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Clinical Populations

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Individualize the exercise program (duration, intensity, freq) ... Modified program': risk stratification, home exercise, telephone contact support ... – PowerPoint PPT presentation

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Title: Clinical Populations


1
Clinical Populations Cardiac Rehabilitation
  • KINE 2000
  • Psychology of Physical Activity

2
Overview
  • Exercise Therapy in clinical populations
  • Psychosocial factors associated with heart
    disease
  • Cardiac rehabilitation
  • Home-based

3
Exercise Therapy
  • Set of procedures aimed at facilitating improved
    physical mental functioning
  • Exercise can be an inexpensive, time-efficient
    adjunct to traditional psychological therapy
  • Less side effects,
  • with other positive health effects (e.g.,
    cardiovascular, weight management)

4
Benefits of PA as Tx for Mental Health Problems
  • Self-administration
  • Convenience
  • Low Cost
  • Minimal Side Effects
  • Social Acceptability
  • Ancillary physical benefits decreased health
    problems

5
Psychiatric Populations Treated
  • Clinical Depression Anxiety
  • Developmental Disabilities
  • Schizophrenia
  • Pain Disorders
  • Substance abuse disorders
  • Alcohol
  • Smoking

6
Psychological Benefits of Exercise
  • Clinically Depressed Patients
  • Aerobic and anaerobic reduce depression
  • More depressed individuals benefit most
  • Just as beneficial as psychotherapy drug
    therapy
  • Long term exercise regime more effective than
    short term programs
  • Children and Elderly
  • Exercise habits by parents influences children
    and affects their perception of their competence
    and goal orientation
  • Exercise in elderly slows decline of cognitive
    functions
  • Disabled Individuals

7
Guidelines for Exercise Therapy
  • A precise diagnosis of the psychological problem
    is needed
  • Exercise should be used as an adjunct to other
    forms of therapy
  • Individualize the exercise program (duration,
    intensity, freq)
  • A variety of aerobic activities appear to produce
    best effects

8
Clinical Practice
  • Explore clients exercise and medical history
  • Examine clients physical ability and motivation
  • Explain the benefits of exercise
  • Make exercise enjoyable, practical, functional
    (e.g., cycling to work)
  • Evaluate clients support system
  • Teach self-regulation strategies to plan for
    barriers to adherence
  • Evaluate progress
  • Provide useful feedback

9
Heart Disease
10
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11
Burden of Cardiovascular Disease (CVD)
  • CVD is the leading cause of morbidity and
    mortality in Canada, and the developed world
  • 1 in 4 Canadians have some form of CVD
  • 3 in 4 Ontarians 18 -74 have gt 1 major CV risk
    factor
  • CVD is expensive 5.5 billion or 2 GNP in
    Ontario
  • Aging population Burden of heart disease and
    stroke will increase by 77 by 2026

Heart and Stroke Foundation of Canada (1999). The
changing face of heart disease and stroke in
Canada 2000, 1-107, Ottawa.
12
Heart Disease Risk Factors
  • High blood pressure (aka Hypertension)
  • Family history
  • Cigarette smoking
  • High LDL and total cholesterol levels
  • Physical inactivity
  • Diabetes
  • Obesity
  • Stress

13
Behavioural Risk Factors
  • Exercise Cdn ?more physically inactive
  • (56.9) than ?(48.6 NPHS 98/99)
  • Obesity increases with age, higher among men
    than women
  • CCHS ? 41 overweight 27 obese
  • Central adiposity apple vs. pear

14
  • Smoking stronger risk factor for AMI in
    middle-aged women than men, women who use OCs
  • Incidence of smoking among young ??
  • Smoking highest in Quebec Atlantic provinces

15
Vulnerable Sub-groups
  • Socio-economic status less education more likely
    to show early signs of atherosclerosis
  • Lower SES have higher rates of smoking, ?BP, high
    fat diet, DM, inactivity, obesity
  • Low SES less angiography, higher mortality
    (Alter, 1999)
  • Mediated by social isolation, coping style,
    health behaviour, job strain, anger / hostility?

16
Vulnerable Sub-Groups
  • Ethnicity / Culture South Asian highest rates of
    CVD among Canadians
  • Higher morbidity and mortality (Bhopal, 2002)
  • Insulin resistance, physical inactivity, obesity

17
Psychosocial Issues in CVD
  • If you are working with heart patients, what
    should you be on the lookout for??

18
Primary Prev Possible Etiological Role for
  • Type A /hostility
  • Depression
  • Anxiety
  • Psychosocial work characteristics high demands,
    low control
  • Social Support

19
Hostility
  • Do you often find it difficult to fall asleep or
    difficult to stay asleep because you are upset
    about something a person has done? 
  • Do you believe that most people are not honest or
    are not willing to help others? 
  • Do you become irritated when driving or swear at
    others? 
  • Does your partner, when riding with you, ever
    tell you to cool or calm down? 
  • Do you often have a feeling that your partner is
    competing against you or is too critical of your
    inadequacies? 
  • Does the car-driving errors of other drivers, the
    indifference of store clerks, or the tardiness of
    mail delivery upset you significantly?  

