence of ischemia); and - heart rhythm disorders or conduction abnormalities. Co-morbid conditions; Risk factors; Medicine use; and The cardiologist s estimate of exercise capacity (i.e., low, medium or high1) and prognosis. 1 For more information, see Table 11 in the review of the evidence. 3

4 Table 3. Questions in the five areas of enquiry used in rehabilitation screening, taken from the Cardiac Rehabilitation Guidelines 1995/1996: I. Has physical aerobic capacity been reduced objectively, in terms of the patient s ability to work and carry out domestic and leisure activities? Are there any motor limitations that restrict the patient s functional abilities? II. Has physical aerobic capacity been reduced subjectively because of anxiety about aerobic capacity (including sexual capabilities) or because the patient feels very handicapped? III. Is there a problem with emotional balance? Does the patient deal with the sickness in a dysfunctional manner? In other words: What is the difference between the patient s present and optimal psychological functioning? IV. Is there a problem with social functioning? What is the prognosis for the patient s return to a normal social role in relation to work, leisure and family relationships? What is the quality and extent of the patient s social network? V. Are there any influenceable risky behaviors, involving, for example, smoking, diet (e.g., leading to obesity or lipid disorders), physical inactivity, or non-compliance with therapy? provide answers to the questions posed in area I above. Physical, psychological and social functioning, covered in areas II, III and IV, can be determined objectively using screening questionnaires, which are currently being developed. Some of these questionnaires can be used for rehabilitation screening as well as for evaluating treatment. A risk factor checklist can be used to determine risk factors objectively and to relate them to the patient s lifestyle, to help answer questions in area V. Diagnosis The objectives of the physical therapy diagnostic process are to investigate the severity and nature of the health problem in relation to functional movement and to identify any influenceable prognostic factors. Of central importance are the patient s concerns and goals. The physical therapist will assess the patient s health status and identify the most important disorders, the desired health condition, any existing influenceable and noninfluenceable risk factors, and the patient s need for information. The diagnostic process makes use of the referral, history-taking, assessment, analysis and the formulation of a treatment plan. The recommended measuring instruments are described and explained in Supplement 2 to the review of the evidence. History-taking In history-taking, information is obtained partly by the rehabilitation team, and includes referral data from the cardiologist, and partly from the patient himself or herself. History-taking involves: recording the patient s concerns and goals, including his or her desired level of activity; assessing the patient s level of activity before the present health situation developed; assessing the overall health situation, including taking details of: - the nature and severity of any impairments, disabilities and problems with social participation; - the start and course of the condition; - any factors that led to the condition (e.g., poor circulation); - prognostic and risk factors; recording the present situation, including noting details of: - any current impairments, disabilities and problems with social participation associated with the heart disease; - present general health status, including information on functioning, and levels of activity and participation; - present treatment, including medications used and medical treatment received; - personal factors; - the patient s motivation; and - the patient s need for information. 4

5 The patient s most important complaints, including any activity problems, can be determined using a specially designed questionnaire, called the patientspecific complaint questionnaire, and a visual analogue scale for assessing activity level. The risk factor checklist should be used to identify risk factors. Assessment Functional human movement can be expressed in terms of physical load and aerobic capacity but is also affected by the presence of any functional impairments. Assessment involves observation, functional evaluation and, if necessary, palpation. Basically, assessment centers on determining the levels of functional impairment, activity limitation and problems with participation, all of which influence the choice of exercises used in the rehabilitation program. Activities may be limited in terms of their nature, duration or quality. In dealing with psychosocial functioning, the physical therapist adopts a signaling function. During activity evaluation, the physical therapist should pay attention to how the patient deals with the health problem. For example, does the patient have a fear of movement? The following measuring instruments or techniques can be used during assessment: the Borg scale, an ergometer, MET s units, the specific activity scale, the six-minute walking test, and the fear, angina pectoris and/or dyspnea scale. If indicated by the physician, heart rate and blood pressure can also be monitored. Analysis Analysis is based on assessment and evaluation. The physical therapist must obtain answers the following questions: 1. What is the patient s health status in terms of impairments, disabilities and participation problems? How much can the patient currently handle, physically, mentally and socially? 