FACTORS WHICH MAY PREDICT SUCCESSFUL REHABILITATION IN PATIENTS WHO HAVE UNDERGONE CORONARY ARTERY BYPASS SURGERY: A PILOT STUDY C Eales M Sc Physiotherapy Physiotherapy Department University o f the W itwatersrand A Stewart BSc Physiotherapy, M Sc M edicine, DPE Physiotherapy D epartment University o f the W itwatersrand INTRODUCTION Coronary artery bypass surgery is be­ ing used increasingly as a method of treat­ ment for patients with ischaemic heart dis­ ease1. Some patients seem well equipped to deal with the challenge of returning to a productive and active lifestyle and oth­ ers simply cannot cope. It seems that there are many factors which influence the out­ come of successful rehabilitation. The World Health Organization de­ fines successful rehabilitation of cardiac patients as the sum of activity required to ensure them the best possible physical, mental and social conditions "so that they may by their own efforts regain as normal as possible a place in the com m unity"2. This definition implies that the patient should assume an active role in his reha­ bilitation and accept responsibility for himself. Responsibility is defined as being morally accountable for one's actions and so self-responsibility is then the moral ac­ countability for one's own actions, as re­ gards to one's self. Unfortunately, however, this impor­ tant aspect of rehabilitation is frequently neglected, both by patients and the medi­ cal profession. Central to the WHO's definition of re­ habilitation given above, is the concept of a p atien t accep tin g resp o n sib ility for his/her own progress. This responsibility or self-responsibility should then become a major objective for cardiac rehabilitation programmes. The issue of who is ultimately respon­ sible for an individual's health or illness is one which can be debated. Many patients and most medical doctors believe that doc­ tors are primarily responsible. Increas­ ingly, however, the feeling is that indi­ viduals themselves must take responsibil­ ity for their health and until this is done, improvements in existing health care sys­ tems will not materialise. In order to assume this responsibility in d iv id u als m ust understand disease processess, know what is preventable and be interested in maintaining good health. In a chronic disease such as coronary artery disease, it is perhaps appropriate to consider reduction of disability and handi­ cap, which may be equated with an im­ provement in quality of life, and an accep­ tance of self-responsibility for compliance with long term changes in health style, as the predictors for the successful outcome of rehabilitation. With ever increasing health costs, fac­ tors which may contribute to successful rehabilitation become important consid­ erations. Oldridge considers cost-effective reha­ bilitation services the challenge o f the 1990's3. The two most important components for successful rehabilitation therefore be­ come: • An improved quality of life. • An acceptance of self-responsibility for rehabilitation2. However, improvement in quality of life is a subject which has been well re­ searched and documented in the litera­ ture4'5 The concept of patients accepting re­ sponsibility for their own rehabilitation has received little attention. In order to establish if the acceptance of self-responsibility is indeed a major com­ ponent of successful rehabilitation and to identify the factors which indicate the ac­ ceptance o f self-responsibility, a pilot study was undertaken. For this purpose a questionnaire was designed to meet the following objectives: To assess: • The socio-economic status, fitness pro­ files, exercise habits and obesity pro­ files of a group of patients who had undergone coronary artery bypass sur- gery. • The post-operative medical status of this group. f ABSTRACT r _ ^ i A study was conducted to deter­ mine the factors which may predict the successful outcom e of rehabili­ tation in patients who had under­ gone coronary artery bypass sur­ gery. Rehabilitation was considered suc­ cessful if the patient experienced an improved quality of life and had a c ­ cepted the responsibility for his/her own rehabilitation. Ten patients who had undergone coronary artery bypass surgery one year ago, were selected from the Cardiac Rehabilitation Unit of the Johannesburg Health and Housing Department. The outcome of rehabilitation was determined in these ten patients by judging their improvement in quality of life and their acceptance of self­ responsibility. This was done by administering a questionnaire to the patients and their spouses w hich co vered as­ p ects o f c o m p lia n c e to a pro­ gramme to modify risk factors, the patients' ability to manage stress, their fitness and obesity profiles and their exercise habits. - From this study the authors co n ­ cluded that the a c cep tan ce of self­ responsibility for rehabilitation is an important factor in the outcom e of ^successful rehabilitation. • T h e p a tie n ts ' k n o w le d g e of: * exercise * diet * medication * e ffe c ts o f s m o k in g . • The patients' satisfaction with the out­ come of the operation, work status of the patient, mood state and extent of acceptance of responsibility for their re­ habilitation. • T h e s p o u s e 's / c a r e -g iv e r 's k n o w le d g e of: * exercise * diet * medication * e ffe c ts o f s m o k in g . T h e s p o u s e s ' s a tis fa c tio n w ith th e o u t­ c o m e o f the o p e r a tio n , p e r c e p