20
Secondary Prevention Prognostic role.
  • Depression 2-3fold increase in mortality
    (Frasure-Smith)
  • Anxiety
  • Work Characteristics
  • Social Support / Isolation

21
Depression
  • Independent risk factor for heart disease
    (Cochrane Collaborative Review)
  • Prevalence after coronary event ranges from
    15-23 (Lavie et al., 1999)
  • Decreases likelihood of adhering to lifestyle
    changes
  • Leads to poorer recovery (Arnold, 1997 Carney,
    Freedland, Jaffe, 1990 Frasure-Smith et al.,
    1993 1999 Ziegelstein et al., 2000)
  • Women experience more depression than men, 21
    (Ai et al., 1997 Bosworth, 2000 Hamilton et
    al., 1993 Halm et al., 2000 Lavie et al., 1999)

22
Anxiety
  • Early and intense response to MI
  • Investigated less often than depression (Abbey
    Stewart, 2000)
  • Women at greater risk (Brezinka et al., 1998
    Frasure-Smith et al., 1999 Halm et al., 2000
    Schuster Waldron, 1991)
  • Predictive of recurrent coronary events (Eaker et
    al., 1992 Frasure-Smith et al., 1999)
  • Anxiety could compromise performance of
    activities in CR but anxiety could be reduced
    through education and support in CR

23
Social Support Recovery
  • Emotional sustenance, informational guidance,
    tangible assistance
  • Gender differences (Ahto et al., 1997 Conn et
    al., 1991 Halm et al., 1999 Eaker, 1998
    Orth-Gomer, 2000)
  • women more often widowed
  • lack of spousal support related to lower program
    compliance rates in women (Halm et al., 1999)
  • Source physician referral, encouragement from
    adult children (Lieberman, Meana, Stewart,
    1998)

24
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25
Why Secondary Prevention?
  • Health risks continue after cardiac event
    therefore, secondary preventive efforts are
    important
  • Risk of recurrence is 47 in the first year

26
What is Cardiac Rehabilitation?
  • World Health Organization definition
  • the sum of activity required to ensure cardiac
    patients the best possible physical, mental and
    social conditions so that they may, by their own
    effort, regain as normal as possible a place in
    the community and lead an active life.

27
Cardiac Care and Heart Health Program at TWH
  • Team members
  • Dietitian
  • Registered nurse
  • Kinesiologist
  • Nurse practitioner
  • Pharmacist
  • Psychologist
  • Cardiologist
  • 6 languages

28
Cardiac Rehabilitation (CR)
  • Outpatient CR has two major components over 4-6
    months
  • Exercise training (avg. 2x / wk.)
  • Education and counseling
  • medications, nutrition, maintenance of health
    behaviour change, smoking cessation, support,
    stress reduction, depression

29
Rehabilitation Includes
  • Exercise
  • Physiological and psychological benefits
  • Weight management
  • Smoking cessation
  • Lipid and BP management including evidence-based
    medications (titrated) dietary changes
  • Stress management
  • Vocational Counselling

30
Beneficial Effects of CR
  • A multifactoral Cardiac Rehabilitation (CR)
    program can reduce mortality by 25 compared to
    usual MD care (Carhart Ades, 1998)
  • CR reduces use of interventional procedures
  • CR reduces blood lipid (cholesterol) levels,
  • improves psychosocial well-being,
  • aids in stress reduction,
  • reduces cigarette smoking,
  • improves exercise tolerance,
  • and reduces need for, and cost of
    re-hospitalization

31
  • Exercise is the key component but
  • 50 drop-out rate within first 6 months
  • For those who continue benefits include
  • Improved self concept, perceived health,
    involvement in social activities, return to work.
  • Those who stop are more likely to
  • Smoke, have poorer cardiac function, have higher
    body weight, be more sedentary, experience
    greater anxiety and depression.

32
CR in Ontario
  • Uptake
  • 16 CR programs in Ontario
  • 16,033 referrals to CR in Ontario in 2002
  • 11, 883 intakes

33
Referral and Uptake
  • Physician guidelines for referral show few real
    contraindications to participation in stable
    patients (AACVPR CACR)
  • But only 15-20 use CR
  • Should be referred regardless of age, gender, or
    whether they have arthritis or depression

34
Referral and Participation in Ontario
  • Of the estimated 100,000 people living with CVD
    in Ontario, the current system serves lt20 of the
    population eligible for CR
  • even fewer from marginalized populations (i.e.,
    women, low SES, ethnocultural diversity)
  • Most American, Australian, UK, and Canadian data
    show lower referral of women to cardiac rehab,
    and subsequently lower uptake
  • MOHLTC funded the Cardiac Care Network (CCN) to
    assess process of providing CR in Ontario

35
Gender and Secondary Prev of CVD
  • Women may have poorer outcome the year after a
    coronary event
  • could be accounted for by comorbid conditions and
    older age
  • Demographics women have fewer psychosocial
    supports, are 10 years older, live alone, more
    likely to be retired than men (Benson, Arthur,
    Rideout, 1997 Cristian, Mandy, Root, 1999
    Shaffer Corish, 1998)
  • Women experience more mood disturbance following
    M.I.- depression, anxiety, guilt (Eaker, 1998
    Lavie, 1999 Shaffer Corish, 1998)

36
  • Most studies on CR and secondary prevention do
    not include women. Only outcome data on
    short-term QOL, functional capacity, risk factors
  • However, women who attend rehab show the same or
    greater improvements in functional capacity as
    men (Carhart Ades, 1998 Halm et al., 1999
    Hamm Kavanagh, 2000 OFarrell et al., 2000
    Richardon et al., 2000)
  • Improvement is also seen among older women (Ades
    et al., 1999)

37
Results of Patients Referred to
Participating in CR
38
Who Recommended CR?
39
Reasons for Not Attending CR Assessment
40
Patient Preferences for On-Site Versus Home-Based
Cardiac Rehabilitation
41
Home-based Cardiac Rehabilitation
  • Modified program risk stratification, home
    exercise, telephone contact support (Carlson et
    al., 2000)
  • Equivalent efficacy to hospital-based CR (Carlson
    et al., 2000)
  • A low-cost complement/ alternative to traditional
    CR, with larger catchments, and possibly, early
    integration/long-term maintenance of exercise
    behaviour (Cannistra, 2003)

42
Cardiac Care and Heart Health Program at TWH
Event
Referral (MD)
Intake to CCHH
Exercise treadmill test
Intake seminar
Hospital Program
Home Program
Risk Reduction
48 sessions total (2 or 3 session per wk.)
ea. 2 wks for 4 mos.
43
Research Question
  • What are the preferences and barriers to
    participation in home-based versus hospital-based
    cardiac rehabilitation programs?
  • Design Retrospective chart review
    cross-sectional study with mailed
    survey/questionnaire.

44
Methods
45
No significant difference between participants
and non-participants in age, gender, length of
stay in hospital after event, or length of time
between event and referral to CR.
46
Demographics of Participants, N80
47
Preferences by Self-Reported Ethnocultural
Background
48
What issues factored in decision?
49
Benefits and drawbacks of the programs?
50
Frequency, Duration and Intensity of Exercise
During and Post-CR

Mean Score

p 0.000 p 0.042
51
What Participants Liked Best About the Program
  • I found that the staff were excellent in every
    way possible.
  • I thought all of it was excellent. It's between
    the education and exercise.
  • The exercise program was and is (very) important
    in my life. (The team members) were phenomenal
    people to work with. Very non-judgmental,
    understanding, professional.
  • This program works. The staff are great people.
    They get a lot of resources for the patients. The
    cardiologist is a great doctor. He really
    treated us with support and dignity. His staff
    are wonderful people. Keep up the great work.
  • At the time I went I was much impressed with 3
    of your staff. The nurse practitioner, the
    dietician and the pharmacist. On a 1 to 1, I was
    encouraged to ask questions. Facts, ideas and
    plans were presented in an easily understandable
    manner.

52
Suggestions for improvement
  • Call patient at intervals for a brief time to
    check on progress/questions.
  • Not enough help with home exercise.
  • Limited information on progress. Did initial
    assessment and then little feedback after that,
    other than blood pressure and pulse checks.
  • At the beginning I was given a list of
    appointments, some were changed, and this was
    inconvenient.
  • Being forced to stop program because of time
    allowed - feeling like I was just starting to get
    into it.

53
Conclusions
  • Demographics
  • Non-white and Non-working (retired or other)
    participants chose the hospital-based program
  • Adherence to exercise
  • Home-based participants exercised more
    frequently, less duration DURING CR than
    hospital-based. Hospital-based participants
    exercised more frequently and less duration AFTER
    CR than BEFORE.
  • Home-based participants may better be able to
    adopt physical activity into daily life

54
Recommendations
  • Tailor the home-based program to those who work.
    They can fit in physical activity during
    off-hours.
  • Doing a great job at reaching non-white cardiac
    patients, considering they are generally
    under-represented at CR programs. Capitalize on
    their preference for the hospital-based program,
    for support and monitoring.
  • Make sure patients understand the option of home
    vs. hospital-based programs.
  • Monitor and support the home-based program more
    rigorously.

55
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56
Find Out More
  • Cardiac Care Network
  • http//www.ccn.on.ca/
  • Cdn Association of Cardiac Rehab
  • http//www.cacr.ca/
  • Canadian Cardiovascular Society
  • http//www.ccs.ca/
  • Heart and Stroke Foundation
  • www.heartandstroke.ca
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