2. Are there physical problems that limit increases in the patient s physical, mental and social performance? These may be: - related to a cardiac disorder (e.g., myocardial infarction or chronic heart failure); or - related to other sicknesses or disorders, including other physical complaints. 3. Are there any other factors that have a negative influence on exercise capacity? For example: - fear, depression, mental handicap or sleep problems; - stress or exhaustion; - lifestyle, involving, for example, smoking, physical inactivity or eating problems; - medication use; or - social problems. 4. How does the patient envisage his or her future performance of daily activities, leisure activities, work and hobbies (i.e., the patient s goals and expectations)? 5. Is the desired level of performance attainable, according to the information obtained in answering questions 2 and 3? - can any negative factors be influenced? - if so, negative factors should be reduced or eliminated and exercise capacity increased; - if not, the situation should be optimized and the patient should learn to accept it. 6. Can physical therapy help ameliorate the health problem? In terms of: - reducing impairments; - reducing disabilities; - reducing participation problems; or - improving functions, activities and the level of participation. In addition to the above-mentioned problem areas, patients may experience other health problems that may or may not be related to heart disease. On occasion, additional physical therapy may be indicated. These problems are not covered by these guidelines. Treatment plan The rehabilitation team will decide if there are discrepancies between the patient s present condition and the desired level of functioning and determine whether there is an indication for further rehabilitation (see the flow chart in Figure 3 in the review of the evidence). The rehabilitation team, together with the patient, will formulate therapeutic goals with help from the answers given to questions in the five areas of enquiry used in rehabilitation screening, which were taken from the Cardiac Rehabilitation Guidelines 1995/1996. These goals are translated into an individual rehabilitation plan that 5

6 Table 4. Data held by the rehabilitation team that is relevant for physical therapy: The physician s diagnostic and prognostic referral data and information about the patient s exercise capacity (See Table 2 above); Individual aerobic capacity goals and reasons for any aerobic capacity limitations, such as fear or a dysfunctional way of coping with heart disease; Physical therapist s diagnosis. If necessary: information about work rehabilitation and prognosis; information on the patient s family. consists of a number of different modules. If necessary, these modules can be implemented with individual guidance. The rehabilitation team decides when the rehabilitation program will start and which module the patient should use first. The Cardiac Rehabilitation Guidelines 1995/1996 describe four modules: short and long exercise modules (FIT), an information module (INFO), and a psychoeducational preparation module (PEP). The KNGF guideline working group advises the addition of a fifth module, on relaxation instruction (RELAX). The information given in these guidelines is divided into exercise programs. Table 4 provides an overview of the data held by the rehabilitation team that is relevant to physical therapists. Patients who have to employ physical training to achieve their most important goal must undergo a symptom-limited aerobic capacity test using an ergometer to provide relevant information for therapy. The following are the six specific goals for physical therapy (the numbers in square brackets refer to the goals listed in the Cardiac Rehabilitation Guidelines 1995/1996): 1. Learning to find one s own physical limits [1]. The goal is to enable the patient to go about daily life and to manage at a physical level. By coming up against objective boundaries, the patient learns what his or her personal exercise capacity is and where his or her physical limits lie. 2. Learning to deal with physical limitations [2]. The goal is to confront the patient with his or her physical disabilities and to help him or her learn how to deal with different physical situations and types of movement. Acceptance is essential. It is important to encourage the patient s active involvement in discovering his or her level of physical capability. 3. Finding the optimum aerobic capacity level [3]. The goal is to enable the patient to reach a desired level of physical capability. Capabilities are improved up to a level at which the patient can function better in performing normal daily activities, work, sports and hobbies. 4. Diagnosis: evaluating aerobic capacity level and correlating symptoms with objective disorders [4]. The goal is to assess the patient s exercise capacity on a number of occasions. It is important to find correlations between symptoms and objective disorders, and to determine which disabilities the patient has problems with in daily life. The results of the diagnostic process provide an insight into the patient s exercise capacity and identify opportunities for increasing these capabilities. 5. Reducing fear of movement [5]. The goal is to enable the patient to experience movement, with the hope that, through experience, fear for movement will decrease. 6. Developing and attaining a physically active lifestyle [14]. The goal is to help the patient enjoy exercising. Providing guidance that enables the patient to be active at home will reduce the risk factors associated with an inactive lifestyle. The patient will learn to integrate exercises into his or her lifestyle. The idea is that the 6

