REVIEW ARTICLE
Cardiac rehabilitation and the changing cardiac rehabilitation directions in
Hoensbroeck rehabilitation centre P.AKH.F. van de Sande, Y.M.C. Curfs, A.M.T.M. Derks, J.J.J. Graus, J.G. Maessen, F.W. Bar
Hoensbroeck Rehabilitation Centre has been providing inpatient and outpatient cardiac rehabilitation services since 1980. In these twentyyears the patient population has changed considerably. Rehabilitation is currendy focussing on the complex and often old patient The programme that has been developed during this period consists of standard activities that are mainly group oriented. However, certain actMities are provided on an individual basis. Based upon this variety of actiities, a tailor-made programme can be composed for every individual meis compared patient Ifthe Hoensbro ro with the directions given by the Dutch Sodety of Cardiology and the Netherlands Heart Foundation, the main difference is the use of an integrated approach instead of separate modules. In our view, this is a must for complex cardiac rhabilitaton (NethHeart J2002;10:277-82.)
valve surgery, often have to deal with physical and psychosocial problems. The goal ofcardiac rehabilitation has stayed the same over the years, namely recovery of the physical, psychological and social functioning to the level before the incident.' In these twenty years the team's composition, with a representation from medical, paramedical as well as psychosocial disciplines, has not changed fundamentally. The treatment programme, however, has been adapted to the changed population. In this artide, we will first present some data concerning the changes in the population being treated, then we will discuss the contents of the current treatment programme and we will finish by looking at the relationship between the Hoensbroeck programme and several developments in cardiac rehabilitation over the past few years, particularly the cardiac rehabilitation directions as formulated by the Dutch Society of Cardiology and the Netherlands Heart Foundation.2'3
Key words: cardiac rehabilitation, programme, old patients
The changed population Earlier research provided us with data from the period 1985-1991. By means of a retrospective record search, data from 1999 were gathered. Some demographic data were also collected from our patient administration for 2001. It appeared that the number of patients aged 70 and over has increased from 11% in 1985, to 28% in 1991, to 48% in 1999 and to 56% in 2001. Furthermore, there was an increase in female patients. In 1986 one-third ofthe population consisted of women. In 1999 slightly more women than men were being rehabilitated and in 2001, 50% of our population were women. In our 1999 population, 150 patients (64%) underwent cardiac surgery in the University Hospital Maastricht in 1999. When we select this group, a comparison with the total population of surgery patients in Maastricht in 1999 can be made. As shown in table 1, our group is clearly older than the total surgery population. Furthermore, the percentage of valve operations is higher in the Hoensbroeck population. In other words, mainly the elderly and more complex patients are referred to Hoensbroeck. Table 2 shows that not only severe physical problems but also especially psychosocial problems are more common
r'ncouraged by the medical insurance companies, the OHoensbroeck Rehabilitation Centre started cardiac rehabilitation in 1980. At first, the patients were primarily young men who were being referred after an uncomplicated coronary artery bypass graft (CABG). Nowadays, the patient population consists mainly of elderlypeople often with substantial premorbid physical problems who, after a frequently complex CABG or P.A.H.F. van de Sands. Y.M.C. Curfs. A.M.T.M. Doks. JJJ. Graus. Hoensbroeck Rehabilitation Centre, Zandbergsweg 111, 6432 CC Hoensbroek.
J.G. Maesen. F.W. Bir. University Hospital Maastricht, PO Box 5800, 6202 AZ
Maastricht.
Address for correspondence: P.A.H.F. van de Sande. E-mail: [email protected]
Netherlands Heart Journal, Volume 10, Number 6, June 2002
277
Cardiac rehabilitation and the changing cardiac rehabilitation directions in Hoensbroeck rehabilitation centre
Tabe 1. The total population of cardiac surgery patients from the Maastricht University Hospital in 1999 compared with the selection of that group which was rehabilitated in Hoensbroeck in 1999. Surgical candidates In Maastricht (1999)
Rehablitation patints In Hoensbroeck (1999) 16
150
100
952
70.2 (±8.4)
64.7 (± 9.9)
Age in years (mean/sd) Older than 70 years Women CABG (novalve) Valve (+ other)
61 52 65 34
91 78 98 51
34 29 76 21
319 274 726 202
among
the 1999 patient population. The percentage of patients suffering from pump function disturbances has increased from 3% to 8% and the percentage of patients with (mainly superventricular) arrhythmias from 4% to 11%. To further illustrate the type of patients rehabilitated in Hoensbroeck Rehabilitation Centre, case reports ofthree patients are included.
To start with, most programme parts are group activities. Working with a group is not only efficient, it is also effective because the patient performs these activities in a group of fellow sufferers. The fact that others, who have already been rehabilitating for a longer period and have undergone the same operation, have made so much progress and are able to do so many more things will give hope and trust to the new-
The treatment programme In Hoensbroeck all patients are offered several parts of the basic programme. Table 3 shows a survey of these activities. As many programme parts can have an increasing intensity ofactivities or can be emphasised in various ways, it is possible to compose a programme focussed on an individual patient with his or her specific goals in mind, taking into account his or her possibilities and limitations. The individual programmes do, however, have a number of common characteristics.
comers.
Table 2. Physical and psychosocial problems on admission.
