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Rehabilitation of coronary patients
J. chron. Dis. 1967, Vol. 20, pp, 815-821. Pergamon
REHABILITATION JAN J.
KELLERMANN,
M.D.,
Press Ltd. Printed in Great Britain
OF CORONARY
MOSHE
LEVY, M.D.,
ITZHAK KARIv,
PATIENTS*
SALOMON FELDMAN, M.D.
and
M.D.
Tel Hashomer Government Hospital, Tel Hashomer, Israel
(Received 25 October 1966; in revised form 25 May 1967; further revised 13 July 1967) THE REHABILITATION of coronary patients has become important in recent years, owing to the growing numbers of patients with myocardial infarction and angina pectoris. [I] Some of the main and, as yet, unsolved problems are: When should the patient return to work? What limits should be imposed on his physical activities? What kind of work can he perform? Are conditioning measures needed in order to enable him to resume his previous employment or some other work? Four years ago we started with a rehabilitation program of coronary patients, in two parallel groups, both suffering from coronary insufficiency and/or post myocardial infarction state.
Dormitory group
Patients were hospitalized in quarters close to the main hospital during the week and were permitted to spend weekends at home. The criteria for acceptance into this group were inability to return to work after recovery from the acute phase of myocardial infarction due to angina pectoris. Ambulatory group
Patients visit the hospital three times a week for gradual physical training. Patients accepted to this group were active in their professions (predominantly sedentary occupations), mostly on a part-time basis, and complained of angina pectoris. These patients were afraid of increasing physical activity. Both groups were accepted for a period of four months. In this communication an attempt is made to describe the programs of rehabilitation and to assess their effect. MATERIAL
The coronary patients in this study represent various professional groups with different time intervals of inactivity after the acute onset. The age range is between 40 and 60. The upper limit of age of 60 yr was chosen because, practically, only a few patients beyond this age return to active work. [2, 31 The patients of the ambulatory group represented mainly members of the free *Supported by Grant No. ISR 17-62 of the Vocational of Health, Education and Welfare, Washington, D.C. 815
Rehabilitation
Administration,
Department
816
JAN J. KELLERMAN et al.
professions (doctors, lawyers, journalists, managers), who returned to work, but continued to suffer from moderate to severe angina, or had been unable to take a full-time job because of low physical capacity and weariness. Many of them suffered either from professional competition-feeling themselves unable to compete with healthy and younger co-workers-or from depression, with subsequent complete indifference to their work and future. The dormitory group consisted of patients who did not return to work at all after the initial attack, sometimes owing to misguided medical instructions. Some of them lived on welfare allowances or sent their wives and children to work, some did not believe that they could ever take up active, productive work again. Severe social problems resulted from this long incapacity, some of the patients having been out of work for as long as 7 yr. Both groups were free of intractable angina pectoris, severe arrhythmia, heart failure or diastolic blood pressure over 115 mm Hg. Twenty-six patients of the dormitory group and 44 patients of the ambulatory group form the material of this communication. In all these patients typical ECG findings of old myocardial infarction and/or coronary insufficiency have been found. METHODS
The hospitalized patients were attended by a house matron, who remained with them from late afternoon until morning. They had their meals in the hospital dining room (three times a day). Work performed by patients was supervised by trained hospital personnel, upon instructions of the medical staff as to the time and range of work permitted for each individual. Treatment was based on a gradual progressive physical program. At first, patients performed light tasks twice a day for 15 min, and attained an average of 7 hr of work at the end of the program-after four months of rehabilitation. They began by walking to and from the dining room, place of work and ward (a total of 2800 m). Patients started with light gardening (sprinkling, etc.) twice a day for 15 min, and occupational therapy for 15 min twice a day. At the end of the first month the working periods (garden, workshops) were gradually prolonged to 1 hr, in addition to 1 hr of occupational therapy. Thus, the patients were kept busy (with gardening and other work) from7.30a.m.to12.00p.m.andfrom3.30p.m.to5.00p.m.bytheendoftheprogram. Gymnastics lessons were held three times a week and the duration of the lesson was 40-60 min. Twice a month patients took walks to a distance of 6 km, at a speed of 3 km/hr, with several short rest periods. By the end of the treatment, the distance of 10 km, at a speed of 4 km/hr, with one or two rest periods, was reached. The ambulatory group par?icipated only in a gradual physical training, which was based on breathing exercises, muscle relaxation, and gymnastics. Effort was gradually increased within the four months of treatment. This was done under medical supervision of the program by a physician and a nurse. It should be noted that care was taken to discourage any competition among the patients, either at work or during physical training. Smoking was prohibited. Patients were kept on a low calorie and low salt diet. Medication was permitted at the beginning of the program and then gradually stopped. By the end of the second month, most of the patients gave up medication of their own accord. In hot weather, time
Rehabilitation