7 patient will make exercise a normal daily activity and will, therefore, progress to rehabilitation phase III. The physical therapist can also have an influence on the achievement of other goals, such as achieving secondary prevention [12 16], acquiring emotional balance [6], and learning how to deal with heart disease in a functional manner [7]. Each patient usually has a combination of goals. If improving aerobic capacity is not indicated, then goal 1 or 2, or both, are recommended. If improving aerobic capacity is indicated, then goal 1 or 3, or both, are recommended. If there is a subjective decrease in aerobic capacity, treatment should focus on goal 1 or 5, or both. The problem areas covered by goals 1 and 5 are usually the initial focus of treatment. For example, the patient must first reduce the level of fear or learn what his or her personal limits are before being ready for training. If there is no clear objective reduction in aerobic capacity, then goal number 4 is recommended. It is important that patients are divided into groups with high, medium or low exercise capacity, as estimated by the cardiologist and rehabilitation team, before deciding on an exercise program. It is also important that the patient s motor capabilities and degree of motivation for carrying out activities are also taken into consideration. Patients who have little motivation need an exercise program in which the main exercises can be incorporated into normal daily activities. This is more enjoyable and ensures better functioning during exercise. individual rehabilitation schemas, which are drawn up by the rehabilitation team. If rehabilitation screening occurs shortly before hospital discharge, the patient can immediately enter rehabilitation phase II in the same hospital where screening was carried out. If rehabilitation screening is carried out and indications for therapy are determined at the end of rehabilitation phase I but the patient does not immediately progress to phase II (for example, because rehabilitation only starts four weeks after hospital discharge) or the patient is referred from another hospital, the physical therapist will repeat the diagnostic process before therapy starts. During the therapeutic process, the physical therapist will evaluate individual goals systematically (see description of evaluation given below). The therapeutic process is divided into the following areas for descriptive purposes: informing and advising, patient-orientated exercise program, and relaxation instruction. In cardiac rehabilitation, the patient s physical functioning is of central concern, not his or her sporting abilities. Informing and advising Providing information and advice, and supporting the patient are both part of physical therapy and fall under the general category of providing guidance. The patient s need for information, advice and coaching, which becomes apparent during diagnosis, forms the basis for the patient information plan. Consultation with practitioners of other disciplines is important. An exercise program may consist of exercises that focus on improving health or exercises that focus on improving performance, or both. Exercises aimed at improving health involve practicing skills and activities, and training is less intensive. Exercises aimed at improving performance involve physical training. Attention must always be paid to helping patients enjoy the exercises. The provision of patient education is divided into four tasks: informing, instructing, educating and guiding. In practice, these four tasks overlap. Each task involves a different approach, which depends on the time and educational aids available, and on the therapist s experience. The physical therapist coaches the patient and helps him or her to make the desired behavioral adjustments by providing education, by giving positive feedback, and by enabling the patient to have positive movement experiences. Therapy The application of physical therapy is based on The goals of patient education are: To provide an insight into the disorder and 7

8 subsequent rehabilitation the physical therapist informs the patient about the nature and course of heart disease, surgery, rehabilitation (including its goals, therapeutic content and estimated duration), risk factors and prognosis; To improve compliance and increase trust in therapy the learning process involves extending and incorporating the activities and behaviors learned during treatment into the patient s daily life. The patient has to learn to feel how to deal with heart disease; To encourage an adequate way of coping with the condition the patient should learn what symptoms mean and how to control them. The learning process may be based, for example, on reducing fear of movement. The physical therapist ensures that the patient does not receive any unclear or conflicting information. For example, reassuring information can counteract a negative view of the cardiac condition and can, therefore, help prevent unnecessary invalidity. If the patient s partner is worried, it is important that the partner as well as the patient is provided with information. Patient-oriented exercise programs In developing