-
Severe physical problems when hospitallsed
1986 (n=911) 1999 (n=236) n
%
n
%
6 6 5 8 8
3 3 2 4 4
5 19 5 27 20
2 8 2 11 8
Depression
30 13
14 6
56 40
24 17
Being single Relationship problems Work
39 7 35
18 3 17
116 14 33
49 6 14
Cardiac problems Angina (NYHA 2-4) Dyspnoea (NYHA 3-4) Conduction disturbances Arrhythmia Neurological problems
Psychosocial problems at admission Extreme anxiety
278
Second, functional moving is paramount in almost activities. There are only few moments (once to twice a week) when patients talk together; the rest consists of moving together. This moving is packed in useful activities that have to do with sports, play, housekeeping, body care, locomotion, leisure activities or work. Especially in the last part ofthe rehabilitation programme, when working in the Rehabilitation Centre is less intensive (two days a week), patients get to do assignments at home to put what they have learned into practice. Moreover, in this way we confront them very implicitly with the fact that moving is safe and can be pleasant (again). Third, the movement activities are repeated several times daily: this is important, as learning requires repetition. Apart from the learning by repetition, there is sufficient room for variation: the same message is offered in a broad spectrum of activities, every time in a slightly different way. This variation is important in view of generalisation. However, it does require the therapists to be a good team and pass on things that matter to each other quite quickly. In other words: an important learning point during one day should be repeated the next day given as another activity. A fourth point that returns in all activities is reflection on moving and feedback. Although moving is the central issue in most activities, there is more involved than pure moving. The patients are asked to consider the sensations that particular movements cause. This sensation is also discussed with the patient. The patient and the therapist together will try to find an explanation for these sensations. Eventually the goal is that people feel at home in their own bodies. For others the learning moments are showing them the fact that signals from the body have to be managed all
-
Netherlands Hcart Journal, Volume 10, Number 6, June 2002
Cardiac rehabilitation and the changing cardiac rehabilitation directions in Hoensbroeck rehabilitation centre
Table 3. Parts of the basic programme. Type of activity
Number of levels
Frequency
Medical - nursing care Hometrainer cycling Movement therapy Walking (Movement economy)' (Play at skittles) (Swimming) (Sport and play) (Outdoor cycling) (Individual occupational training) (Work therapy or household training) Intro group Info group Family day Partner group
n/a continuous 4 continuous different accents different accents different accents different accents continuous different accents different accents n/a n/a n/a n/a
24 hour care max. max. max. max. max. max. max. max. max. max. max. max. max. max.
once a day once a day twice a day twice a week twice a week twice a week once a day once a day twice a week twice a week once per hospitalisation once a week once every 2 weeks once every 2 weeks
'The activities in brackets are not offered to all patients, but to most of them.
carefully: fatigue is a signal, pain is a signal. These signals cannot be ignored for a long time without the patient being punished for it. Initially, every patient is supervised carefully in all movements: the exertion increases gradually, the exertion is registered (ECG, heart rate) and a supervisor is present. When the exercises are performed properly, not only the exertion is increased gradually, but also the supervision will be reduced. This is because the best way to deal with anxiety is graded exposure to the stimulus that causes the anxiety. This means a gradual increase of exertion for the cardiac patient and a gradual decrease in supervision by the therapists. Finally, during all the movement activities themes related to secondary prevention are regularly discussed. Earlier we mentioned that listening to one's own body's signals is important. It is pointed out to patients that they have to alternate physical activities with rest. They are not only told this, such behaviour is part of the programme: also resting periods are planned. For many patients it is completely new that such breaks between activities should be planned. Apart from relaxation instruction, people are taught to be more economical with their energy, which is generally quite limited. The info groups pay a great deal of attention to themes such as information about various forms of cardiac suffering, quitting smoking, healthy nutrition, compliance with medication and coping with stress more prudently, in accordance with the advice of the Netherlands Heart Foundation. Some parts of the programme are not followed by all patients simply because this is not necessary. These are summed up in table 4 and will be elucidated further on.
Netherlands Heart Journal, Volumc 10, Number 6, June 2002
Anxiety
Anxiety is a very common emotion in cardiac patients. Sometimes the standard approach is not sufficient. People could have been slightlyphobic before the cardiac condition started or traumatic incidents could have taken place at about the same time as the cardiac event. In such cases an individual programme is set out: a hierarchy of anxiety provoking situations is made and a plan is drawn up in consultation with the patient. They are put in such circumstances but this time accompanied by a psychology assistant. For example, we go in search of lonely places to take a walk outside the terrain ofthe Rehabilitation Centre orwe visit rather crowded shops. Here too, homework assignments without supervision play an important role, just like the principles ofcognitive restructurng. Moreover, skills are used that are taught in relaxation instruction and breathing therapy. -
-
Work
A small number of patients rehabilitated in Hoensbroeck are still working. Return to work is planned after the rehabilitation. For those individuals a function analysis is made. This means that the occupational therapist maps out the contents and the physical condition required for the job. The physiatrist and the cardiologist evaluate whether the cardiac condition is sufficient for the job. The psychologist passes a judgement on psychological strength and stressful factors at work. The social worker finally looks into financial and social security matters. The team members all discuss their findings with the patient and with each other, and formulate a united advice. Together with the patient we consult the employer and the company medical officer, constructing a reintegration plan.
