R e s e a r c h
A r t i c l e

S u c c e s s f u l  R e h a b l il it a t io n  i n  
P a t ie n t s  w i t h  C h r o n i c  D i s e a s e

ABSTRACT: The aim  o f  m e d ic a l intervention in p a tie n ts  suffering fro m  chron­
ic d ise a se s is to m aintain a life o f  quality. P a tie n ts w ho h ave undergone c o ro ­
na<ry a rte ry  b y p a ss su rgery p r o v id e  a g o o d  exa m ple o f  an in terven tion  th at w ill 
n ot n e c essa rily  resu lt in the p ro lo n g a tio n  o f  life bu t the im p ro v ed  qu a lity o f  life.
R e h a b ilita tio n  ou tcom e sh ou ld f o c u s  on the im p ro ved  q u a lity o f  life a n d  the 
issu e o f  who sh o u ld  b e resp o n sib le f o r  m aintain ing im p ro v e d  qu a lity o f  life. In o rd er to d eterm in e if  se lf-re sp o n sib il­
ity w a s an a sp e c t o f  im p ro ved  qu a lity o f  life 73 su b je cts an d th eir sp o u se s w ere f o llo w e d  up o v e r  a p e r io d  o f  one 
year. S elf-resp on sibility w a s id en tified a s a sig n ifican t v a ria b le  (p = 0 .0 0 3 ) in p a tie n ts  w ith  im p ro ved  q u a lity o f  life. 
B a se d  on the e vid en ce p r o v id e d  b y this stu dy it w a s c o n clu d ed  th at unless p a tie n ts  a c c e p te d  resp o n sib ility  f o r  th eir 
re h ab ilitation  th ey w o u ld  not h ave an im p ro ved  qu a lity o f  life.

C EA LES\ A  STEWART*,
T N O A K E S " , M GOODMAN*
•UNIVERSITY OF THE WITWATERSRAND 

"UNIVERSITY OF CAPE TOWN

INTRODUCTION
T h e  a cc ep te d  d efin itio n  o f re h a b ilita ­

tio n  is that it is the red u ctio n  o f  d is a b ili­
ty an d  h an d icap  w ith  o r w ith o u t ch an g es 
in th e u n d e rly in g  im p a irm e n t. T h e se  
ch an g es are n o t u n related  to th e in d iv id ­
u als in w h o m  they  o c c u r alth o u g h  n o t 
m u ch  atten tio n  has b een  g iv e n  to the 
reac tio n  o f  p atie n ts to them . T h e effects 
o f the d isease p ro c e ss can  n e v e r b e sep ­
arated  b etw een  b o d y  an d  m in d  (W H O , 
1980).

H u m an  life is the re su lt o f h u m a n  v a l­
ues (C o h en , 1982). W h a te v e r w e strive 
fo r in life can  o n ly  be a ch iev ed  w h en  liv ­
ing. A  h u m an  life is lived  acc o rd in g  to a 
h u m a n  plan. T h e aim  o f m e d ical in te r­
v e n tio n  is to m a in tain  life an d  it is w id e ­
ly a cc ep te d  th a t it is n o t life itse lf th a t is 
so im p o rtan t b u t the q u ality  o f life. M ost 
d isease s are n o t d ra m atically  fatal b ut 
they  affect the p atie n ts c o m fo rt an d  h a p ­
p in ess an d  as a resu lt the p a tie n t can  no 
lo n g e r le a d  life  a c c o rd in g  to p la n  
(M osteller, 1983).

In ch ro n ic d isease w h ere the g oal o f 
m e d ical in terv en tio n  can n o t be co m p le te 
cu re, the h ealth  care p ro v id e r sh o u ld  
striv e to ach iev e im p ro v em e n t in fu n c ­
tio n  by d ecreasin g  the sy m p to m s an d  the 
sev erity  o f  the d isease p ro g re ssio n  an d  in 
this w ay  im p ro v e the q uality  o f p a tie n ts ’ 
lives.