tio n o f the p a tie n t's m o o d -s ta te a n d th e d e g r e e o f a c ­ c e p ta n c e o f s e lf-r e s p o n s ib ility b y the p a ­ tien t, w e r e a lso d e te r m in e d 4' ,6,7, '9. METHOD Patient selection: Eleven Caucasian patients, who had had bypass surgery one year prior to this study, and their spouses were identified at the Cardiac Rehabilitation Centre of the Physiotherapy, May 1994 Vol 50 No 2 Page 23 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Johannesburg Health and Housing De­ partment. One of these patients did not wish to participate in the study. Five of the patients were considered to be success­ fully rehabilitated by the staff of the Centre (Group A : patients 1-5) and the other five (Group B : patients 6-10) were considered not successfully rehabilitated. The arbitrary criteria used by the staff of the Centre to select the patients for this study were : • Regular attendance at the rehabilitation unit. • Exercise compliance. • Not smoking. • Weight loss. All the patients and their spouses /care­ givers were interviewed telephonically by the same assessor. All the patients in group A were males. The mean age was 62.8 (±4.76). In group B there were four males and one female. The mean age for this group was 55.8 years (±13.820). For the purpose of this study, successful rehabilitation was judged using the crite­ ria suggested by Oldridge2. They are the following: IMPROVED QUALITY OF LIFE • Improved functional status which was assessed by an exercise stress test. • The am elioration of cardiac related symptoms. • The retu rn to gain fu l em p loym ent and/or recreational activities after the 4intervention . ACCEPTANCE OF SELF-RESPONSIBILITY • Social status. • Compliance with a programme to mod­ ify risk factors. • A positive attitude to recovery. • The ability to manage stress. • The ability to take decisions regarding health and the acceptance of the respon­ sibility for these decisions. • A knowledge of the prescribed medica­ tion. • Fitness and obesity profiles. • Exercise habits. Group A had an average std. 7 educa­ tional level and group B, std. 9. There was one patient with a university degree in each group. The average rating on the social scale, as suggested by Schlemmer and Stopforth, 1979, w as 72 for group A and 67 for group B10. This research project was approved of by the committee for research on human subjects. Protocol number: 18/10/90. RESULTS AND DISCUSSION IMPROVED QUALITY OF LIFE. Functional capacity was assessed by an exercise stress test. The mean peak MET level of group A was 7.6(±1.8) and of group B was 5.54(±2.02) (Figure 1). (Mean peak MET is a unit used to estimate the metabo­ lic cost of physical activity). The peak MET levels were lower for the patients who were unsuccessfully rehabili­ tated (Group B, patients 6-10) except in the case of patient no.8 who was only 32 years old. In group A, none of the patients had any cardiac related symptoms. Two patients in group B had angina, another two complained of severe fatigue and only one subject seemed to be symp­ tom free. Six subjects were back in full-time em­ ployment, four in group A and two in group B. Each group had a subject who was on pension. Two patients in group B who had been employed prior to the op­ eration were unemployed one year post- operatively (Figure 2).Both these patients Figure 2. Employment Status were still symptomatic. It seems, from the information gained from the patients on improved functional capacity, amelioration of cardiac related symptoms and return to gainful employ­ ment, that our results follow the same trend as the results of the CASS report4. ACCEPTANCE OF SELF-RESPONSIBILITY The educational and social status of the two groups were similar. According to the literature, the outcome of rehabilitation m aybe influenced by the educational level and the social status of the patients11. It is possible that this may be observed in a larger study but in our pilot study it was not the case. All the patients in group A knew that smoking was detrimental to their health and had stopped smoking. Two of the pa­ tients in group B were still smoking. Only two patients from each group knew that smoking had a deleterious effect on the cardiovascular system. ■ Mo. of madlctnM 0 CTwda known D Name* knovffl r Figure 5. Knowledge of Medication Patients in group A had lower choles­ terol levels (Figure 3) and lower body mass indices (Figure 4) than patients in group B. A ll p a tie n ts w ere aw a re that they should be on a low fat diet. Patients and spouses generally had a good knowledge of dietary requirements. All the patients knew the exact number of medicines they had to take daily (Fig­ ure 5). Patients in group A had better knowledge of the names and effects of the medication than the patients in group B (Figure 5). In Group A the spouses knew the exact number of medicines taken by the patient but three of the spouses in Group B had absolutely no knowledge of the patients medication. Patients in both groups were satisfied with the outcome of the operation. Only one patient from group B was dissatisfied and he had to have a further bypass opera­ tion three months later, still with no ame­ lioration of his cardiac symptoms. Bladsy 24 Fisioterapie, Mei 1994 Dee! 50 no 2 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Seven patients (four from Group B) were still experiencing unacceptable stress levels (Figure 6) and the activity levels of six patients (three from each