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Cardiac rehabilitation and the changing cardiac rehabilitation directions in Hoensbroeck rehabilitation centre
Table 4. Parts of the additional programme. Type of activity
Disciplines Involved
Street training Return to work Exercise training Weekend preparation General daily activity training Individual relaxation therapy Individual counselling
Psychology Occupational therapy, social work, psychology, physiatry, cardiology Physiotherapy Nursing care, social work, occupational therapy Nursing care Physiotherapy Social work, psychology, occupational therapy
Exercise
In the physical training of the basic programme, we focus on optimising exercise tolerance. Emphasis is put on coordination of movements, moving in a relaxed way and moving efficiently, not on maximising the exercise tolerance. A real exercise training is only implemented when the patients start working at more than 50-60% oftheir maximal capacity. This is not the primary goal for most patients because we try to enable people to rebuild a normal life rhythm. For the majority of our patient population it is unnecessary to exert oneself to the utmost. We add a heavier exercise training to the programme for those patients who want to start with sports on a competitive level or with people who will have to carry out heavy, physical work.
Weekend The weekend is an important part ofthe rehabilitation programme, especially for those people hospitalised in the Rehabilitation Centre. Some of these patients can function well within the surroundings of the Centre, but cannot function at all at home. That is why we insist that people go home in the weekends as soon as possible. For single people (almost halfof our patient population) this proves to be a major problem. Depending on the nature of the problems, a plan is made in collaboration with the patient and possibly their family or neighbours, by nursing care, occupational therapy or social work. In most cases initial relief and some supervision is arranged. When the patient returns to the Centre the weekend is evaluated and plans are modified for the next weekend. General daily activities A number of patients (especially elderly) do have problems with general daily activities in the first penod after the operation: they have difficulty washing or dressing themselves. These problems more commonly occur in patients who are confused after the operation, for people who were bedridden for a long time due to complications, or for people who could only just manage at home independently before the event. An interfering occasion like hospitalisation or an operation is enough to totally disturb the fragile balance. Also
280
problems with medication management belong to this category. When necessary the nursing staff will take over, but from the start we systematically try to create independency for the patient as much as possible. Relaxation In the basic programme, relaxation instruction is offered as group therapy. However, this is not adequate for every patient. It is possible that someone needs more help or that the instructions need to be more specifically designed for the individual patient. This applies especially to patients who suffered from anxiety before their cardiac problems. It is also possible that a patient needs more extensive training in breathing. If this is the case, the patient is individually instructed by a physiotherapist. Often such patients also need extra attention from other disciplines. To streamline these activities, the different therapists frequently keep in touch with each other. Individual counselling Finally, individual counselling by social work or psychology is possible. Psychosocial problems that can be linked directly to the cardiac condition are treated. Problems that have existed for a longer period oftime are only dealt with if they hinder the rehabilitation process. For these problems patients are generally referred to the appropriate institution.
Discussion The change in the population in cardiac rehabilitation at Hoensbroeck is in line with the changes in cardiac rehabilitation in the Netherlands. Soons and Bar reported that in 1985 only 5% of the cardiac patients sent to cardiac rehabilitation were over the age of 70 years, in 1987 this had already increased to 10%.5 According to Bar and Falger& in 1989 this appeared to have increased up to 17%. The percentage of women who were offered cardiac rehabilitation increased accordingly from 13% in 1985 to 26% in 1989. The fact that the numbers presented here are even higher is on one hand related to the fact that the data are more recent. A further increase of this trend is shown over time. On the other hand this is linked with the fact that in Hoensbroeck only patients with complex
Netherlands Heart Journal, Volume 10, Number 6, June 2002
Cardiac rehabilitation and the changing cardiac rehabilitation directions in Hoensbroeck rehabilitation centre
problems are rehabilitated. Due to the tendency to perform surgery on older and sicker patients, the average age has increased: this explains the large number ofwomen. The comparison between the total population of all surgical patients in Maastricht and the part of that population that is rehabilitated in Hoensbroeck (16%) illustrates the same point: the highly selected population admitted in Hoensbroeck is older and has more complex medical problems than the regular population. That is why rehabilitation in Hoensbroeck differs from cardiac rehabilitation given on an outpatient basis in regular hospitals. The Dutch Society ofCardiology and the Netherlands Heart Foundation published the directions for cardiac rehabilitation in 1995. Its further elaborations in several treatment modules in 1996 are another important development in the field of cardiac rehabilitation in the Netherlands. What are the differences between the programme described in this article and this advice? As mentioned earlier, in Hoensbroeck patients with complex problems are hospitalised. During cardiac rehabilitation complex problems and many rehabilitation subgoals of a varied nature should be aimed at. Thus, as well as somatic goals, there are psychological, social and secondary prevention subgoals that need attention. In the notation 'Cardiac Rehabilitation, premises for the provision ofcardiac rehabilitation' simple, multiple and complex problems are distinguished.7 For patients with complex problems, specialised cardiac rehabilitation is a necessity. Contrary to the programmes for patients with simple and multiple problems, this programme is characterised by an individual approach. The problem is that the several cardiac rehabilitation modules as given by the Netherlands Heart Foundation (FITshort, FIT-long, Info module, Psycho Educative Prevention module and Relaxation instruction) are not the answer to this. They only focus on one category of subgoals and together these do not automatically form a complete rehabilitation package that is tailormade. On the contrary, our premise is that in complex cardiac rehabilitation, several more or less separate modules should not be used: one integrated programme for the individual patient is needed. In this programme the means and principles from the directions should be designed differently. The programme for complex cardiac rehabilitation in Hoensbroeck is an example of such an integrated approach and forms an excellent completion or further elaboration to the directions ofcardiac rehabilitation. U References 1 2
3
Bar FW, Vonken HJM. Wat is het nut van hartrevalidatie? Ned Tiydschr Geneeskd 1990;3:107-12. Revalidatiecommissie. Richtlijnen hartrevalidatie deel I. Nederlandse Vereniging voor Cardiologie en de Nederlandse Hartstichting, 1995. Revalidatiecommissie. Richtlijnen hartrevalidatie deel II. Nederlandse Vereniging voor Cardiologie en de Nederlandse Hartstichting, 1996.
