Title: Clinical Populations
1Clinical Populations Cardiac Rehabilitation
- KINE 2000
- Psychology of Physical Activity
2Overview
- Exercise Therapy in clinical populations
- Psychosocial factors associated with heart
disease - Cardiac rehabilitation
- Home-based
3Exercise 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)
4Benefits of PA as Tx for Mental Health Problems
- Self-administration
- Convenience
- Low Cost
- Minimal Side Effects
- Social Acceptability
- Ancillary physical benefits decreased health
problems
5Psychiatric Populations Treated
- Clinical Depression Anxiety
- Developmental Disabilities
- Schizophrenia
- Pain Disorders
- Substance abuse disorders
- Alcohol
- Smoking
6Psychological 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
7Guidelines 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
8Clinical 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
9Heart Disease
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11Burden 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.
12Heart Disease Risk Factors
- High blood pressure (aka Hypertension)
- Family history
- Cigarette smoking
- High LDL and total cholesterol levels
- Physical inactivity
- Diabetes
- Obesity
- Stress
13Behavioural 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
15Vulnerable 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?
16Vulnerable Sub-Groups
- Ethnicity / Culture South Asian highest rates of
CVD among Canadians - Higher morbidity and mortality (Bhopal, 2002)
- Insulin resistance, physical inactivity, obesity
17Psychosocial Issues in CVD
- If you are working with heart patients, what
should you be on the lookout for??
18Primary Prev Possible Etiological Role for
- Type A /hostility
- Depression
- Anxiety
- Psychosocial work characteristics high demands,
low control - Social Support
19Hostility
- 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?
20Secondary Prevention Prognostic role.
- Depression 2-3fold increase in mortality
(Frasure-Smith) - Anxiety
- Work Characteristics
- Social Support / Isolation
21Depression
- 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)
22Anxiety
- 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
23Social 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)
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25Why Secondary Prevention?
- Health risks continue after cardiac event
therefore, secondary preventive efforts are
important - Risk of recurrence is 47 in the first year
26What 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.
27Cardiac Care and Heart Health Program at TWH
- Team members
- Dietitian
- Registered nurse
- Kinesiologist
- Nurse practitioner
- Pharmacist
- Psychologist
- Cardiologist
- 6 languages
28Cardiac 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
29Rehabilitation 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
30Beneficial 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.
32CR in Ontario
- Uptake
- 16 CR programs in Ontario
- 16,033 referrals to CR in Ontario in 2002
- 11, 883 intakes
33Referral 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
34Referral 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
35Gender 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)
37Results of Patients Referred to
Participating in CR
38Who Recommended CR?
39Reasons for Not Attending CR Assessment
40Patient Preferences for On-Site Versus Home-Based
Cardiac Rehabilitation
41Home-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)
42Cardiac 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.
43Research 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.
44Methods
45No 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.
46Demographics of Participants, N80
47Preferences by Self-Reported Ethnocultural
Background
48What issues factored in decision?
49Benefits and drawbacks of the programs?
50Frequency, Duration and Intensity of Exercise
During and Post-CR
Mean Score
p 0.000 p 0.042
51What 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.
52Suggestions 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.
53Conclusions
- 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
54Recommendations
- 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.
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56Find 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