group) were the same or less than they had been pre-op- eratively. One would expect that if patients were accepting self-responsibility, their control of stress levels would be better and they would be at least as active as before the operation. ✓ s' s' s s s’ > 1 -v. _ y' S' s' s' s' s' > > > > > >1 fTTTn s S S' s S' s' s' s > > "s Patients / Spouses ■ MedSR □ Med UR S DietSR E 2 Diet UR □ ExsSR E 3 E » UR □ Smoke SR S Smoke UR SR « S ucce ssful Rehab. UR = U nsuccessful Rehab. Figure 7. Assessment of Responsibility When asked to assess their acceptance of self-responsibility patients were of the opinion that they were more responsible for themselves than their spouses/care- givers thought they were (Figure 7). A 2 3 4 5 6 7 Patients I Spouses | Patients ^ Spouses Figure 8. Knowledge of Exercise Programme Because group A were regular atten- ders at a rehabilitation programme, their knowledge of the benefits of exercise and management of an exercise programme was generally good. The knowledge dis­ played by group B in this regard was lack­ ing (Figure 8). All the spouses in Group B (unsuccessfully rehabilitated) were com­ pletely ignorant on every aspect of the pa­ tients' exercise regimes. Eight of the 10 patients were actively involved in sport while still at school. Of these eight, only two participated in en­ durance type activities,one being a runner and one a swimmer. All the others partici­ pated in the traditional team sports offered at South African schools. After school, four subjects in group A and one in group B continued to partici­ pate in sport. They spent an average of 4.2 (±1.30) hours on their activities weekly. Only one of the ten patients was ac­ tively exercising at the time of his bypass operation. Most subjects had stopped ex­ ercising many years before (group A, on average 19 years and group B, 31 years). The patients in group A all attended the Cardiac Rehabilitation Centre regularly. Their b etter exercise h istory possibly played a role in their better compliance with exercise. The spouses/care-givers were gener­ ally well informed about diet and that sm oking w as generally bad for one's health. They were however particularly uninformed about the medication and ex­ ercise programmes of the patients. This was particularly true of the spouses of the patients in group B. This lack of knowledge could be due to poor com m unication between patients and their spouses or simply disinterest in the patient and his rehabilitation pro­ gramme. CONCLUSIONS Although this is a small pilot study, the factors investigated appear to be valid de­ terminants of improvement in quality of life and in acceptance of self-responsibil­ ity. The patients in Group A generally had a better quality of life and at the same time were more aware of what to do in order to become responsible for their own rehabili­ tation. If the im provem ent of the patients' quality of life is an important determinant of successful rehabilitation then it would seem that the acceptance of self-responsi­ bility is also an important factor to con­ sider when assessing the successful reha­ bilitation of patients who have undergone coronary artery bypass surgery. Acknowledgment The authors would like to thank the staff of the Cardiac Rehabilitation Unit of the Johannesburg Health and Housing De­ partment for their assistance in this study. REFERENCES 1. Bolli R. Bypass surgery in patients with coro­ nary artery disease. Indications Based on the M u lt i c e n t e r R a n d o m iz e d T r ia ls . Chest 1987;91(5):760-764. 2. Oldridge NB. Cardiac Rehabilitation, Self-re- sponsibility and Quality of Life. J Cardiopul­ monary Rehabil 1986;6:153-156. 3. Oldridge NB. Cardiac Rehabilitation Services: What are they and are they worth it? Compre­ hensive Therapy 1991;17(5):59-66. 4. Cass Principal Investigators and their Associ­ ates. A Randomized trial of coronary artery bypass surgery. Quality of life in patients randomly assigned to treatment groups. Cir­ culation 1983;68(5):951-960. 5. Wenger NK, Mattson ME, Turberg CD et al. Assessment o f Quality of Life in Clinical T rails o f C ard io v ascu lar T h erap ies. The American Journal o f Cardiology 1984;54:908- 913. 6. Kinchla J, Weiss T. Psychologic and Social Outcomes Following Coronary Artery By­ p a ss S u rg e ry . J C ardiopu lm onary Rehabil 1985;5:274-283. 7. Knowles JH. Responsibility for Health. Science 1977;198:NO,4322. 8. Caradoc-Davies TH. Rehabilitation in New Zealand: now and the future. New Zealand M edical Journal 1990;103:210-214. 9. Russel RO. Return to work after Coronary Bypass Surgery and Quality of Life. Quality o fL ifea n d Cardiovascular Care 1986;l(2):55-60. 10. Schlemmer L, Stopforth P. A guide to the coding of occupations in South Africa 1979. Centre for Applied Social Sciences. Fact pa­ per No 4. University of Natal. 11. Oldridge NB et al. Predictors of drop-out from Cardiac Exercise Rehabilitation. The American Journal o f Cardiology 1983;51:70-74. WCPT-AFRICA The First Regional Congress was held in Nairobi, Kenya during April. The SASP representatives at the General Meeting included Doctor Jo Beenhakker (voting delegate), Lucy Bendle, Marge Stef­ fen, Tasneem Mosam and Dakshika Eccharan. Sheena Irwin-Car- ruthers attended as Regional Treasurer. Several SASP members were invited to take part in the Con­ gress, which had a full programme of pre- and post-Congress courses, keynote addresses and papers. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )