VOLUME 11 NUMBER 3 • SEPTEMBER 2014
111
SA JOURNAL OF DIABETES & VASCULAR DISEASE
REVIEW
Correspondence to: Melisha Rabilal
Physiotherapy Department, Grey’s Hospital,
Pietermaritzburg
e-mail:
S Afr J Diabetes Vasc Dis
2014;
11
: 111–114
A review of the literature on multidisciplinary interventions
in cardiac rehabilitation
Melisha Rabilal
Introduction
Cardiovascular disease (CVD) is a worldwide problem, with an
increased prevalence in sub-Saharan Africa. Rheumatic heart
disease, hypertension and cardiomyopathy are already prevalent,
and coronary heart disease is assuming growing significance. It is
vital that in developing countries, rehabilitative care be incorporated
into the existing healthcare system.
1
Cardiac rehabilitation is a complex intervention that requires
the input of a multidisciplinary team of qualified and competent
professionals to encompass and deliver the recommended core
components. Cardiac rehabilitation can reduce morbidity and
mortality rates for patients with many types of cardiac disease, yet
is generally underutilised in South Africa.
Cardiac rehabilitation is cost effective, reduces mortality rates by
26% and improves quality of life for many. It can also help reduce
unplanned admissions and yield significant savings.
2-4
The beneficial
effects of rehabilitation include a reduction in the rate of death
from cardiovascular disease, improved exercise tolerance, fewer
cardiac symptoms, improved serum lipid levels, decreased cigarette
smoking, improvement in psychosocial well-being and increased
likelihood of return to work.
The American Heart Association and American Association of
Cardiovascular and Pulmonary Rehabilitation (AACVPR) recognise
that all cardiac rehabilitation/secondary prevention programmes
should contain specific core components that aim to optimise
cardiovascular risk reduction, foster healthy behaviours and
compliance with these behaviours, reduce disability, and promote
an active lifestyle for patients with cardiovascular disease.
5
In 1994, the American Heart Association stated that cardiac
rehabilitation programmes should consist of a multifaceted and
multidisciplinary approach to overall cardiovascular risk reduction,
and that programmes that comprise exercise training alone are not
considered cardiac rehabilitation.
The staff of a cardiac rehabilitation programme usually include
a medical doctor, physician, cardiologist trained in cardiac
rehabilitation, physiotherapist, exercise physiologist/biokineticist,
dietician, psychologist, and a cardiac-trained sister. Occupational
therapists and social workers may also be involved in the
programme. The importance of a mutlidisciplinary team approach
to cardiac rehabilitation has been stressed by Kellerman.
6
Physiotherapy management of patients with coronary
artery disease: current practice in South Africa
The Association of Chartered Physiotherapists in Cardiac
Rehabilitation (ACPICR) and the British Association for Cardiac
Rehabilitation (BACR) describe the phases of cardiac rehabilitation
as follows:
• Phase I: hospital in-patient period
• Phase II : convalescent stage following discharge
• Phase III: structured rehabilitation programme
• Phase IV: long-term maintenance.
According to the ACPICR and BACR, physiotherapists play a
role in the physical activity component of all phases of cardiac
rehabilitation (many phase IV programmes however, are delivered
by appropriately trained BACR exercise instructors).
Internationally, physiotherapists treat patients with coronary
artery disease (CAD) in the acute stage following a coronary event
and/or following coronary artery bypass (CABG) surgery. These
patients are then subsequently followed up as out-patients during
cardiac rehabilitation in order to improve function and quality of life
and to delay the occurrence of subsequent coronary events.
7-9
A study conducted recently in South Africa by Roos and van
Aswegen
10
aimed at establishing the number of physiotherapists
working in the cardiopulmonary field of physiotherapy and involved
in the care and rehabilitation of patients with CAD. The current
physiotherapy interventions that are used in the management of
patients with CAD were examined. The clinical settings (acute
or out-patient care) in which patients with CAD regularly receive
physiotherapy interventions was determined.
The study determined the frequency of physiotherapy interventions
and follow up of patients with CAD. Also, explanations were
presented as to the reasons for non-involvement of physiotherapists
who work in a cardiopulmonary setting in rehabilitation of patients
with CAD in certain instances.
An observational, cross-sectional study was conducted with
questionnaires mailed to 50 regional and tertiary government
institutions and 137 electronic questionnaires were circulated. A total
of 187 questionnaires were sent out and 142 were returned (76%).
Results showed that 62% of the physiotherapists provided
care to patients with CAD (50 government physiotherapists and
38 private practitioners). Of the 38% who did not treat patients
with CAD, 38 were government physiotherapists and 16 private
practitioners. Care was mostly provided in a hospital setting (81%)
and out-patient phase III cardiac rehabilitation was lacking (11%).
In a study by Taylor
et al
.,
11
a systematic review and meta-analysis
of randomised, controlled trials was undertaken with reference
to exercise-based rehabilitation for patients with coronary heart
disease. The purpose was to review the effectiveness of exercise-
based cardiac rehabilitation in patients with coronary heart
disease.
Databases such as MEDLINE, EMBASE and the Cochrane Library
were searched up to March 2003. Trials with six or more months
