"Exercise of almost any kind, suitable in degree and duration, can and does play a useful role in the maintenance of both physical and mental health of the coronary patient". This phrase, by Dr. Paul Dudley in the mid 1950's in many ways summed up the consensus of the benefits of physical activity for cardiac rehab patients. So what, if anything has changed in the past 45 years? Since the goals of cardiac rehab have been, and continue to be the returning of patients with cardiac diseases to optimum function physically, emotionally, socially, vocationally, and economically1,2,7, optimizing both short term and long term rehabilitation needs has always been the primary concern.
In today's managed care era, short term care in some instances is becoming shorter, and long term programming is not universal, we look for guidance as to how current recommendations will affect future cardiac rehab programs across the US. Therefore, the purpose of this article will identify elements of the recent HHS guidelines in cardiac rehab, present a post rehab program for strength training and complimentary exercise, and predict some trends that may occur within the framework of cardiac rehab in the coming years.
A Review of the Health and Human Services Guidelines
In November of 1995, the US Department of Health and Human Services published volume 17 of their cardiac rehabilitation guidelines7. These guidelines give a general overview of the epidemiology of exercise as it relates to cardiac rehabilitation. The strength of evidence is basically favorable for both observational and randomized studies. Although there are considerable differences in the designs of the studies, the long-term treatment of CHD patients suggests a moderate association between participation in rehab programs and reduction in the morbidity over time as seen with sedentary post-op patients.
The publication also looks at the effects of rehab on lipid status, psychological well-being, return to work, and job safety issues. Information on exercise tolerance, heart failure, body weight maintenance, and alternative approaches to delivery services are also discussed.
The general recommendations made by the council include: expanding the populations who may be served by cardiac rehab programs (women, ethnic groups, lower SES brackets), expanding the outcomes measurements in acute infarct patients and evaluating those outcomes with and without ECG monitoring, developing optimal education strategies, and finally, integrating cardiac rehab into a total lifestyle change in large populations.
Applying Guidelines to Clinical Practice
Physiological testing is still the cornerstone of cardiac rehabilitation programming, as it initially defines the condition, and sets parameters of acute conditioning. Periodic tests allow practitioners to re-assess cardiac status and modify training protocols. There is some controversy as to the applicability of ECG testing to the many types of conditioning protocols in use, but it is the cornerstone of the cardiologist's work, and it will always be used to assess current status of the patient6.
The past decade has seen growth in cardiac rehab programs from basic treadmill and stationary cycles, to strength training, aquatic rehab, yoga, T'ai Chi, and walking. As rehab programs expand their base, incorporating clinical monitoring and progression become more difficult. This section will define some of the elements of conditioning from a clinical and post rehab perspective, keeping close to the new HHS guidelines, but expanding our thought on what post rehab in the cardiac setting may become.