Netherlands Heart Joumal, Volume 10, Number 6, June 2002
4
5 6 7
Cluitmans JJM, Vonken H, Bar F. Hartrevalidatie deel 6: Hartrevalidatie in revalidatiecentrum 'Hoensbroeck'. Cardiologie 1996;3: 367-9. Soons PHGM, Bar FW. Revalidatie van hartpatienten tijdens opname en ontslag uit het ziekenhuis: cijfers en trends. Ned Tijdschr Geneeskd 1990;3:103-6. Bar FW, Falger P. Hartrevalidatie. In: Roelandt J, Lie K, Wellens H, WerfF van de, red. Leerboek Cardiologie. Houten: Bohn, Stafleu, Van Loghum, 1995:609-17. Zorgverzekeraars Nederland, Nederlandse Vereniging van Ziekenhuizen, Vereniging van Revalidatie-Instellingen in Nederland, Nederlandse Vereniging voor Cardiologie, Vereniging van Artsen voor Revalidatie en Physiche Geneeskunde, Nederlandse Hartstichting. Hartrevalidatie: uitgangspunten voor de verstrekking van hartrevalidatie, July 2000.
Appendix Case I Mrs B. is a 69-year-old married woman. She had been complaining about fatigue and pain in the chest for a long time. Medication was insufficiently effective. Coronary angiography revealed two-vessel disease. It was decided to perform a PTCA. Five months later she suffered a myocardial infarction; during that admission emergency CABG was carried out. During the postoperative period several complications occurred: mediastinitis and a right ventricle rupture. This last was overstitched. Ultimately she had an omentumplastic because ofthe infection. Seven weeks later she was transferred from hospital to the rehabilitation centre. Initially, sending her to a nursing home was considered, but it was decided to refer her to Hoensbroeck because of the knowledge and experience of the cardiac rehabilitation section in cardiovascular complications and infected wounds. On admission at Hoensbroeck she could hardly walk 80 metres, and she had to rest every 10 metres. She was very insecure: she did not dare to move her hands above her head, because of the omentum-plastic. The fact that her cardial pulsations were clearly visible at the front ofthe thorax frightened her considerably. Moreover, she was homesick, which is not strange after a three-month stay in the hospital. The basic programme was offered to Mrs B., in a slow built-up manner, with extra attention from the physiotherapist and the occupational therapist and supporting sessions with the social worker. No cardiac complications occurred. The thorax wound that had initially been infected, gradually calmed down and started to heal. She was discharged after four weeks and was treated for a further four weeks in daycare (twice a week). After rehabilitation she could walk one kilometre, she was used to seeing her breast pulsations, she dared to move her hands above her head and she was able to treat her wounds. She now has domestic help and she is able to do the housekeeping together with her husband. Her only problem is that she is physically not at the same level as she used to be before surgery. Case 2 Mr. C is an 80-year-old widower, who could sfill manage at home quite well before the operation. He underwent
281
Cardiac rehabilitation and the changing cardiac rehabilitation directions in Hoensbroeck rehabilitation centre
CABG. The postoperative course was uncomplicated except for atrial fibrillation. Nevertheless, physically he was not able to get the engine started and he was still slightly confused. That is why he was transferred from the operating hospital to a peripheral hospital after 12 days. Two weeks later he was sent to the rehabilitation centre. When hospitalised he proved to be almost independent in his daily activities, but he tired very quickly. He was afraid that he would no longer be able to function independently and that he would have to go to a retirement home. He walked 200 metres with great difficulty using a stick. The basic programme was offered to him. He experienced the exercises as being very hard, so the programme was adapted. Apart from physical reconditioning, he was mainly taught to do things at a slower pace. When discharged he was able to walk one kilometre at a slow pace with a stick. He was able to take care of his housekeeping again with the help ofvoluntary aid.
Case 3 Miss A. is a 55-year-old divorced lady. She suffered a myocardial infarction eight years ago. The last year she had a numb, painfild feeling in her arms and an op-
282
pressive feeling in her chest. She quit working as a volunteer. She was seen by a cardiologist who felt that she had severe angina refractory to medication. He decided to perform angiography. Three-vessel disease was found. After the cardiac catheterisation it was decided to perform bypass surgery. The CABG was uncomplicated. She had rehabilitation in her hospital on an outpatient basis. However, insufficient progress during the rehabilitation process resulted in referral to Hoensbroeck. At the beginning of the rehabilitation programme she was very insecure and gloomy, and she complained about the same feelings in her chest as she had had before the operation. She did not dare to stay at home alone. Therefore she mobilised her family and friends to keep her company during the day and at night. During the basic programme no indications of angina were present. Also the exercise test proved to be negative. She'visited the psychologist twice during the rehabilitation phase. After a special training programme focussing on her anxiety, she dared to stay at home alone again and she was able to function independently. Her mood was appropriate. She has stopped voluntary work because of other longer existing, phobic complaints, for which she does not want to be referred.
Netherlands Heart Joumal, Volume 10, Number 6, June 2002
Cardiac rehabilitation and the changing cardiac rehabilitation directions in
Hoensbroeck rehabilitation centre P.AKH.F. van de Sande, Y.M.C. Curfs, A.M.T.M. Derks, J.J.J. Graus, J.G. Maessen, F.W. Bar
Hoensbroeck Rehabilitation Centre has been providing inpatient and outpatient cardiac rehabilitation services since 1980. In these twentyyears the patient population has changed considerably. Rehabilitation is currendy focussing on the complex and often old patient The programme that has been developed during this period consists of standard activities that are mainly group oriented. However, certain actMities are provided on an individual basis. Based upon this variety of actiities, a tailor-made programme can be composed for every individual meis compared patient Ifthe Hoensbro ro with the directions given by the Dutch Sodety of Cardiology and the Netherlands Heart Foundation, the main difference is the use of an integrated approach instead of separate modules. In our view, this is a must for complex cardiac rhabilitaton (NethHeart J2002;10:277-82.)
valve surgery, often have to deal with physical and psychosocial problems. The goal ofcardiac rehabilitation has stayed the same over the years, namely recovery of the physical, psychological and social functioning to the level before the incident.' In these twenty years the team's composition, with a representation from medical, paramedical as well as psychosocial disciplines, has not changed fundamentally. The treatment programme, however, has been adapted to the changed population. In this artide, we will first present some data concerning the changes in the population being treated, then we will discuss the contents of the current treatment programme and we will finish by looking at the relationship between the Hoensbroeck programme and several developments in cardiac rehabilitation over the past few years, particularly the cardiac rehabilitation directions as formulated by the Dutch Society of Cardiology and the Netherlands Heart Foundation.2'3
Key words: cardiac rehabilitation, programme, old patients
The changed population Earlier research provided us with data from the period 1985-1991. By means of a retrospective record search, data from 1999 were gathered. Some demographic data were also collected from our patient administration for 2001. It appeared that the number of patients aged 70 and over has increased from 11% in 1985, to 28% in 1991, to 48% in 1999 and to 56% in 2001. Furthermore, there was an increase in female patients. In 1986 one-third ofthe population consisted of women. In 1999 slightly more women than men were being rehabilitated and in 2001, 50% of our population were women. In our 1999 population, 150 patients (64%) underwent cardiac surgery in the University Hospital Maastricht in 1999. When we select this group, a comparison with the total population of surgery patients in Maastricht in 1999 can be made. As shown in table 1, our group is clearly older than the total surgery population. Furthermore, the percentage of valve operations is higher in the Hoensbroeck population. In other words, mainly the elderly and more complex patients are referred to Hoensbroeck. Table 2 shows that not only severe physical problems but also especially psychosocial problems are more common
r'ncouraged by the medical insurance companies, the OHoensbroeck Rehabilitation Centre started cardiac rehabilitation in 1980. At first, the patients were primarily young men who were being referred after an uncomplicated coronary artery bypass graft (CABG). Nowadays, the patient population consists mainly of elderlypeople often with substantial premorbid physical problems who, after a frequently complex CABG or P.A.H.F. van de Sands. Y.M.C. Curfs. A.M.T.M. Doks. JJJ. Graus. Hoensbroeck Rehabilitation Centre, Zandbergsweg 111, 6432 CC Hoensbroek.
J.G. Maesen. F.W. Bir. University Hospital Maastricht, PO Box 5800, 6202 AZ
Maastricht.
Address for correspondence: P.A.H.F. van de Sande. E-mail: [email protected]
Netherlands Heart Journal, Volume 10, Number 6, June 2002
277
Cardiac rehabilitation and the changing cardiac rehabilitation directions in Hoensbroeck rehabilitation centre
Tabe 1. The total population of cardiac surgery patients from the Maastricht University Hospital in 1999 compared with the selection of that group which was rehabilitated in Hoensbroeck in 1999. Surgical candidates In Maastricht (1999)
Rehablitation patints In Hoensbroeck (1999) 16
150
100
952
70.2 (±8.4)
64.7 (± 9.9)
Age in years (mean/sd) Older than 70 years Women CABG (novalve) Valve (+ other)
61 52 65 34
91 78 98 51
34 29 76 21
319 274 726 202
among
the 1999 patient population. The percentage of patients suffering from pump function disturbances has increased from 3% to 8% and the percentage of patients with (mainly superventricular) arrhythmias from 4% to 11%. To further illustrate the type of patients rehabilitated in Hoensbroeck Rehabilitation Centre, case reports ofthree patients are included.
To start with, most programme parts are group activities. Working with a group is not only efficient, it is also effective because the patient performs these activities in a group of fellow sufferers. The fact that others, who have already been rehabilitating for a longer period and have undergone the same operation, have made so much progress and are able to do so many more things will give hope and trust to the new-
The treatment programme In Hoensbroeck all patients are offered several parts of the basic programme. Table 3 shows a survey of these activities. As many programme parts can have an increasing intensity ofactivities or can be emphasised in various ways, it is possible to compose a programme focussed on an individual patient with his or her specific goals in mind, taking into account his or her possibilities and limitations. The individual programmes do, however, have a number of common characteristics.
comers.
