Rethinking Rehabilitation

Abstract

Rethinking Cardiac Rehabilitation 389C ardiac rehabilitation (CR) is a class 1 guideline-based therapy that provides comprehensive secondary prevention strategies. Best practices for CR include exercise training, outcome assessments, risk factor management, and nutritional/behavioral education to individuals who qualify. Research indicates that CR participation provides many health benefits including reduced risk for morbidity and mortality, increased cardiorespiratory fitness (CRF), enhanced quality of life, and improved mood and symptoms. 1,2 Furthermore, CR is cost-effective by reducing the rate of recurrent myocardial infarctions (MIs) and hospital readmissions. 3 Several meta-analyses have demonstrated the benefits of CR programs, specifically examining the individual components of these programs and their impact on patient well-being. 4,5 Despite the large number of different cardiovascular diseases (CVD), only seven diagnoses or procedures qualify an individual for CR (Table 1).While this list may seem robust to some, it is only a fraction of the chronic health conditions that physical activity and lifestyle interventions (ie, education, counseling, and social support) have been shown to benefit. Specifically, exercise is beneficial for individuals with conditions that are strongly associated with CVD including chronic kidney disease (CKD) [6][7][8][9][10][11] and breast cancer (BC). [12][13][14][15] Given the observed associations between these diseases and CVD, it seems appropriate to consider the inclusion of these individuals in CR as a strategy to help manage their CVD risk.Additionally, some patients who attend CR present with cardiovascular comorbid conditions (eg, spontaneous coronary artery dissection, [SCAD]; left ventricular assist device, [LVAD]), not easily identified in Table 1. Often, these individuals will make up a relatively small proportion of the populations that traditionally participate in CR and thus professionals may be less familiar with the current guidelines for patient-centered care.The purpose of this review is to present relevant information for the CR practitioner about patient populations that either do not currently qualify for (ie, chronic and end-stage CKD, BC survivor) or who are eligible but less commonly cared for in CR (ie, SCAD and LVAD). We also address special CR-related considerations and expected outcomes to better inform clinicians and researchers. Additionally, randomized control trials and clinical trials from the past decade, which support the benefits of exercise programming for CKD, SCAD and LVAD patient populations, have been summarized in Tables 2, 3, and 4. While not a systematic review, our tables provide important references for CR professionals to better understand the potential benefits of exercise for these populations. A summary for BC survivors was not provided, as a recent systematic review by Furmaniak et al 16 provides the information CR professionals would find beneficial regarding this population.

High Fitness Levels Attenuate the Increased Risk of Chronic Kidney Disease in Men With High Systolic Blood Pressure: A Prospective Cohort Study

“…Even for populations with established chronic diseases such as CKD and breast cancer, which are strongly associated with cardiovascular disease, regular exercise training has been shown to improve CRF and other parameters that may mitigate cardiometabolic risk. 5 Strengths of this evaluation include the use of a prospective cohort design and the objective gold standard measure of CRF. The study was limited by the generalizability to only middle-aged and older Finnish men.…”

“…4 Exercise or PA is also beneficial for pre-existing conditions that have a strong relationship with cardiovascular disease (CVD), such as CKD. 5 Cardiorespiratory fitness (CRF), which is primarily increased through regular PA and/or exercise training, is one of the strongest predictors of adverse vascular outcomes. 6 Higher CRF is also associated with a reduced risk of CKD.…”

“…Regular physical activity (PA) and/or exercise training have numerous health benefits, which include reducing the risk of chronic diseases such as CKD 4. Exercise or PA is also beneficial for pre-existing conditions that have a strong relationship with cardiovascular disease (CVD), such as CKD 5. Cardiorespiratory fitness (CRF), which is primarily increased through regular PA and/or exercise training, is one of the strongest predictors of adverse vascular outcomes 6.…”

Technical Requirements for Clinical Exercise Physiologists as Qualified Health Professionals

“…Minimal competencies for CEPs are assessed by a national certification examination such as ACSM's Certified Clinical Exercise Physiologist examination (ACSM-CEP). Before sitting for the ACSM-CEP, a candidate must either 1) earn a master's degree in Clinical Exercise Physiology (or related field) and obtain more than 600 hours of hands-on clinical experience or 2) earn a bachelor's degree in Exercise Science (or related field) and obtain more than 1,200 hours of clinical hands-on experience (13). It is recommended that students take 21 semester hours of coursework related to exercise physiology, strength and conditioning, applied kinesiology or biomechanics, anatomy and physiology, exercise testing and prescription, and health risk appraisal.…”

A Review on the Role of Exercise Training to Prevent a Decline in Cardiorespiratory Fitness and Cardiac Function in Breast Cancer Survivors

“…10,11 Exercise training is a key component for managing CVD, including HF. [12][13][14] In individuals with CVD, ExT is typically incorporated as part of a multimodal cardiac rehabilitation (CR) program alongside nutritional modification, education, behavioral counseling, and psychological support. [12][13][14] An adapted CR model referred to as cardio-oncology rehabilitation (CORE) has been endorsed by the American Heart Association as a critical intervention for the prevention and management of CVD in at-risk cancer survivor groups (including BCS).…”