a patient-oriented exercise program, it is important to take into consideration the patient s goals and desires, the patient s exercise capacity, and the individual goals and choices made regarding (a) the priorities of the exercise program, (b) the types of exercise to be used, and (c) training variables and loading. If the exercise program is directed at improving objective aerobic capacity, the choices made in selecting training variables should be based on physiological training concepts, such as specificity, overloading, supercompensation, reduced output, and reversibility. (a) Exercise program priorities The different exercise program priorities are described below along with the general goals to be achieved and with individual goals listed in parentheses: 1. Practicing specific skills, with the goal of increasing general aerobic capacity and strength during motor activities (goals 1, 2, 3, 5 and 6). Result: improved performance of the skills and activities practiced, a higher level of activities of daily living, a reduction in risk factors, and improved postoperative mobility. 2. Aerobic exercise (goals 1, 2 and 3). Result: increased general aerobic capacity, reduced blood pressure and heart rate through submaximal exercise, decreased myo-cardial oxygen uptake, and a reduction in risk factors. 3. Strength and aerobic exercise (goals 1, 2 and 3). Result: increased strength and aerobic capacity, and a higher level of daily activity in housework, occupational work, sports and hobbies. 4. Learning how to enjoy exercise by practicing specific functions and activities (goals 5 and 6). Result: patient enjoys exercising and integrates exercises into his or her normal lifestyle. 5. Training to reduce risk factors, such as hypertension, hyperlipidemia, diabetes mellitus, obesity, inactivity and emotional factors. Result: increased energy, weight loss, blood pressure control, controlled insulin responses, and an active lifestyle. The treatment used in cardiac rehabilitation is not all given at the same level. The therapeutic approach can vary from professional sports training to learning the most efficient way to tie shoelaces. (b) Types of exercise Cardiac rehabilitation involves a wide range of activities, such as practicing basic skills and daily life activities, and sports training. Therapy can take the form of fitness or aerobics exercises, swimming, or exercises in water. The therapeutic approach chosen must provide the most appropriate and specific way of increasing the patient s daily activities. If therapy is focused on physical training, use of an ergometer and sports training are involved. ECG and blood pressure monitoring are carried out if indicated by the rehabilitation team. Ergometers are mostly used during training in highrisk patients whose ECG recording, blood pressure and heart rate are being monitored. (c) Training variables and loading Examples of training variables are the intensity, frequency and duration of training, and the length of the rest intervals. However, training structure is also 8

9 Table 5. Determining exercise intensity, and hence aerobic capacity level, in a training session lasting Relative intensity (%) Borg scale score Exercise intensity HR-max* VO 2 -max * or HR-reserve* < 35% < 30% < 10 very light 35 59% 30 49% light 60 79% 50 74% medium 80 89% 75 84% heavy > 90% > 85% > 16 very heavy * HR-max = maximum heart rate; VO 2 -max = maximum oxygen uptake; HR-reserve = HR-max - resting heart rate. This table has been reproduced with permission from WB Saunders Company. Source: Pollock ML, Wilmore JH. Exercise in health and disease: evaluation and prescription for prevention and rehabilitation. Second edition. Philadelphia: WB Saunders; important. General indications of training variable values according to exercise program priorities, as noted above, are: 1 and 4. Practicing specific functions, skills and activities while encouraging the patient to enjoy exercise: training frequency should be 2 3 times a week. 2. Aerobic exercise: training intensity should be at 40 85% of maximum oxygen uptake and at on the Borg scale; training should consist of a warm-up period, aerobic training, and a coolingdown period, and should last minutes; training frequency should be 3 7 days a week. 3. Strength and aerobic exercise: training intensity should be at 40 50% of maximum strength; each training session should comprise 1 3 sequences of repetitions with pauses lasting 1 2 minutes; resistance should increase with time, both relatively and absolutely; training frequency should be 2 3 times a week. Circuit training should last for minutes and should consist of a warm-up period, strength training, and a cooling-down period. 