Table 2. Physical and psychosocial problems on admission.
-
Severe physical problems when hospitallsed
1986 (n=911) 1999 (n=236) n
%
n
%
6 6 5 8 8
3 3 2 4 4
5 19 5 27 20
2 8 2 11 8
Depression
30 13
14 6
56 40
24 17
Being single Relationship problems Work
39 7 35
18 3 17
116 14 33
49 6 14
Cardiac problems Angina (NYHA 2-4) Dyspnoea (NYHA 3-4) Conduction disturbances Arrhythmia Neurological problems
Psychosocial problems at admission Extreme anxiety
278
Second, functional moving is paramount in almost activities. There are only few moments (once to twice a week) when patients talk together; the rest consists of moving together. This moving is packed in useful activities that have to do with sports, play, housekeeping, body care, locomotion, leisure activities or work. Especially in the last part ofthe rehabilitation programme, when working in the Rehabilitation Centre is less intensive (two days a week), patients get to do assignments at home to put what they have learned into practice. Moreover, in this way we confront them very implicitly with the fact that moving is safe and can be pleasant (again). Third, the movement activities are repeated several times daily: this is important, as learning requires repetition. Apart from the learning by repetition, there is sufficient room for variation: the same message is offered in a broad spectrum of activities, every time in a slightly different way. This variation is important in view of generalisation. However, it does require the therapists to be a good team and pass on things that matter to each other quite quickly. In other words: an important learning point during one day should be repeated the next day given as another activity. A fourth point that returns in all activities is reflection on moving and feedback. Although moving is the central issue in most activities, there is more involved than pure moving. The patients are asked to consider the sensations that particular movements cause. This sensation is also discussed with the patient. The patient and the therapist together will try to find an explanation for these sensations. Eventually the goal is that people feel at home in their own bodies. For others the learning moments are showing them the fact that signals from the body have to be managed all
-
Netherlands Hcart Journal, Volume 10, Number 6, June 2002
Cardiac rehabilitation and the changing cardiac rehabilitation directions in Hoensbroeck rehabilitation centre
Table 3. Parts of the basic programme. Type of activity
Number of levels
Frequency
Medical - nursing care Hometrainer cycling Movement therapy Walking (Movement economy)' (Play at skittles) (Swimming) (Sport and play) (Outdoor cycling) (Individual occupational training) (Work therapy or household training) Intro group Info group Family day Partner group
n/a continuous 4 continuous different accents different accents different accents different accents continuous different accents different accents n/a n/a n/a n/a
24 hour care max. max. max. max. max. max. max. max. max. max. max. max. max. max.
once a day once a day twice a day twice a week twice a week twice a week once a day once a day twice a week twice a week once per hospitalisation once a week once every 2 weeks once every 2 weeks
'The activities in brackets are not offered to all patients, but to most of them.
carefully: fatigue is a signal, pain is a signal. These signals cannot be ignored for a long time without the patient being punished for it. Initially, every patient is supervised carefully in all movements: the exertion increases gradually, the exertion is registered (ECG, heart rate) and a supervisor is present. When the exercises are performed properly, not only the exertion is increased gradually, but also the supervision will be reduced. This is because the best way to deal with anxiety is graded exposure to the stimulus that causes the anxiety. This means a gradual increase of exertion for the cardiac patient and a gradual decrease in supervision by the therapists. Finally, during all the movement activities themes related to secondary prevention are regularly discussed. Earlier we mentioned that listening to one's own body's signals is important. It is pointed out to patients that they have to alternate physical activities with rest. They are not only told this, such behaviour is part of the programme: also resting periods are planned. For many patients it is completely new that such breaks between activities should be planned. Apart from relaxation instruction, people are taught to be more economical with their energy, which is generally quite limited. The info groups pay a great deal of attention to themes such as information about various forms of cardiac suffering, quitting smoking, healthy nutrition, compliance with medication and coping with stress more prudently, in accordance with the advice of the Netherlands Heart Foundation. Some parts of the programme are not followed by all patients simply because this is not necessary. These are summed up in table 4 and will be elucidated further on.
Netherlands Heart Journal, Volumc 10, Number 6, June 2002
Anxiety
Anxiety is a very common emotion in cardiac patients. Sometimes the standard approach is not sufficient. People could have been slightlyphobic before the cardiac condition started or traumatic incidents could have taken place at about the same time as the cardiac event. In such cases an individual programme is set out: a hierarchy of anxiety provoking situations is made and a plan is drawn up in consultation with the patient. They are put in such circumstances but this time accompanied by a psychology assistant. For example, we go in search of lonely places to take a walk outside the terrain ofthe Rehabilitation Centre orwe visit rather crowded shops. Here too, homework assignments without supervision play an important role, just like the principles ofcognitive restructurng. Moreover, skills are used that are taught in relaxation instruction and breathing therapy. -
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Work
A small number of patients rehabilitated in Hoensbroeck are still working. Return to work is planned after the rehabilitation. For those individuals a function analysis is made. This means that the occupational therapist maps out the contents and the physical condition required for the job. The physiatrist and the cardiologist evaluate whether the cardiac condition is sufficient for the job. The psychologist passes a judgement on psychological strength and stressful factors at work. The social worker finally looks into financial and social security matters. The team members all discuss their findings with the patient and with each other, and formulate a united advice. Together with the patient we consult the employer and the company medical officer, constructing a reintegration plan.
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Table 4. Parts of the additional programme. Type of activity
Disciplines Involved
Street training Return to work Exercise training Weekend preparation General daily activity training Individual relaxation therapy Individual counselling
Psychology Occupational therapy, social work, psychology, physiatry, cardiology Physiotherapy Nursing care, social work, occupational therapy Nursing care Physiotherapy Social work, psychology, occupational therapy
Exercise
In the physical training of the basic programme, we focus on optimising exercise tolerance. Emphasis is put on coordination of movements, moving in a relaxed way and moving efficiently, not on maximising the exercise tolerance. A real exercise training is only implemented when the patients start working at more than 50-60% oftheir maximal capacity. This is not the primary goal for most patients because we try to enable people to rebuild a normal life rhythm. For the majority of our patient population it is unnecessary to exert oneself to the utmost. We add a heavier exercise training to the programme for those patients who want to start with sports on a competitive level or with people who will have to carry out heavy, physical work.
Weekend The weekend is an important part ofthe rehabilitation programme, especially for those people hospitalised in the Rehabilitation Centre. Some of these patients can function well within the surroundings of the Centre, but cannot function at all at home. That is why we insist that people go home in the weekends as soon as possible. For single people (almost halfof our patient population) this proves to be a major problem. Depending on the nature of the problems, a plan is made in collaboration with the patient and possibly their family or neighbours, by nursing care, occupational therapy or social work. In most cases initial relief and some supervision is arranged. When the patient returns to the Centre the weekend is evaluated and plans are modified for the next weekend. General daily activities A number of patients (especially elderly) do have problems with general daily activities in the first penod after the operation: they have difficulty washing or dressing themselves. These problems more commonly occur in patients who are confused after the operation, for people who were bedridden for a long time due to complications, or for people who could only just manage at home independently before the event. An interfering occasion like hospitalisation or an operation is enough to totally disturb the fragile balance. Also
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problems with medication management belong to this category. When necessary the nursing staff will take over, but from the start we systematically try to create independency for the patient as much as possible. Relaxation In the basic programme, relaxation instruction is offered as group therapy. However, this is not adequate for every patient. It is possible that someone needs more help or that the instructions need to be more specifically designed for the individual patient. This applies especially to patients who suffered from anxiety before their cardiac problems. It is also possible that a patient needs more extensive training in breathing. If this is the case, the patient is individually instructed by a physiotherapist. Often such patients also need extra attention from other disciplines. To streamline these activities, the different therapists frequently keep in touch with each other. Individual counselling Finally, individual counselling by social work or psychology is possible. Psychosocial problems that can be linked directly to the cardiac condition are treated. Problems that have existed for a longer period oftime are only dealt with if they hinder the rehabilitation process. For these problems patients are generally referred to the appropriate institution.
Discussion The change in the population in cardiac rehabilitation at Hoensbroeck is in line with the changes in cardiac rehabilitation in the Netherlands. Soons and Bar reported that in 1985 only 5% of the cardiac patients sent to cardiac rehabilitation were over the age of 70 years, in 1987 this had already increased to 10%.5 According to Bar and Falger& in 1989 this appeared to have increased up to 17%. The percentage of women who were offered cardiac rehabilitation increased accordingly from 13% in 1985 to 26% in 1989. The fact that the numbers presented here are even higher is on one hand related to the fact that the data are more recent. A further increase of this trend is shown over time. On the other hand this is linked with the fact that in Hoensbroeck only patients with complex
Netherlands Heart Journal, Volume 10, Number 6, June 2002
Cardiac rehabilitation and the changing cardiac rehabilitation directions in Hoensbroeck rehabilitation centre
problems are rehabilitated. Due to the tendency to perform surgery on older and sicker patients, the average age has increased: this explains the large number ofwomen. The comparison between the total population of all surgical patients in Maastricht and the part of that population that is rehabilitated in Hoensbroeck (16%) illustrates the same point: the highly selected population admitted in Hoensbroeck is older and has more complex medical problems than the regular population. That is why rehabilitation in Hoensbroeck differs from cardiac rehabilitation given on an outpatient basis in regular hospitals. The Dutch Society ofCardiology and the Netherlands Heart Foundation published the directions for cardiac rehabilitation in 1995. Its further elaborations in several treatment modules in 1996 are another important development in the field of cardiac rehabilitation in the Netherlands. What are the differences between the programme described in this article and this advice? As mentioned earlier, in Hoensbroeck patients with complex problems are hospitalised. During cardiac rehabilitation complex problems and many rehabilitation subgoals of a varied nature should be aimed at. Thus, as well as somatic goals, there are psychological, social and secondary prevention subgoals that need attention. In the notation 'Cardiac Rehabilitation, premises for the provision ofcardiac rehabilitation' simple, multiple and complex problems are distinguished.7 For patients with complex problems, specialised cardiac rehabilitation is a necessity. Contrary to the programmes for patients with simple and multiple problems, this programme is characterised by an individual approach. The problem is that the several cardiac rehabilitation modules as given by the Netherlands Heart Foundation (FITshort, FIT-long, Info module, Psycho Educative Prevention module and Relaxation instruction) are not the answer to this. They only focus on one category of subgoals and together these do not automatically form a complete rehabilitation package that is tailormade. On the contrary, our premise is that in complex cardiac rehabilitation, several more or less separate modules should not be used: one integrated programme for the individual patient is needed. In this programme the means and principles from the directions should be designed differently. The programme for complex cardiac rehabilitation in Hoensbroeck is an example of such an integrated approach and forms an excellent completion or further elaboration to the directions ofcardiac rehabilitation. U References 1 2
3
Bar FW, Vonken HJM. Wat is het nut van hartrevalidatie? Ned Tiydschr Geneeskd 1990;3:107-12. Revalidatiecommissie. Richtlijnen hartrevalidatie deel I. Nederlandse Vereniging voor Cardiologie en de Nederlandse Hartstichting, 1995. Revalidatiecommissie. Richtlijnen hartrevalidatie deel II. Nederlandse Vereniging voor Cardiologie en de Nederlandse Hartstichting, 1996.
