Return to work after rehabilitation in coronary bypass patients. Role of the occupational medicine specialist during rehabilitation
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1 European Heart Journal (1988) 9 (Supplement L), Return to work after rehabilitation in coronary bypass patients. Role of the occupational medicine specialist during rehabilitation C. MONPERE*, G. FRANCOIS*, C. RONDEAU DU NoYERf AND J. PHAN VAN *Centre de Readaptation Cardiovasculaire 'Bois Gibert', Ballan Mire and flnstitut de Medecine du Travail, 2, bd Tonnele, Tours, France KEY WORDS: Cardiac rehabilitation, vocational counselling, coronary surgery, return to work. The aim of the study was to assess the role of the occupational medicine specialist in improving return to work (RTW) after coronary bypass graft (CABG) surgery, with an early intervention in the rehabilitation programme of the patients. There were 57 patients (56 male, 1 female, mean age was 50-7 years), sent for rehabilitation 22 days after surgery (49% of them had a prior myocardial infarction, and the ejection fraction (EF) was ^0-55 in 67%, 0-30 < EF <0-55 in 25%, or = 0-30 in 8%; myocardial revascularization was complete in 47% of the patients). Jobs required a high level of physical activity in 52-5% of the patients, a medium or low level in 44% and 3-5% of the patients were unemployed. At 7 months follow-up, 73-2% out of the 56 alive patients had returned to work with a mean delay of ± 84 days after surgery. The causes of non-return to work were social and economical factors (46-6%), psychological factors (40%) and medical reasons (13-4%). No clinical data were correlated with return to work (age, EF, extent of revascularization, or results of the stress tests), but return to work varied with the energy requirement in jobs with 97-3% return to work in case of low physical level, and 46-7% in case of high physical level (P < 0-001). The comparison with a previous study performed in 1984 in 45 rehabilitation patients (with non-systematic vocational counselling), showed an increase in return to work in cardiac patients from 51% to 78% (P < 0-05) after intervention of the occupational physician. So, the different ways of improving return to work in post-cabg patients are complementary: exercise training and secondary prevention are important, but must be completed with individual vocational counselling that should be included in every rehabilitation programme. Myocardial revascularization is now known to The aim of this study, therefore, was to assess the improve the functional capacities and quality of life role of the occupational medicine specialist in of patients suffering from angina pectoris. However, improving return to work after CABG surgery, with available reports on return to work after coronary an early intervention in the rehabilitation proartery bypass graft (CABG) surgery reveal no gramme of the patient, improvement in resumption of professional activity and the level of return to work is often lower for.,.,.....,,...,. ti_4. Material and methods CABG than for myocardial infarction patients 1 '. The economic consequences of this situation are PATIENT POPULATION important, for bypass surgery seems to increase the Clinical status overall cost of the atherosclerotic heart diseases This study involved 57 consecutive (group 1) postbecause of the high cost of the procedure and the low CABG patients, sent for cardiac rehabilitation at a level of return to work' 4 '. The determinants of non- mean time of 22 days after surgery. All these patients return to work are varied and numerous, but non- were below 60 years of age or had an occupational medical factors (economical and psychological activity at the time of their cardiac accident, factors) are predominant. The study group comprised one woman and 56 men, of mean age 50-7 (range years), and the :, «"» duration of the P* ie nt rehabilitation was 21-8 France. ± 3-3 days X/88/9L $02.00/ The European Society of Cardiology
2 Rehabilitation of coronary bypass patients 49 The preoperational data are summarized below. (1) Risk factors. Nearly three risk factors/patient: tobacco smoking 73-7%, hyperlipoproteinemia 72%, and heredity 45-6%. (2) Previous myocardial infarction in 28 patients (49%): anterior infarction 46%, inferior infarction 54%. (3) Ventricular function. The ejection fraction (EF) in 55 patients was: EF > 0-55 in 37 patients (67%), 0-30 < EF < 0-55 in 14 patients (25%), EF =s 0-30 in 4 patients (8%). (4) Angiograms: one-vessel disease in 5 patients (9%), two-vessel disease in 18 patients (31-5%), three-vessel disease in 34 patients (59-5%). (5) Number of graft(s) per patient: one graft 14%, two grafts 38-5%, 2=3 grafts 47-5%. (6) Complete revascularization in 27 patients (47%). Post surgery complications were: myocardial infarction in four cases, and mediastinitis in two cases. During rehabilitation, four patients still suffered from angina pectoris, and significant ventricular dysrhythmia occurred in six patients, but all the patients could, nevertheless, follow their rehabilitation programme after modification of the therapy. Vocational status Jobs were classified into those requiring heavy levels of physical activity and those requiring medium or low levels of physical activity: heavy activity, 30 patients (52-5%); medium or low activity, 25 patients (44%); unemployment, 2 patients (3-5%). The different social classes were classified as: executive, 15 patients (26-5%); employees, 10 patients (17-5%); workers, 10 patients (17-5%); craftsmen, 20 patients (35%); unemployed, 2 patients (3-5%). Methods heart rate was reached. A second test was performed at the end of the rehabilitation programme using the same protocol. Training Patients trained five days per week for three weeks. The training consisted of: (i) 30 min bicycle exercise to maintain the heart rate at 75% of the first stress test maximal heart frequency, with 5 min warm-up and cool-down periods, controlled by telemetry monitoring; (ii) callisthenics, with gradually increasing energy requirements, using all the major muscle groups with stretching movements, for 30 min per day; and (iii) walking for 1 h every day with some periods of jogging at the third week. Secondary prevention During the three-week rehabilitation programme, information was given to the patients concerning their cardiac risk factors and how to prevent them by adopting a new lifestyle. Counselling was particularly focused on diet, stress and cigarette smoking. INTERVENTION OF THE OCCUPATIONAL MEDICINE SPECIALIST IN THE REHABILITATION CENTRE The interventions involved: (i) giving vocational information on return to work every three weeks with general and individual considerations; (ii) at the end of the rehabilitation programme booklets were given to the patients with information about clinical data and physical possibilities; (iii) these indications were followed by a questionnaire to be completed by the occupational physician, or the general practitioner at the time of return to work (or non-return to work asking for the clinical status of the patients, the conditions of return to work, or the reasons of nonreturn to work. Physicians who failed to return the questionnaire were reminded via telephone contact. REHABILITATION PROGRAMME Testing The exercise test was conducted as follows. The first test was performed in the third post-surgical week on an ergometer bicycle: heart rate, blood pressure, and 12-lead electrocardiograms were taken at rest, at every 3 min of the exercise, at peak exercise, and at 2-min and 5-min of recovery. The test was started at 30 W, with the workload increasing gradually by 30 W every 3 min. The exercise was stopped in the event of ST-segment depression of >2-5 mm, arrhythmia, falling systolic blood pressure, dizziness or fatigue, or when the maximal STATISTICAL METHODS (DATA ANALYSIS) All values are expressed as mean ± standard error. The significance of differences between means was calculated using the Student distribution for paired and unpaired samples. The x 2 analysis was used for comparison of the groups. A P value of less than 0-05 was considered as being statistically significant. Results GLOBAL RESULTS All the patients could be followed-up within a mean delay of 7 months after their rehabilitation (range 4-11 months).
3 50 C. Monpere et al Time after CABG (months) Figure 1 Evaluation of return to work of patients after CABG. Among the 57 patients, one died after visceral surgery of an extracardiovascular cause (pancreatitis). Of the 56 living patients, 73-2% (41 patients) had returned to work with a mean delay of ± 84 days after CABG surgery (range 7 days to 11 months). Only seven patients returned to work after 6 months delay post-surgery (Fig. 1). The causes of non-return to work are classified into medical, socio-economic and psychological reasons. Medical reasons were the cause of non-return to work in two patients: (i) one sternal dysjunction needing secondary surgery, and (ii) one abdominal aortic aneurysm to be operated on. Social and economic causes were predominant (46-6%) and include previous unemployment (two cases, 58 and 56 years old), early retirement (two cases), or redundancy (three cases). Psychological reasons accounted for 40% of non-return to work, with sensation of 'fatigue' or 'depression'. Among these six depressed patients, four were already mentioned as 'anxious' or depressed at the time of their rehabilitation. SUBGROUP ANALYSIS Role of clinical factors Patients resuming work are younger than those who do not return to work, 49-4 ± 7 years vs ± 6 years, but this difference is not significant. Neither left ventricular function, nor the extent of the revascularization played any role and return to work was higher (80%) in the incomplete revascularization group than in the complete revascularization group (63%). In the two groups of return-to-work and nonreturn-to-work patients a significant increase in physical capacities was assessed by the workload level of the exercise stress tests, before and after rehabilitation (Table 1). However, there are no statistical differences between the energetic level in METs between the two groups, at the first or second stress test. Role of socio-economic factors (Fig. 2) The level of return to work varied with the different professional classes from 60% (workers), to 100% (executive class). This is, in fact, correlated with the physical level of these activities, with 97-3% return to work in the case of a low physical level of work, and 46-7% in the case of a high physical level (P > 0-01), as assessed by several studies' 3 " 51. To summarize, 73-2% of our post-cabg patients could resume work with a mean delay of three months after surgery. No clinical factors could be correlated with the level of return to work and, as shown in several studies, the main causes of nonreturn to work were socio-economic and psychological factors 13 " 5 '. Comments ROLE OF THE OCCUPATIONAL MEDICINE SPECIALIST IN THE CARDIAC REHABILITATION PROGRAMME The level of return to work after rehabilitation in our Centre has been regularly increasing since 1984, from 51% to 78% in this latest study (Fig. 3). In fact, the rehabilitation programme at its beginning in 1984 did not include systematic vocational counselling, and work resumption was rather low. A first improvement was made by informing the patient's occupational physician: a medical report (including Table I Evolution of workload capacities during rehabilitation. Stress test I Energy requirement (METS) First Second Return-to-work patients (N = 41) 43 *-P< » l-78-i Non-return-to-work patients (A' = 15) ± 1 11 *- P < > '
4 Rehabilitation of coronary bypass patients 51 Figure 2 Socio-economic class and return to work after CABG.* P < diagnosis, physical capacity and possibility of return to work) was given to the physician via the patient himself. An evaluation of this method was done in 33 post-cabg patients in 1985/86: in this group, 60-6% of the patients resumed work with a mean delay of 3-5 months post surgery. The results varied between the different economic classes, as in our latest study, from 48-4% return to work in workers to 82-4% in the executive class. Since 1986, the role of the occupational medicine specialist has been increasing by a direct and early intervention in the cardiac rehabilitation centre, with general and individual counselling, and possibility of follow-up of the patient at work after rehabilitation. This intervention has raised the level of return to work in post CABG patients to 73-2%. In this study, therefore, the early intervention of the occupational Figure 3 Intervention of the occupational physician and return to work a, No intervention; b, medical report to occupational physician; c, intervention of the physician. medicine specialist seems to be quite favourable, due to the planning of the modalities of return to work, in cooperation with the cardiologist's advice and the patient himself. COMPARISON OF RETURN TO WORK OF C A B G PATIENTS AND OTHER CARDIAC PATIENTS In the study, 57 post-cabg patients comprised a subgroup of 129 consecutive cardiac patients sent for rehabilitation from December 1986 to June 1987, included with the same criteria as mentioned above. There were 46 myocardial infarction (MI) patients, six angina pectoris patients without infarction, 20 post valvular surgery patients and 57 post-cabg patients. It can be seen from Fig. 4 that there is a difference between surgical and non-surgical patients, with a lower return to work after valvular or bypass surgery, but this is not significant in our study. However, this difference is quite usual, as shown in many previous studies. Surgical intervention, as it is usually termed, seems to have a negative effect on resumption of work despite a good heart status. These facts emphasize the important role of the patient's medical environment before and after cardiac surgery, and the necessity to inform the patient and his family about his vocational possibilities' 5-8 '. For many years, the role of the occupational medicine specialist in counselling cardiac patients was not easy, because the evaluation of the physical requirement of each type of job was difficult to appreciate and, in many cases, we could not know if the work would be suitable to the cardiac possibilities of the
5 52 C. Monpere et al. Figure 4 Comparison of return to work in cardiac patients Climbing up thecrane Climbing down the crane Time Figure 5 Cardiac pulse meter recording at work in a crane driver after CABG surgery and its correlation with the stress test., Heart rate at work; , heart rate at stress test (180 W, 89% maximum heart rate). patient; there were only rough correlations between the maximal workload level reached during the stress test and the metabolic energy requirements of some jobs. Now, with the development of cardiac ambulatory recording, which can be used at work, more information is available on the real energetic cost of the cardiac patient's job. Twenty-four-hour Holter recording certainly gives the most complete information about heart rate, arrhythmia, and silent ischaemia, but because of its cost and weight, it cannot be used routinely to evaluate cardiac patients at work. An interesting alternative is provided by the new generation of cardiac pulsemeters which are easier for the physician to use with the patient at work, and which can give a good evaluation of the cardiac cost of a job by correlation with the latest stress test. These new methods provide the physician with objective information and, thereby, provide better safety for the cardiac patient returning to work after cardiac bypass (Fig. 5). Conclusion Determinants in the return to work of post-cabg patients are multifactorial, including cardiac condition, psychological state, prior work status and socioeconomic environment. Post-CABG patients need special help because cardiac surgery seems to have a negative influence on return to work, when compared to post-mi patients or angina patients. Therefore, the different actions to improve the rate of return to work in post-cabg patients are complementary: exercise training and secondary prevention are important, but must be complemented with individual vocational counselling that should be included in all rehabilitation programmes. Vocational counselling in bypass surgery patients should now be easier than it was previously, with a wider and more routine use of Holter recording or cardiac pulsemeters at work, and this emphasizes the absolute necessity of good coordination between the cardiologist and the occupational medicine specialist. References [1] Oberman A, Wayne JB, Kouchouka NT et al. Employment status after coronary artery bypass surgery. Circulation 1982; 65 (Suppl II): [2] Varnauskas E, and the European Coronary Surgery Study Group. Survival myocardial infarction and employment status in a prospective randomized study of coronary bypass surgery. Circulation 1985; 72 (Suppl V): V90.
6 Rehabilitation of coronary bypass patients 53 [3] Wenger NK. Rehabilitation of the coronary patient: status 86. Prog Cardiovasc Dis 1986; 29: [4] Naughton J. Vocational and avocational rehabilitation for coronary patients. In Wenger NK, Hellerstein HK, eds. Rehabilitation of the coronary patient. New York: Wiley Medical, 1984: [5] Gohlke H, Gohlke-Barwolf Ch, Schnellbacher K et al. Long-term effects of aorto coronary bypass surgery of exercise tolerance and vocational rehabilitation. In: Mathes P, Halhuber MJ, eds. Controversies in cardiac rehabilitation. Berlin: Springer Verlag, 1982: [6] Boulay F, David P, Danchin N, Girard C, Bourassa MG. Rehabilitation et retour au travail des malades apres pontage aorto coronarien. Arch Mai Coeur 1983; 76: [7] Benari E, Kellermann J, Fisrnan EL. Benefits of long term physical training in patients after coronary artery bypass grafting. A 58 months follow-up and comparison with a non-trained group. J Cardiopulmon Rehabil 1986; 6: [8] Russell RO, Mansour PA, Wenger NK. Return to work after coronary bypass surgery and percutaneous transluminal angioplasty: issues and potential solutions. Cardiology 1986; 73:
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