Saturday, 28 July 2018

SC- Cardiac Rehabilitation

There is a saying that “what goes around comes around”, and exercise training as a treatment for patients severing from coronary heart disease is no exception to the rule. The eighteenth century English physician, William Heberden, recorded the case of a patient severing from angina “who set himself the task of sawing wood every day and was nearly cured”.1 Almost a century later in 1854, the Irish doctor, William Stokes wrote “the symptoms of debility of the heart are often removable by a regulated course of gymnastics, or by pedestrian exercise”.2 His “pedestrian cure” consisted of comfortable walking initially on level ground, the distance and gradient being increased as tolerance improved—always, however, cautioned against excessive fatigue, breathlessness, or chest pain. Have we progressed that far since then? Over the ensuing years, Stokes’ exercise training regime was largely forgotten, obscured by the teaching of the London surgeon John Hilton, who stressed the value of strict bed rest.3 Unfortunately, Hilton’s precept was carried to extremes. Prolonged immobilization in bed became the cornerstone of medical care for close to a century; seldom was it practiced more assiduously than after a myocardial infarction. However, by the 1950s, doctors had begun to question the wisdom of strict bed rest, and when Levine and Lown introduced their innovative and highly successful “armchair treatment”, in which they progressed their heart attack patients to sit up in a chair by the bed a few days after admission, the era of early mobilisation had arrived.

Thus, the past five decades of the twentieth century have seen noteworthy advances in the application of exercise training as part of a comprehensive approach for the secondary prevention and rehabilitation of coronary heart disease. As a result, national and international health bodies have stressed the importance of exercise rehabilitation and have advocated that it be made available to all cardiac patients. Unfortunately, in most countries, this goal has not been achieved. Cardiac rehabilitation is grossly undervalued and underused, and it has been estimated that only about 20–30% of potential candidates receive the service. Greater efforts are required on the part of the government, health professionals, and the public alike if we are to meet the challenge of providing improved cardiac rehabilitative care for patients into the next century.

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