Q u ality  o f life m a y  be d efin ed  in term s 
o f  three m a jo r co m p on ents:

1) F u n ctio n al c ap acity
2) P e rc e p tio n s held  by the p atie n t
3) S y m p to m s an d  th e ir co n se q u en ces 

(W eng er et al, 1984)
In  p atie n ts w ith  card iac d isease the 

re d u c tio n  o f d isab ility  an d  h an d icap  is
C O RRESPO N D EN CE: 

M s C  J .  E ales 
P h y sio th erap y  D ep artm e n t 

U n iv ersity  o f the W itw atersran d  
7 York R o ad, P ark to w n , 2193

co n sid e re d  a m o re a p p ro p riate d e te rm i­
n an t o f o u tco m e th a n  a re d u c tio n  in m o r­
tality  o r m o rbid ity . T h e re  is also  c o n se n ­
sus th a t crite ria  su ch  as fu n ctio n  in daily 
life, p ro du ctivity , e m o tio n al stab ility  and 
life  s a tis fa c tio n  c a n  b e  c o n s id e re d  
in d icativ e o f th e im p ro v ed  q u a lity  o f life 
o f p atie n ts (W eng er et al, 1984).

In  c o ro n ary  artery  d is e a se  the im p a ir­
m e n t is co ro n ary  a th ero sclero sis, th e d is ­
ab ility  is the p re sen ce o f  an g in a an d  the 
h an d icap  is th e in a b ility  to  fu n c tio n  n o r­
m a lly  in the co m m u n ity  an d  this lead s to 
p o o r q u ality  o f life (O ld rid g e, 1986). A 
co m m o n  in terp retatio n  o f reh ab ilitatio n  
fo r p atie n ts w ith  card iac d isease is that 
th e y  sh o u ld  b e “ re sto re d  an d  m a in tain e d  
” at o p tim al clin ic al, so cial , v o ca tio n al 
an d  p sy ch o lo g ica l statu s. T h is im p lies 
th a t all this w o u ld  be d o n e fo r the patient, 
p o ssib ly  b y  a h ealth  p ro fe ssio n a l, an d  
that th e ir ro le w o u ld  be p assiv e. T h e d e f­
inition  o f the W H O  is sligh tly  d iffere n t 
an d  im p lie s th a t p atie n ts sh o u ld  assum e 
so m e resp o n sib ility  fo r th e ir re h a b ilita ­
tio n  in the p ro cess o f  reg ain in g  an  as n o r­
m al as p o ssib le  p la ce in the c o m m u n ity  
(W H O , 1984).

R eh ab ilitatio n  o u tco m es h av e to  focus 
on the im p ro v ed  q u a lity  o f life an d  issues 
su c h  as th e p a tie n t’s o w n  p e rs o n a l 
b elie fs, p e rc e p tio n s an d  m o tiv atio n  i.e. 
th e  s e n se  o f  s e lf-re s p o n s ib ility . T h is 
sen se o f  self-resp o n sib ility  in ch ro n ic 
d isease is p ro b a b ly  the b e st p re d ic to r o f 
r e d u c tio n  o f  d is a b ility  a n d  h a n d ic a p  
(O ld rid g e, 1986).

R eh ab ilitatio n , as stated  ab o v e m eans 
resto rin g , o r crea tin g  a life o f  acc ep ta b le 
q u a lity  fo r p a tie n ts w h o  su ffe r fro m  
ch ro n ic d isease s. R eh ab ilitatio n  sh ou ld  
n o t b e d o n e fo r p eo p le b u t w ith  them .

P erh a p s w e as p h y sio th e ra p ists n eed  to 
lo o k  at o u r p ersp e ctiv es on reh ab ilitatio n  
an d  sh o u ld  co n sid e r five im p o rtan t c o n ­
cep tu a l ch an g es th a t S arto riu s su gg ests; 
(S arto riu s, 1992).

• T h e im p ro v e m e n t o f  o v erall q uality  
o f  life as p e rc e iv e d  by th e p atie n t as w ell 
as th e p a tie n t’s fam ily.

• I f  the q u a lity  o f  life is g o in g  to 
b eco m e a crite ria  fo r assessin g  im p ro v ed  
re h a b ilita tio n , the o p in io n  o f  th o se w h ose 
life is b ein g  ch a n g e d  m u st b e c o m e  a ' 
d e c isiv e  facto r, ra th e r th a n  an  in tere stin g  
p o in t o f o b serv atio n .

• P e o p le  a re d iffe re n t an d  so  are  
im p aired  p eo p le an d  re h a b ilita tio n  w o rk ­
ers sh ou ld  b e to lera n t o f  th e se d iffe r­
e n c e s. T h e  o u tc o m e  o f  re h a b ilita tio n  
sh o u ld  n o t b e ju d g e d  by th e p a tie n t’s 
a b ility  to ab id e b y  rig id , p re d e te rm in e d  
ru le s o f  “ n o rm a l” b eh a v io u r. B ein g  able 
to  fin d  a jo b  is still co n sid e re d  co n firm a ­
tio n  o f  a p a tie n t’s w o rth  an d  activ ities 
su ch  as h elp  an d  su p p o rt o f o th ers, the 
b rin g in g  up o f  c h ild re n  an d  crea tiv e art, 
are g iv en  m u ch  less atte n tio n  and resp ect 
than  the a b ility  to fu n c tio n  in a tra d itio n ­
al jo b .

• P e o p le  an d  im p airm en ts ch an g e o v er 
a p e rio d  o f  tim e. T h e se ch an g es as w ell 
as the ch an g es in the w o rld  that they  live 
in sh o u ld  be resp ected . It h as to  b e a p p re ­
ciated  th a t re h a b ilita tio n  is a lo n g -lastin g  
p ro cess an d  p eo p le m u st be a c c o m m o ­
d a te d  as th e y  m o v e  fo rw a rd  in this 
p ro cess. A s p eo p le are m o v in g  fo rw ard s 
to w a rd s ch an g e the ru les an d  o u r o p in ­
io n s w ill h ave to k eep  c h a n g in g  too.

• R e h a b ilita tio n  is an in terv en tio n  to 
im p ro v e the q u ality  o f  life so it b eco m es 
im p o rtan t to  ap p rec iate th a t th e re is n o t a 
strict d istin ctio n  b etw een  serv ices d e a l­
ing w ith  reh ab ilitatio n  an d  th o se  th a t aim  
to  h elp  p eo p le in o th e r w ay s. T h is co n ­
n ectio n  d o es n o t o n ly  im p ly  the d iffe r­
en ces b e tw e e n  h ealth  an d  re h a b ilita tio n  
serv ices b u t also  b etw een  th e se serv ices 
an d  o th e r c o m m u n ity  serv ices. T h is w ill 
resu lt in u n ity  o f p u rp o se an d  aim  and 
w ill g iv e re h a b ilita tio n  a h ig h e r priority.

Im p ro v in g  p a tie n ts ’ q u a lity  o f life w ill 
in c lu d e certain  facto rs th a t are im p o rtan t

6 SA J o u r n a l  o f  Ph y sio t h e r a p y 1998 V o l 54 No 2

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to all h e a lth  care w o rkers an d  c ertain  fa c ­
tors that are sp ecifically  im p o rta n t to the 
p a tie n t (C ohen, 1982).

T h e m e asu rem en t o f o utco m e o f treat­
m e n t, s p e c ific a lly  in  te rm s o f  the 
p a tie n ts ’ p ercep tio n  o f ch an g es in their 
h ealth , h as b eco m e a v ery  im p o rtan t fa c ­
to r p a rtic u la rly  w h en  costly, in v asiv e 
treatm e n ts are c o n c ern ed  (C ain e et al , 
1991). T h e  em p h asis h as m o v e d  tow ards 
a s s e s s in g  o u tc o m e  in  te rm s o f  the 
p a tie n t’s p ercep tio n  o f ch an g es in h ealth  
o v er a p erio d  o f tim e. T h e re is gro w ing  
c o n se n su s that p a tie n ts th e m selv es are 
the o n ly  p ro p e r ju d g e  o f  th e ir q u ality  o f 
life (F erran s C E , 1993). U n til rece n tly  
the p re v ale n t m e th o d s o f  ju d g in g  o u t­
c o m e  h a v e  b e e n  c lin ic a l ju d g e m e n t, 
retu rn  to w o rk  an d  su rv iv al rates. It does 
see m  th a t b o th  ap p ro ach es h av e m erit 
an d  sh ou ld  co m p le m en t each  other.

R e s p o n s ib ility  is d e fin e d  as b e in g  
m o rally  acc o u n tab le fo r a ctio n s (O x ford  
D ic tio n a ry , 1991). S e lf-re s p o n s ib ility  
m e an s that an in d iv id u al can  b e held  
m o rally  acc o u n tab le for h is o r h e r a ctio ns 
reg ard in g  the self. T h is can  b e in a p h y s ­
ical sense, a p sy ch o lo g ica l (attitud in al) 
sen se o r an  e d u c atio n a l sense.