4. Reduction of risk factors: exercises that have a longer duration, lower intensity and higher frequency are recommended for patients with obesity, hypertension, diabetes mellitus (type-ii), and lipid disorders. Individual exercise programs are devised using the results of tests of maximum symptom-limited aerobic capacity. Table 5 shows the relationship between exercise intensity, percentage maximum heart rate (HR-max), heart rate reserve (HR-reserve) or maximum oxygen uptake (VO 2 -max), and Borg scale score. The reserve heart rate, which is defined as the maximum heart rate minus the heart rate in a resting state, is used during training when VO 2 -max is unknown. The Karvonen formula is used to derive the heart rate during training, as follows: heart rate during training = heart rate in the resting state + (X/100 x HR-reserve), where X = target percentage VO 2 -max. Relaxation instruction Progressive relaxation, autogenic training and deepbreathing therapy are the approaches to relaxation used during instruction. The important elements of these methods were used to develop the relaxation instruction approach used in the Cardiac Rehabilitation Guidelines 1995/1996. The specific type of instruction given is formulated to meet the patient s needs and to suit the patient s current situation. Relaxation instruction takes place during exercise, as active relaxation, and during rest periods, as passive relaxation, or it could form part of warmup or cooling-down activities. Relaxation instruction can also be provided by itself in a separate treatment session. The need for relaxation instruction determines therapy frequency. Two or three sessions 9

10 Table 6. Final evaluation criteria The patient has achieved the specified goals. The patient has partially achieved the specified goals and it is expected that the patient will achieve all the goals by himself or herself and be self-sufficient in performing activities. The patient has not met the specified goals but it is thought that the patient s maximum capacity has already been reached. (The patient is sent back to the rehabilitation team.) are necessary to determine whether instruction can be given in a group setting or individually. There are very few patients in whom this amount of instruction is enough to learn relaxation methods, usually more than five or six sessions are required. Evaluation carried out after more than five or six sessions indicates that most patients can relax successfully without follow-up sessions. However, a small number of patients will still need individual relaxation instruction. These are usually patients who have difficulty following instructions or relaxing. It is important that the physical therapist also pays attention to psychosocial factors. Evaluation In addition to carrying out continuous evaluation during treatment, thorough evaluations should take place every four weeks during treatment, or more frequently if necessary, and at the end of therapy. Table 6 outlines the final evaluation criteria and Table 7 describes the desired end result for each goal along with the recommended means of evaluating the achievement of these goals. Reporting The rehabilitation team evaluates the rehabilitation process during and at the end of treatment by using information about the treatment process and treatment results and gives advice on aftercare. The rehabilitation team decides if rehabilitation is still needed or if it should be ended. Reporting is carried out in accordance with KNGF guidelines on reporting. Aftercare The patient is given information that encourages activity after rehabilitation. This could be information on, for example, continuing independently with training, such as walking or cycling, or joining a gym. It is important that the patient chooses a sport or activity that he or she enjoys to ensure that it will be continued for a long time. Patients and their partners can also be given information about local heart patient clubs (e.g. Heart-in-Movement and Heart Care Federation clubs in the Netherlands) and heart rehabilitation programs (e.g., Corefit). Evaluating the effects of therapy must be carried out during treatment as well as at the end. The evaluation method chosen depends on the individual goal. 10

11 Table 7. Physical therapy goals and means of evaluating the achievement of these goals. Goal End result Means of evaluation When used in the program 1. Learn about Patient knows own the top five problem Beginning and end physical limits physical limits and areas are identified activity levels achievable and scored using a questionnaire 2. Learn to cope with Patient can cope with activity problems are physical limitations physical limitations identified and scored using the fear, dyspnea and/or angina pectoris scale Borg scale scores on exhaustion, chest pain and shortness of breath are obtained if necessary, heart rate and blood pressure are monitored 3. Optimize aerobic Aerobic capacity is questionnaire Beginning and every capacity level optimum for the patient (as in goals 1 and 2) four weeks ergometer MET s units, specific activity scale, sixminute walking test 4. Make a diagnosis There is insight into the all methods used in Continuous monitoring patient s capabilities evaluating goal 3 during rehabilitation scoring before, during and after movement activities, Borg scale score (see goals 1 and 2) 5. Overcoming fear of Patient is no longer history-taking and Beginning and end reduced aerobic afraid to perform physical observation capacity activities 6. Developing an active Patient has an active history-taking Beginning and end lifestyle lifestyle start of rehabilitation phase III activities 7. Attaining knowledge Patient has knowledge about secondary about secondary prevention prevention risk factor checklist Beginning and end 8. Learning to relax Patient has knowledge questionnaire During and at the end about relaxation and can flow chart use this information to relax 11

12 Review of the evidence General introduction The guidelines on cardiac rehabilitation issued by the Royal Dutch Society for Physical Therapy (KNGF) provide a guide to the physical therapy of patients who are eligible for cardiac rehabilitation. The guidelines describe a methodical approach to the diagnostic and therapeutic processes involved in providing physical therapy. The guidelines were developed by the Dutch Physical Therapy Association for Cardiac and Vascular Diseases (NVFH), the Royal Dutch Society for Physical Therapy (KNGF) and the Dutch Institute of Allied Health Professions (NPi). They are consistent with the Cardiac Rehabilitation Guidelines 1995/1996 developed by the Dutch Cardiology Association (NVVVC) and the Dutch Heart Foundation (NHS). 1,2 The guidelines are multidisciplinary and interdisciplinary and have been developed for rehabilitation therapists who are directly involved with the practical treatment of patients who require cardiac rehabilitation in rehabilitation phase II. The rehabilitation team consists, at a minimum, of a physician, a physical therapist, a social worker and a nurse. The physician in the team, who is usually a cardiologist, has the final responsibility for treatment. If necessary, information on the patient is discussed by the team and it is decided whether practitioners of other disciplines should be involved, such as a nutritionist, a psychologist, a rehabilitation physician, a primary care physician, or an occupational physician. The rehabilitation process should be designed to meet the individual patient s needs, as expressed in the Individual Rehabilitation Plan concept. These clinical guidelines have been developed for circumstances in the Netherlands. Definition KNGF guidelines are defined as a systematic development from a centrally formulated guide, which has been developed by professionals, that focuses on the context in which the methodical physical therapy of certain health problems is applied and that takes into account the organization of the profession. 3,4 Objective of the KNGF guidelines on cardiac rehabilitation The objective of the guidelines is to describe the optimal physical therapy, in terms of effectiveness, efficiency and tailored care, for patients who are eligible for cardiac rehabilitation and who have had an acute myocardial infarction, or who have undergone coronary artery bypass grafting, percutaneous transluminal coronary angioplasty, a heart valve operation, or operative correction of a congenital heart disorder. Guideline recommendations are based on current scientific knowledge and the physical therapy provided should result in a decrease in symptoms and in improvements in the patient s functions and levels of activity participation. In addition to the above-mentioned objectives, KNGF guidelines are explicitly designed: to adapt the care provided to take account of current scientific research and to improve the quality and uniformity of care; to provide some insight into, and to define, the tasks and responsibilities of the physical therapist and to stimulate cooperation with other professions; and to aid the physical therapist s decision-making process and to assist in the use of diagnostic and therapeutic interventions. To promote implementation of the guidelines, recommendations have been made concerning the levels of professionalism and expertise needed to ensure that treatment is carried out in accordance with the guidelines. Main clinical questions The group that formulated these guidelines set out to answer the following questions: How many patients are eligible for cardiac rehabilitation in the Netherlands, in terms of incidence and prevalence? Which health problems can be described in this group of patients? Which risk factors and prognostic factors are known and can be influenced by physical therapy? 12

13 What is the normal course of development in patients eligible for cardiac rehabilitation? Which parts of the physical therapy approach to treatment and prevention are valid in this group of patients and what are the effects of different forms of treatment, such as movement programs (e.g., exercises), relaxation instruction, psychoeducational interventions, and the provision of advice and information? Which diagnostic and evaluative measuring instruments are useful? Formation of the monodisciplinary working group In May 1998, a monodisciplinary working group of professionals was formed to find answers to these clinical questions. In forming the working group, an attempt was made to achieve a balance between professionals with experience in the area of concern and those with an academic background. Patients desires and preferences were expressed via the Dutch Heart Foundation. All members of the working group stated that they had no conflicts of interest in participating in the development of these guidelines. Guideline development took place from May 1998 until June Monodisciplinary working group procedure The guidelines were developed in accordance with concepts outlined in a document entitled A method for the development and implementation of clinical guidelines. 