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Multidisciplinary work to provide cardiac rehabilitation for patients

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VOL: 101, ISSUE: 04, PAGE NO: 26

Feryad Hussain, DClinPsy, is clinical psychologist

Dianne Wooller, RGN, is acting cardiac rehabilitation coordinator; both in the cardiac rehabilitation team, Oldchurch Hospital, North East London Mental Health Trust/Barking, Havering and Redbridge Trust

Addressing misconceptions about angina and helping patients set their own goals has been shown in a pilot study to improve outcomes in cardiac rehabilitation (Chatterjee, 2005). The National Service Framework for Coronary Heart Disease (Department of Health, 2000) highlighted the need for such rehabilitation programmes, and since then a range of approaches has been taken in developing services of this type.


Addressing misconceptions about angina and helping patients set their own goals has been shown in a pilot study to improve outcomes in cardiac rehabilitation (Chatterjee, 2005). The National Service Framework for Coronary Heart Disease (Department of Health, 2000) highlighted the need for such rehabilitation programmes, and since then a range of approaches has been taken in developing services of this type.



One such intervention is a multidisciplinary project involving a cardiac rehabilitation team consisting of specialist nurses with additional input from occupational therapy, physiotherapy and clinical psychology based at Oldchurch Hospital in Essex.



This article discusses the benefits of cardiac rehabilitation using a case study approach and highlights the impact holistic rehabilitation can have on individual patients.



Patient history
Mary Brown (not her real name), aged 54, was referred for assessment following surgery for an aortic valve replacement. She had long-term aortic valve disease and had become progressively more breathless on exercise over the past two years. More recently she had complained of mild chest pain on exertion and occasional light-headedness, though no actual syncope.



Her echocardiogram showed calcific aortic stenosis, which was confirmed by angiogram. Coronary arteries were normal and there was a moderate dilation of the ascending aorta. Ms Brown was then assessed for the cardiac rehabilitation programme and was thought suitable to attend the low-risk cardiac rehabilitation group.



The programme
The programme is split into two levels of intensity - low or high - depending on the results of a patient’s individual clinical risk assessment.



The low-risk group has a high intensity exercise programme and includes:



- Patients with a negative exercise stress-test result;



- Patients with successful angioplasty/cardiac surgery;



- Patients approved by their consultant to step up to a higher intensity programme following attendance in the high-risk group.



The high-risk group has a low-intensity exercise programme and includes:



- Patients with a positive exercise stress-test result;



- Continuing ischaemia;



- Patients who are considered by their consultants to be unsuitable for the low-risk group;



- Patients with a left ventricular function that is below 50 per cent.



Patients attend as outpatients, twice weekly, over a six-week period. Each session lasts for two-and-a-half hours and each programme accommodates 10 patients. The programme comprises exercise, relaxation and education (Box 1).



Referrals to the programme come from the consultant, GP or health professionals from the rehabilitation team and are directed to patients who have specifically had a myocardial infarction (MI), angioplasty or cardiac surgery. Pending further assessments, appropriate patients are invited to attend some or all components of the programme.



Coronary support groups are also available locally as well as exercise prescription schemes in the community, and these can all be accessed by patients as and when required.



Psychological assessment
Although Ms Brown appeared to have made a good physical recovery, information presented at this assessment suggested that psychologically there were a number of difficulties to deal with.



After further exploration of these difficulties, Ms Brown was referred to the team clinical psychologist. A detailed psychological assessment was carried out and in defining the aims of the intervention, Ms Brown prioritised her psychological needs as follows:



- Anxiety about sounds emanating from the replacement valve, which were manifest in muscular tension, breathlessness, inability to distract, and emotional distress. This was exacerbated by a belief that this experience was somehow ‘abnormal’ and a fear that she would be seen as ‘mad’ if she disclosed her concerns;



- Fear about a repeat heart attack and therefore avoidance of any risk-taking behaviours, particularly physical exertion. This, in turn, resulted in pain (due to lack of exercise) when attempting physical exertion, reinforcing the belief that exercise was dangerous. Related to the above was poor sleep onset, which was exacerbated by fear of heart attack during the night, possibly resulting in death;



- Distress about appearances from operational scarring and the impact of this on her relationship with her husband. This was manifest in emotional and physical distancing within the relationship. Ms Brown felt that this strategy protected her from ‘predicted’ rejection by her husband when he saw the scarring.



These difficulties had begun soon after the valve replacement operation. Ms Brown reported feeling ‘cheated’ because although she had been advised of potential difficulties, the problems appeared to be worse than expected. Her anxiety was found to be worse in the mornings but Ms Brown could not elaborate on this.



During these times Ms Brown felt life was a chore and a burden and felt tearful and low. Consequently, she would withdraw from all social contact. This, in turn, left her feeling isolated.



Ms Brown’s daily activity level before the operation had been high, but she was currently limited to her home. The health professionals caring for her had reported some concerns about her fear of taking ‘risks’ during her supervised exercise in the programme. Her main coping strategy was distraction. However, this had failed her and she had felt increasingly hopeless in motivating herself.



Upon exploration, it appeared the management of these difficulties was exacerbated by lack of understanding of her cardiac problem as well as a ‘personally historical’ coping strategy of avoidance when facing change.



The intervention
The initial stage of intervention was carried out primarily by the rehabilitation nurse who normalised some of Ms Brown’s physical/postsurgical experiences.



This also enabled the process of ‘myth-busting’ to begin, in terms of Ms Brown’s condition and the nature of the recovery process.



Information here was also shared (with patient consent) with the psychologist who was then able to reinforce ideas and make links when normalising Ms Brown’s psychological reactions.



The psychologist then began to work with Ms Brown on psychoeducational information about anxiety and anxiety maintenance, exploring the fear-avoidance cycle relating to her beliefs that ‘If I move I will die’ and ‘I won’t sleep in case I have a heart attack and die’.



This essentially involved cognitive behavioural techniques to help Ms Brown identify and challenge negative automatic thoughts during times of anxiety.



This process also examined ideas and implications of ‘risk-taking’ as defined by Ms Brown. Again feedback was given to staff supervising exercise sessions during the rehabilitation programme, enabling increased support (both psychological and practical) for Ms Brown as and when required.



The next stage involved teaching Ms Brown self-hypnotic relaxation to help tackle general levels of anxiety. She was asked to practise this skill in between sessions and potential obstacles were identified. She reported that her hypnotic relaxation skills had significantly reduced the sleep problems.



The psychologist began by asking Ms Brown to identify beliefs and fears related to noises from the replacement valve. Following discussion with the nurse, it was discovered that noise from replacement valves was a common complaint from patients. Again, this normalised some of Ms Brown’s reaction and the remaining focus of the intervention was management.



This was carried out over a number of sessions, using hypnotic techniques in conjunction with cognitive behavioural strategies, whereby Ms Brown was asked to visualise a ‘dial’ that could be used to alter the volume of sounds. Ms Brown was advised to practise reducing the volume of these sounds to as low a level as she was capable.



Ms Brown’s sense of achievement of these two core aspects of her problem resulted in her having increased confidence and she now felt able to tackle the relationship/identity issues without any further need for psychological input.



Following multidisciplinary input, Ms Brown reported that she was better able to manage the psychological and physical consequences of her valve-replacement surgery. This improvement was reaffirmed by her progress within the rehabilitation programme.



Continual review and feedback with team members reinforced the messages and advice offered, so avoiding confusion for the patient. Consequently, Ms Brown felt able to manage her recovery more successfully and with greater independence. This article has been double-blind peer-reviewed.



For related articles on this subject and links to relevant websites see

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