M ost p eo p le are n o t c o n c ern ed  about 
th e ir h ealth  until they  lo o se it. In  m any 
cases p re v en tin g  d isease m eans that the 
in d iv id u al m u st give u p  certain  h abits, 
fo r ex am p le sm ok in g, o r do thin gs w h ich  
req u ire an effo rt, su ch  as ex ercisin g  re g ­
ularly. T h e freed o m  o f in d iv id u als to 
m a k e  th e ir o w n  d e c is io n s  re g a rd in g  
h e a lth  p u ts trem en d o u s p re ssu re on g o v ­
e rn m e n ta l re s o u rc e s  fo r h e a lth  care. 
E v e n tu a lly  this b eco m es a n atio n a l and 
n o t an in d iv id u al resp on sib ility. M ore 
d o cto rs an d  m o re ex p e n siv e h osp itals 
w ill n o t im p rov e h ealth . J.H . K n o w les 
(1977) argues th a t the “ rig h t” to h ealth  
sh o u ld  b e rep laced  by a m o ral o b lig atio n  
to p re serv e o n e ’s h ealth . T he ind ivid ual 
then  w o u ld  h av e the “rig h t” to:

1. B etter and m o re in fo rm atio n
2. A cc essib le serv ices o f  g o o d  q u ality
3. M in im a l fin a n cial b arrie rs to these 

services
In d iv id u als w h o  are w illin g  to take 

resp o n sib ility  fo r th e m selv es an d  follo w  
re aso n ab le ru les fo r h ealth y  living p o ssi­
b ly  can ex ten d  th e ir p ro d u c tiv e  w o rking  
life by av oid in g  d isease and d isability. If  
this is the case fo r h e a lth y  ind ivid uals 
then  tho se w ho h a v e  h ad  co stly  in terv en ­
tion  b ecau se o f d isease p ro cesses sh ou ld  
be re sp o n sib le fo r fo llo w in g  p re scrib e d  
life sty le ch an ges to m a in tain  th e ir h ealth  
(G inzberg , 1977).

T h is sen se o f se lf-re s p o n sib ility  in 
ch ro n ic disease co uld  p ro b a b ly  be the 
b e st p re d icto r o f re d u ctio n  o f d isab ility  
an d  hand icap .

A  h y p o th e sis c a n  b e m a d e that fo r su c ­
c e ssfu l re h a b ilita tio n  o f p atie n ts w ith  
c h ro n ic  d isease an im p ro v ed  q u ality  o f 
life an d  acc ep ta n ce o f resp o n sib ility  for 
th e ir re h a b ilitatio n  are p re req u isites.

E x ten siv e rese arch  h as b een  co n d u c te d  
to  d e te rm in e  th e q u a lity  o f  life  o f 
p a tie n ts ’ w h o  h a v e  u n d erg o n e b y p ass 
surgery. In the C o ro n ary  A rtery  S urgery 
S tu d y  (C A S S , 1984) th e life  o f  the 
p atie n t w as co n sid ered  im p ro v ed  w h en  :

1. T h e re is im p ro v ed  fu n ctio n al status
2. A m e lio ra tio n  o f  c a rd ia c  re la te d  

sy m p to m s h as o ccu rred
3. T h e re  is retu rn  to g ain fu l e m p lo y ­

m e n t an d  recre atio n al activ ity
T his m o del w as u se d  in this stu d y  to 

id e n tify  im p ro v e d  q u a lity  o f  life  in 
p atie n ts o ne y ear afte r b y p ass surgery. 
H a v in g  id e n tifie d  p a tie n ts  w ith  an 
im p ro v ed  q u ality  o f  life the h y p o th e sis 
th a t self-resp o n sib ility  w as an a sp e c t o f 
im p ro v ed  q u a lity  o f  life, w as tested.

M easu rin g  the acc ep ta n ce o f se lf­
re s p o n s ib ility  is h o w e v e r n o t a w ell 
re se arch ed  area an d  v ery  little in fo rm a ­
tion  e x ists in the literatu re to g u id e this 
p ro cess. T he m o d e l b elo w  fo r testing 
s e lf-re s p o n s ib ility  w as su g g e s te d  by 
E ales an d  S tew art (1994).

A c c e p ta n c e  o f  self-resp o n sib ility  was 
esta b lish e d  by:

1. T h e p a tie n t’s an d  the sp o u se /c a re ­
g iv e r ’s k n o w le d g e  o f the ch ro n ic 
n atu re o f the disease.

2. T h e p a tie n t’s k n o w le d g e  o f risk  
fa c to r m o d ificatio n

3. T h e  sp o u se /c a re -g iv e r’s ju d g e m e n t 
o f  th e  p a tie n t’s a c c e p ta n c e  o f 
resp o n sib ility  fo r risk  fa c to r m o d ifi­
catio n

4. P a tie n ts ’ a b ility  to m o d ify  an d  
co n tro l th e ir stress.

MATERIALS AND METHODS 

Subjects
S ev en ty  three su b jec ts w h o  h a d  u n d e r­

g o n e  c o ro n a ry  a rte ry  b y p a s s  su rg e ry  
w ere selected  fro m  three c ard io -th o rac ic 
u n its in Jo h an n esb u rg . Tw o o f the u nits 
w ere fro m  the p riv a te  sec to r an d  one 
fro m  the p u b lic sector. In fo rm e d  c o n se n t 
w as o b tain e d  fro m  all p atie n ts fo r b o th  
the in terv iew s an d  to co lle ct in fo rm atio n  
fro m  th e ir m e d ical reco rd s. T h is stu dy  
w as san ctio n ed  b y  the co m m ittee for 
r e s e a rc h  on h u m a n  su b je c ts  o f  the 
U n iv e rs ity  o f  th e  W itw a te rs ra n d . 
(C learan ce no. 3 6/9/9 2)
Procedure:

T h e  73 s u b je c ts  w e re  in te rv ie w e d  
b etw een  d ays 4  -6 afte r surgery, six 
m o n th s la te r an d  ag ain  o ne y e a r after 
surgery. W h e re  p o ssib le the su b je c ts ’

sp ou ses o r c are g iv ers w ere also  in te r­
v ie w e d  at 6 m o n th s an d  o n e year.

A t the first in terv iew  b asic d e m o g ra p h ­
ic d ata, risk  facto rs p re se n t an d  m e d ical 
h isto ry  w ere esta b lish e d . A t the su b se ­
q u e n t in terv iew s the s u b je c t’s k n o w led g e 
o f  h is o r h e r m e d ical c o n d itio n , o p erativ e 
p ro ced u re , risk  fa c to r m o d ificatio n  an d  
m e d ic a tio n  w a s e s ta b lis h e d . T h e  six 
m o n th s ’ in terv iew  p ro v id ed  in fo rm atio n  
on the d ev e lo p m e n t o f  self-resp o n sib ility  
an d  is n o t co n sid e re d  in  the resu lts and 
d iscu ssio n  o f this paper. T h e sp o u se o r 
c a r e g iv e r ’s k n o w le d g e  o f  ris k  fa c to r 
m o d ificatio n  an d  m ed icatio n  w as also  
estab lish ed .

T h e s u b je c t’s k n o w le d g e  o f  h is o r h e r 
m e d ic a l c o n d itio n , o p e ra tiv e  p ro ced u re , 
risk  fa c to r m o d ificatio n  an d  m ed icatio n  
w as a s s ig n e d  a sco re. S im ila rly , the 
k n o w led g e o f the sp o u se o f  risk  facto r 
m o d ific a tio n  a n d  m e d ic a tio n , w as 
a ssig n e d  a score. T h e to tal sco re for 
p atie n ts w as c alc u lated  o u t o f  a p o ssib le 
sco re o f  35 an d  the sp o u se o u t o f  20.

S tatistic al an alysis: H av in g  id e n tified  
tw o  g ro u p s (im p ro v ed  q u a lity  o f life; no 
im p ro v ed  q u a lity  o f life) a statistical 
an aly sis w as d o n e to d e te rm in e  w h ich  
facto rs w ere sig n ifican tly  d iffere n t in the 
tw o  g ro u p s at d ay s 4 -6  p o st-o p erativ ely , 
six m o n th s an d  tw elv e m o n th s. W h e n  
tw o  v ariab les are ca te g o ric a l (im p rov ed  
q u a lity  o f  life; n o  im p ro v ed  q u a lity  o f 
life), the C h i-sq u ared  test is co m m o n ly  
u se d  to e x a m in e  the n u ll h y p o th e sis 
w h ic h  is th a t the d istrib u tio n s o f the v a ri­
ab les are in d ep en d en t o f  ea c h  other. I f  the 
calc u lated  C h i-sq u ared  v alu e is g re ater 
than  the tab u lated  v alu e, the n u ll h y p o th ­
esis sh o u ld  b e rejecte d  at the 5%  level o f 
sig n ifican ce.T h e M an n  -W h itn e y  U  test 
w as u se d  to co m p are the o rd in a l d ata 
o b tain e d  fro m  ea c h  g ro u p  to see if  they 
d iffere d  significantly.
RESULTS: 

Demographic Information
O f  the 73 p a tie n ts  in te rv ie w e d  on 

a d m issio n  58 re m a in e d  in the stu d y  at 12 
m o nth s. F ifty  sp o u ses w e re  also  in te r­
v ie w ed  at 12 m o nth s.

O n  a d m issio n  there w ere 63 m a le s and 
10 fem ales, b y  tw elv e m o n th s there w ere 
48 m ales an d  10 fem ales. T h e  d ro p o u ts 
fro m  the stu dy  w ere th u s all m a le s. O f 
these fiv e h ad  d ie d  an d  the o th ers co uld  
n o t be traced.

S ev en ty  fiv e p erc e n t o f  the sam p le w as 
m arried . O n  a d m issio n  7 0%  o f the sa m ­
p le w as em p lo y ed , the av erag e an nu al 
in c o m e w as > R 5 0 ,0 0 0  an d  the av erag e 
e d u c a tio n a l level w as > g rad e 12. O ne 
y e a r later only  3 7%  o f the sam ple w as 
em p lo y ed .

SA J o u r n a l  o f  Ph y sio t h e r a p y 1998 V o l 54 No 2 7

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TABLE 1:
The medical factors indicating the severity of the disease

LVEF No. vessels 
bypassed

Previous Ml Previous
CABG

mean value 51% 2.8 58% 7%
LVEF (Left Ventricular Ejection Fraction); Ml (Myocardial Infarct); 
C A B G  (Coronary Artery Bypass Grafting).

Im p ro v e d  q u ality  o f life w as ev alu a te d  in the sam p le at 12 
m o n th s b y  a ssessin g  im p ro v ed  fu n ctio n al cap acity , a b sen ce o f 
an g in a an d  retu rn  to w o rk  o r recre atio n al activ ities. C o m p le te 
d ata w as a v ailab le on 56 o f  the 58 su b jec ts rem ain in g  in the 
study.

S ev en tee n  p atie n ts, all m a le s, h ad  an im p ro v e d  q u ality  o f life 
an d  39 su bjects d id not.

H av in g  esta b lish e d  tw o  g ro u p s (G ro up  1 w ith  a n  im p ro v ed  
q u ality  o f life an d  G ro u p  2 w ith  no im p ro v ed  q u ality  o f life) all 
th e in d ep en d en t v ariab les co u ld  be co m p ared  an d  th o se  that 
w ere sig n ifican tly  d iffere n t are sh o w n  in  T able 2 an d  T ab le 3.

TABLE 2:
Significant variables in subjects with an improved quality 
of life on admission

Chi-square

Improved quality of life if: 

(Categorical data)

df x 2-value p-value

Male 1 5.307 0.012

Married 1 5.439 0.020

Income > R50 000 p/a 1 4.736 0.030

Normal sex life 1 5.094 0.036

Patients with improved quality of life were married men, earning 
an income greater then R50,000 per year and who regarded 
their sex life as normal.

TABLE 3:
Significant variables in subjects with an improved quality 
of life at twelve months

O n e y ear after th e  o p e ra tio n  p atie n ts w ith  im p ro v ed  q u ality  o f 
life rep o rted  th e ir sex ual p e rfo rm a n c e  to  b e n o rm a l o r b e tte r than  
b e fo re  the o p eratio n , th e y  w e re  n o t d e p re sse d , an d  they  h ad  no 
m e d ical sy m p to m s. T h e ir sp o u ses c o n sid e re d  them  m o re active 
th a n  b efo re the o p eratio n  an d  also  re g a rd e d  th e m  as co m p le tely  
cu red  by the o p eratio n .

Id e n tificatio n  o f  se lf-re sp o n sib ility  as a fa c to r in im p rov ed  
q u ality  o f  life

H av in g  e sta b lish e d  tw o  g ro u p s o f p atie n ts, w ith  an d  w ith o u t 
im p ro v ed  q u ality  o f life, a c c ep ta n ce o f  se lf-resp o n sib ility  as a 
fa c to r in im p ro v ed  q u ality  o f  life co u ld  b e d eterm in e d . T h e sta­
tistical an aly sis is sh o w n  in  T ab le 4.

TABLE 4:
Determining self-responsibility in patients with improved 
quality of life

Self-
responsible

Not self- 
responsible

Total

Improved quality 

of life

17 0 17

No improved 

quality of life

24 15 39

Total 41 15 56

A ll 17 p atie n ts w ith  im p ro v e d  q u ality  o f  life w ere re sp o n si­
b le .(C h i-sq u a re  = 8.931, 

p=  0.00 3).
T h e fo llo w in g  statem en t can  th e refo re b e m a d e: self-resp o n - 

sib ility  is a sig n ifican t fa c to r in p atie n ts w ith  an  im p ro v e d  q u a l­
ity o f  life.

A ll the p atie n ts re m a in in g  in th e sam p le at o n e y e a r w ere 
ju d g e d  as resp o n sib le o r n o t resp o n sib le a c c o rd in g  to th e c rite ­
ria su g g ested  b y  E ales an d  S tew art (1 9 9 4 ).T h e se in c lu d e d  
p a tie n ts ’ an d  s p o u s e s ’ k n o w le d g e  o f  th e c h ro n ic  n atu re o f  the 
d isease , co m p lia n ce w ith  risk  fa c to r m o d ific a tio n s an d  the a b il­
ity to co n tro l stress. A ll 58 su b jec ts h ad  su ffic ie n t d ata to allo w  
fo r th is an aly sis as sh o w n  in  T ab le 5 an d  T ab le 6.

Chi-square

Improved quality of life if: 

(Categorical data)

df x 2-value p-value

Absence of breathlessness 1 6.898 0.009
Knowledge that smoking 

had an effect on C V S

1 8.662 0.003

Sexual performance 

normal or better than before

1 9.873 0.002

No symptoms post-operatively 1 5.298 0.021

Not depressed 1 6.842 0.009

Spouse knew diet 

patients had to follow

1 4.325 0.038

Spouses considered 

operation a cure

1 6.105 0.013

Spouse considered patient's 

activity levels > pre-operative 

level

2 8.850 0.012

8 SA J o u r n a l o f  Physiotherapy 1998 V o l  54 No 2

TABLE 5:
Significant variables evaluated on admission in patients who 
were self-responsible

Chi-square

Patients had accepted 

self-responsibility if: 

(Categorical data)

df x 2-value p-value

Married 1 7.739 0.005

Education >grade 12 1 6.371 0.012

Diabetes Mellitus 1 4.417 0.036

Income > 50 000 ,00 1 3.863 0 .049

S e lf-re s p o n s ib le  s u b je c ts w e re  m a rrie d , h a d  a le v e l o f  
ed u c a tio n  b ey o n d  g rad e 12, an d  an  in c o m e  th a t w as g re a te r than 
R 5 0 ,0 0 0  p er an nu m . A ll the d ia b e tic  p atie n ts, w h o  are  p atients 
w h o  h av e learn t to  d eal w ith  a  c h ro n ic  d isease , w ere in 
th is sam ple.

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TABLE 6:
Significant variables evaluated at 12 months in patients who 
were self-responsible

S p o u ses o f the p atie n ts w h o  a cc ep te d  self-resp o n sib ility  
th o u g h t they  w ere cu red  by the o p eratio n . T h e self-resp o n sib le 
p atie n ts w ere d epressed . T h e p atie n ts in  the g ro u p  w h o  h ad  
a cc ep te d  self-resp o n sib ility  w ere satisfied  w ith  the o u tco m e o f 
the o peratio n.

K n o w led g e sco res fo r su b jec ts w ere sco red  o u t o f 35 and 
c o n siste d  o f th e ir k n o w led g e o f the m e d ical co n d itio n , the su r­
g ical p ro ced u re , an d  risk  fa c to r m o d ificatio n . T h e sp ou ses w ere 
scored o u t o f 20 and ev alu a te d  o n  th e ir k n o w le d g e  o f the c h ro n ­
ic n atu re o f the d isease an d  risk  fa c to r m o d ificatio n . T h e sta tis­
tical an aly sis o f these sco res is sh o w n  in  T able 7.