3 6 This document includes practical recommendations on the strategies that should be used for collecting scientific literature. Below, in this review of the evidence for these guidelines, details are given of the specific terms used in literature searches, the sources searched, the publication period of the searched literature, and the criteria used to select relevant literature. The recommendations made on therapy are almost entirely based on scientific evidence. If no scientific evidence was available, guideline recommendations were based on the consensus reached within the working group or between professionals working in the field. External experts commented on guideline recommendations. Once the draft guidelines were completed, they were sent to a secondary working group comprising external professionals or members of professional organizations, or both, so that a general consensus with other professional groups or organizations and with any other existing monodisciplinary or multidisciplinary guidelines could be achieved. The members of the working group individually selected and graded the documentation collected on the basis of the quality of the scientific evidence. Even though the scientific evidence was collected by individuals or smaller subgroups, the results of the process were presented to and discussed by the whole working group. Thereafter, a final summary of the scientific evidence, which included details of the amount of evidence available, was made. In addition to scientific evidence, other important considerations were taken into account in formulating recommendations, such as: the achievement of a general consensus, cost-effectiveness, the availability of resources, the availability of the necessary expertise and educational facilities, organizational matters, and the desire for consistency with other monodisciplinary and multidisciplinary guidelines. Validation by intended users Before they were published and distributed, the guidelines were systematically reviewed, for the purpose of validation, by the target group that would use the guidelines in the future. The draft KNGF guidelines on cardiac rehabilitation were tested in daily practice by members of the working group who were working in different environments in order to provide an overall appraisal of the guidelines. The working group included nine physical therapists who tested the guidelines in their own working environments, with their own teams, or with other professionals working in their field. The comments and criticisms made by the physical therapists were recorded and discussed by the working group. If possible or desirable, they were taken into account in the final version of the guidelines. The final recommendations on practice, then, are derived from the available evidence and take into account the other above-mentioned factors and the results of the guideline evaluation carried out by intended users (i.e., physical therapists). During the period , a prospective cohort study was conducted that involved cardiac 13

14 rehabilitation patients who were treated according to the guidelines. Before the start of the study, documentation and reporting forms were developed for distribution at the end of the study. Patients opinions were sought during the study and an attempt was made to identify organizational aspects of treatment that could be improved, for example, by obtaining information about the cost implications of applying guideline recommendations. Another goal was to identify criteria for ascertaining whether guidelines are being followed (i.e., process indicators), for determining the results of therapy (i.e., outcome indicators), and for determining the extent of care (i.e., benchmarks). The results of this prospective cohort study will be included in the first revision of the guidelines. Composition and implementation of the guidelines The guidelines comprise three parts: the practice guidelines themselves, a schematic summary of the most important points of the guidelines, and a review of the evidence. Each part can be read individually. Immediately after publication of the guidelines and their distribution among members of the Dutch Physical Therapy Association for Cardiac and Vascular Diseases (NVFH), a prospective cohort study was started, which involved implementation of the guidelines in eleven hospitals and rehabilitation centers. In addition, the guidelines were implemented in accordance with the standard method of implementation, which has been described elsewhere. 3 7 Introduction to these guidelines This section describes the choices made in arriving at the recommendations given in the KNGF guidelines on physical therapy in cardiac rehabilitation. The guidelines are based on Dutch Cardiac Rehabilitation guidelines, 1,2 United States guidelines 9 12 and recent scientific literature on cardiac rehabilitation, since Literature was collected using the Cochrane Library 1999 Issue 2, MEDLINE (November 1994 to 1999) and CINAHL (September 1994 to 1999). The following terms were used in literature searches: heart disorder, (acute) myocardial infarction (AMI), coronary artery bypass graft (CABG), percutaneous transluminal coronary angioplasty (PTCA), heart valve operation, and operative correction of congenital heart disorders, together with the additional terms: exercise therapy, movement therapy, physical therapy, postoperative care, cardiac rehabilitation, clinical trial, randomized clinical trial, protocol, metaanalysis, and reviews (in both Dutch and English). Literature was also provided by working group members. Rehabilitation phases I, II and III Cardiac rehabilitation involves actions that take place in the following phases: during hospital admission (phase I), during rehabilitation in the polyclinic (phase II), and after rehabilitation and during aftercare (phase III). 