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5 6 7
Cluitmans JJM, Vonken H, Bar F. Hartrevalidatie deel 6: Hartrevalidatie in revalidatiecentrum 'Hoensbroeck'. Cardiologie 1996;3: 367-9. Soons PHGM, Bar FW. Revalidatie van hartpatienten tijdens opname en ontslag uit het ziekenhuis: cijfers en trends. Ned Tijdschr Geneeskd 1990;3:103-6. Bar FW, Falger P. Hartrevalidatie. In: Roelandt J, Lie K, Wellens H, WerfF van de, red. Leerboek Cardiologie. Houten: Bohn, Stafleu, Van Loghum, 1995:609-17. Zorgverzekeraars Nederland, Nederlandse Vereniging van Ziekenhuizen, Vereniging van Revalidatie-Instellingen in Nederland, Nederlandse Vereniging voor Cardiologie, Vereniging van Artsen voor Revalidatie en Physiche Geneeskunde, Nederlandse Hartstichting. Hartrevalidatie: uitgangspunten voor de verstrekking van hartrevalidatie, July 2000.
Appendix Case I Mrs B. is a 69-year-old married woman. She had been complaining about fatigue and pain in the chest for a long time. Medication was insufficiently effective. Coronary angiography revealed two-vessel disease. It was decided to perform a PTCA. Five months later she suffered a myocardial infarction; during that admission emergency CABG was carried out. During the postoperative period several complications occurred: mediastinitis and a right ventricle rupture. This last was overstitched. Ultimately she had an omentumplastic because ofthe infection. Seven weeks later she was transferred from hospital to the rehabilitation centre. Initially, sending her to a nursing home was considered, but it was decided to refer her to Hoensbroeck because of the knowledge and experience of the cardiac rehabilitation section in cardiovascular complications and infected wounds. On admission at Hoensbroeck she could hardly walk 80 metres, and she had to rest every 10 metres. She was very insecure: she did not dare to move her hands above her head, because of the omentum-plastic. The fact that her cardial pulsations were clearly visible at the front ofthe thorax frightened her considerably. Moreover, she was homesick, which is not strange after a three-month stay in the hospital. The basic programme was offered to Mrs B., in a slow built-up manner, with extra attention from the physiotherapist and the occupational therapist and supporting sessions with the social worker. No cardiac complications occurred. The thorax wound that had initially been infected, gradually calmed down and started to heal. She was discharged after four weeks and was treated for a further four weeks in daycare (twice a week). After rehabilitation she could walk one kilometre, she was used to seeing her breast pulsations, she dared to move her hands above her head and she was able to treat her wounds. She now has domestic help and she is able to do the housekeeping together with her husband. Her only problem is that she is physically not at the same level as she used to be before surgery. Case 2 Mr. C is an 80-year-old widower, who could sfill manage at home quite well before the operation. He underwent
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CABG. The postoperative course was uncomplicated except for atrial fibrillation. Nevertheless, physically he was not able to get the engine started and he was still slightly confused. That is why he was transferred from the operating hospital to a peripheral hospital after 12 days. Two weeks later he was sent to the rehabilitation centre. When hospitalised he proved to be almost independent in his daily activities, but he tired very quickly. He was afraid that he would no longer be able to function independently and that he would have to go to a retirement home. He walked 200 metres with great difficulty using a stick. The basic programme was offered to him. He experienced the exercises as being very hard, so the programme was adapted. Apart from physical reconditioning, he was mainly taught to do things at a slower pace. When discharged he was able to walk one kilometre at a slow pace with a stick. He was able to take care of his housekeeping again with the help ofvoluntary aid.
Case 3 Miss A. is a 55-year-old divorced lady. She suffered a myocardial infarction eight years ago. The last year she had a numb, painfild feeling in her arms and an op-
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pressive feeling in her chest. She quit working as a volunteer. She was seen by a cardiologist who felt that she had severe angina refractory to medication. He decided to perform angiography. Three-vessel disease was found. After the cardiac catheterisation it was decided to perform bypass surgery. The CABG was uncomplicated. She had rehabilitation in her hospital on an outpatient basis. However, insufficient progress during the rehabilitation process resulted in referral to Hoensbroeck. At the beginning of the rehabilitation programme she was very insecure and gloomy, and she complained about the same feelings in her chest as she had had before the operation. She did not dare to stay at home alone. Therefore she mobilised her family and friends to keep her company during the day and at night. During the basic programme no indications of angina were present. Also the exercise test proved to be negative. She'visited the psychologist twice during the rehabilitation phase. After a special training programme focussing on her anxiety, she dared to stay at home alone again and she was able to function independently. Her mood was appropriate. She has stopped voluntary work because of other longer existing, phobic complaints, for which she does not want to be referred.
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