TABLE 7:
Knowledge scores of subjects and spouses.

O v er a p erio d  o f  six m o n th s sp ou ses o f p atie n ts w h o  h ad  
b e c o m e  s e lf-re s p o n s ib le  w e re  th e o n ly  g ro u p  w h o  h a d  
im p ro v ed  th e ir k n o w le d g e  sco res. A ll o th e r g ro u p s h ad  less 
k n o w led g e at 12 m o n th s th a n  at six  m onths.
DISCUSSION:

P atien ts w ith  im p ro v ed  q u ality  o f life w ere m a le s, m a rrie d  
an d  w ith  an  in c o m e ex c e e d in g  R 5 0 ,0 0 0  p.a. T h e a cc ep ta n ce o f 
self-resp o n sib ility  is a sig n ifican t fa c to r fo r the im p ro v ed  q u a l­
ity o f life in p atients su fferin g  fro m  ch ro n ic d isease.

T h e o utco m e o f re h a b ilita tio n  c a n n o t b e ju d g e d  as b ein g  su c ­
c essfu l if  p atients d o  n o t h av e an  im p ro v ed  q uality  o f life as 
w ell as acceptin g  self-resp o n sib ility  fo r th e ir reh ab ilitatio n .

A ll 17 p atients w ith  an  im p ro v ed  q u ality  o f life h ad  accep ted  
self-respo nsib ility . T h e o p p o site h o w e v e r is n o t true b ecau se all

p atie n ts w h o  w e re  self-resp o n sib le d id  n o t h a v e  an  im p ro v ed  
q u ality  o f  life.

M ed ic al facto rs w ere n o t p re d ic tiv e  fo r a c c ep ta n ce o f  se lf­
resp on sib ility.

T h e p sy ch o so c ia l facto rs w ere m o re  im p ortan t. T h a t p atients 
h ad  k n o w led g e, h ad  a c e rta in  in c o m e , w e re  e d u c ated , w e re  su p ­
p o rte d  by th e ir sp ou ses an d  w ere satisfied  w ith  the o u tco m e o f 
the o p eratio n  w ere the m o st im p o rtan t d e te rm in a n ts o f  ac c e p ­
tan ce o f  self-respo nsib ility .
CONCLUSION

S elf-resp o n sib ility  is an im p o rta n t fa c to r in  the su ccessfu l 
o u tco m e o f  c o ro n ary  artery  b y p ass surgery, w h ic h  in this stu dy  
w as u sed  as an ex am p le o f  ch ro n ic d isease . T h e o u tco m e o f 
re h a b ilita tio n  can  b e in flu e n c e d  by assistin g  p a tie n ts to b eco m e 
re s p o n s ib le  fo r th e ir re h a b ilita tio n . S e lf-re s p o n s ib ility  is 
d e p e n d e n t on the k n o w le d g e  o f  the p atie n t, as w ell as the 
sp ou se, on the ch ro n ic n atu re o f  the d isease as w ell as risk  fa c ­
to r m o d ificatio n . A p a rt fro m  h a v in g  the k n o w le d g e  the p atien t 
also  h as to co m p ly  to risk  fa c to r m o d ificatio n . P atien ts sh ou ld  
h av e realistic ex p e ctatio n s o f  the o u tco m e o f re h ab ilitatio n . 
S uch  ex p e ctatio n s w o u ld  assist th e m  to b e sa tisfied  w ith  the 
o utco m e. S atisfactio n  w ith  the o u tc o m e  w o u ld  lead  to ac c e p ­
tan ce o f  self-respo nsib ility .
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Geneva: November: 21-25

Chi-square
Patients accepted 
self-responsibility if:

(Categorical data)

df x 2-value p-value

Satisfied with outcome 
of operation

1 4.526 0.003

Depressed 1 4.462 0.035

Knew effect of smoking 
on the CV S

1 5.546 0.019

Spouses judged patient to be:

Cured by the operation 1 6.105 0.013

More active than 
before the operation

1 7.860 0.005

Patients Mean Score 
(Total = 35)

Mann Whitney test 
(p-value)

Group 1 17.8 0.0177

Group 2 14.5

Spouse/ 
care-giver of:

Mean Score 
(Total = 20)

Group 1 10.9 0.0033

Group 2 6.4

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