1,13 KNGF guidelines focus on phase II, as do the multidisciplinary guidelines. The details of rehabilitation in phase I are given in summary form because the period of hospital admission has been increasingly shortened and rehabilitation treatment in this phase consequently reduced. Rehabilitation in phase III does not take place in the institutional healthcare sector and is not, therefore, covered by these guidelines. Phase III focuses on individual sporting and recreational activities. In the Netherlands, physical therapists in primary healthcare sectors are involved in treatment related to sport and recreation, which may include Heart-in-Movement and Heart Care Federation clubs, the Corefit heart rehabilitation program, and physical therapy sports centers. Defining cardiac rehabilitation Cardiac rehabilitation involves the rehabilitation of normal activities after a cardiac incident. Rehabilitation focuses on optimizing physical, psychological and social activities, so that the patient can regain a normal place in society, and on influencing risk factors. 14 The KNGF guidelines are based on this definition with the addition of the following: Cardiac rehabilitation involves strategic training and education to promote adequate coping behavior and optimal functioning in normal daily life, such that the patient s quality of life is improved, and individual limitations and participation problems are reduced

15 Impairments, limitations and participation problems The physical therapist describes health problem in cardiac patients in terms of impairments (functional or structural), disabilities (affecting activities), and participation problems. These terms are defined in the International Classification of Impairments, Disabilities and Handicaps (ICIDH-2 Beta ). 16 Quality of life is also assessed during the evaluation of paramedical and medical treatments. Quality of life involves physical, psychological and social components, which are related to the patient s perception of whether treatment is having an effect on his or her daily life. The treatment goal of improving quality of life is especially important for those patients in whom full recovery is not possible. Defining cardiac rehabilitation patients The KNGF clinical guidelines on physical therapy in cardiac rehabilitation have been developed for patients who have had an (acute) myocardial infarction, or who have undergone coronary artery bypass grafting, percutaneous transluminal coronary angioplasty, a heart valve operation, or operative correction of a congenital heart disorder. Rehabilitation in all these types of patient is practically identical. This target group coincides with that described in (Dutch) Multidisciplinary Cardiac Rehabilitation Guidelines. 2 Additional screening is necessary for patients suffering from angina pectoris, chronic heart failure, hypertrophic obstructive cardiomyopathy that has not been treated surgically, heart rhythm disorders (for example, after ablation therapy) and atypical thoracic complaints, and for those with a pacemaker or an implantable cardioverter-defibrillator, or who have had a heart transplant. 1 Pathogenesis After a cardiac incident, both objective and subjective aerobic capacity may be reduced. The patient s aerobic capacity level objectively depends on motor characteristics such as strength, speed, flexibility, perseverance and coordination, as well as on the potential application of these characteristics in normal daily activities, sport, work and hobbies. Other impairments and limitations can also have an influence on functioning. Aerobic capacity may be reduced subjectively by fear, invalidity, depression or a limited social life. 1 Emotional disturbances and social factors may also lead to disorders. Fear, aggressiveness and depression can predominate and are often associated with sleeping difficulties, exhaustion, emotional lability, libido problems, and eating, memory and concentration disorders. 1 Acceptance of a reduced social life can also have an influence. 1 It is possible that a patient may deal with his or her heart disease inappropriately. Negative or overpowering reactions from a partner or from the patient s environment can unnecessarily limit or stress the patient. Problems with fulfilling social roles are usually secondary consequences of physical limitations or psychological difficulties. However, elements in the patient s environment, such as an unhelpful employer, can inhibit the return to optimal social functioning. 1,2 Epidemiology In 1997 in the Netherlands, there were 14,274 deaths related to cardiac infarctions: 8,064 men and 6,210 women. In that same year, 27,199 hospital admissions were directly related to cardiac infarctions. In general, the women affected were older than the men. Men had an average hospital stay of 10 days, and women stayed for 11.5 days on average. 17 In 1995, 14,709 open-heart operations were completed in the Netherlands. 18 Cardiac rehabilitation generally takes place in specialized clinics and almost never in the primary healthcare sector. 1,19 In 1999, the Dutch Heart Foundation reviewed the availability of cardiac rehabilitation in the Netherlands. 20 The results showed that, in 1998, 98 locations provided group rehabilitation in polyclinics (rehabilitation phase II). In that same year, 17,000 patients attended polyclinic cardiac rehabilitation programs. The largest subgroups of these patients had suffered from acute myocardial infarctions (46%) or had had coronary artery bypass graft operations (30%). Smaller subgroups received cardiac rehabilitation after percutaneous transluminal coronary angioplasty (11%), valve operations (7%) or chronic heart failure (3%), or after receiving a diagnosis of angina pectoris or heart rhythm disorder (3%). (The percentages given are all approximate.) Exercise therapy, which was given in groups with physical therapy guidance, appeared to be more 15

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