of Coronary
Patients
817
schedules of work and training were revised in such a way thatthe morning sessions began at an earlier hour, and afternoon sessions at a later hour. Caloric requirements of the various efforts are shown in Tables 1 and 2. The gradual increase in work during the four months of training is summarized in Table 3. TABLE1. HOUSEHOLD CHORES Bed-making
Cal/min 3.7-4.5
Shower Dress Simple House-cleaning OCCUPATIONAL THERAPY ACTIVITIES Light Carpentry, Sanding, Polishing, Basket Weaving Light Mechanics WALKING Walking (3 km per day at the rate 2 km/hr) Excursions (at the rate 3.5 km/hr) Excursions (at the rate 5.0 km/hr)
2.1 2.1 1.9-3.5 2.5-3.5 2.0-3.5 2.0-2.5 2.5-3.0 3.54.0
TABLE2. GARDENING Watering by Hose Spading Raking Sowing (Flowers and Vegetables) Picking (Flowers and Vegetables) Watering by Can (6 I.) Hoeing (2.5 kg Hoe with a 1.5 m handlelight to medium soil) Pruning
Cal/min 1.5-2.0 1.5-2.1 1.7-2.5 2.0-3.0 2.1-3.5 2.2-2.5 3.0-5.0 3.0-3.5
TABLE3. AVERAGE CALORICREQUIREMJNI-S CALORIC REQUIREMENT DURING From the 1st until the 14th day From the 14th day until 1 month During the 1st and 2nd month At the end of the 3rd month At the end of the 4th month
WORK 150 300 450 650-750 750-loo0
After recording a detailed history of the patient, with special attention to his physical activities, a routine physical examination, ECG, and X-ray of the chest were performed. If there were no signs of acute cardiac or coronary insufficiency, severe arrhythmia, or diastolic blood pressure above 115 mm, and the patient was not suffering from intractable angina pectoris, a spiroergometric test was performed for determination of submaximal physical working capacity. [4-lo] For this purpose, an electric bicycle ergometer and a spirometer “Pulmotest”, both from the Goddart Company, were used. The multistage spiroergometric and ergometric test used at our institute were based on steady state measurements of various parameters (Sjoestrand, Bengtson, Astrand, Reindell). More than 2000 examinations have been performed so far. Our evaluation and later proposition for proper work is based on
818
JAN
J. K~UERMANN et al.
the so-called “50 per cent load”. As BRODYexpressed it in his book (quoted from ASTRAND)[l l] Bioenergetics and Growth: “Machines are not usually run at more than 50% of their capacity and a similar safety margin should perhaps be allowed to men and animals, so as to avoid injury and untimely death”. Astrand came to the conclusion that the 50 per cent level should probably be considered as the upper limit, at least with work periods of longer duration than 1 hr. We use the 50 per cent load as a peak load for the work capacity and propose proper work in relation to the calorie requirement. [l 1, 121 As an example: a patient who had, under laboratory conditions a physical work capacity of 100 W (600 kg/mm), would need for this work under submaximal test conditions approximately 7 cal/min. In this case we would propose a proper work with a mean requirement of 3.5 cal/min. The energy requirements of the different occupations were estimated according to the table of PASSMORE and DURNIN. [ 121 The parameters recorded during the spiroergometric test were: 1. Pulse rate 2. Blood pressure 3. Oxygen consumption 4. Minute ventilation 5. ECG There data were collected at rest, at various workloads and after effort (recovery time). The workloads were measured in W/min or in kg/min. The submaximal physical work capacity is defined as the highest load at which the patient is able to perform in steady state. Steady state conditions are considered as being maintained if pulse rate TABLE 4. No. of cases
32 zd
:
Mean W.
% P.W.C.
02 Consumpt cm3
Healthy
100
112.5
100
1.500
A.S.H.D.
193
74.5
66
1031
Before _______ After
44
65.3
58
1083
44
93
84
1250
Before
15
50
44
830
After
15
72
64
1012
Before
11
34
30
11
62
54
.z E $
e,
_____
2 c-
-
d
After
-
NB: Age Group of all Cases: 40-60 yr
Rehabilitation
of Coronary
Patients
819
and oxygen consumption remain steady during the last 23 min of a 5-min effort. The tests were started generally with a load of 25 W (150 kg/min), and raised gradually by 25-50 W on a basis of 40 rev/min. Each phase of effort was of 5 min duration. The test was interrupted if: 1. Steady state was not reached 2. The heart rate exceeded 150 beats/min 3. Further pathological ECG changes appeared (“ST” depressions, arrhythmias, etc.) 4. Angina1 pain occurred. RESULTS
A. Dormitory group of 26 patients, 11 of them welfare patients. The 15 nonwelfare patients had, at admission, a mean physical work capacity of 5OW, which is 44 per cent of the normal physical work capacity obtained in a healthy control group of the same age, and a mean oxygen consumption of 830 cmS/min. These patients increased their physical work capacity after rehabilitation to 72W (64 per cent) and 1012 cm3/min submaximal oxygen consumption. The 11 patients who had been referred to our unit through the welfare organization and who had stopped working l-7 yr prior to their rehabilitation had, at the initial examination, a physical work capacity of 34W (30 per cent) and achieved, after rehabilitation, a physical working capacity of 61W (54 per cent). B. The ambulatory group consisting of 44 patients who had a mean physical working capacity of 65.3W and a submaximal oxygen consumption of 830 cm3/min before rehabilitation. After rehabilitation this group achieved a mean physical working capacity of 94W which is 84 per cent of the normal, and the oxygen consumption rose to 1250 cm3/min. The results of the rehabilitated groups have been compared with the spiroergometric examination of two control groups: 1. 100 healthy males, age group 40-60, had a mean physical working capacity of 112.5W and a mean submaximal oxygen consumption of 1500 cm3/min. This had been considered as the normal (100 per cent) physical working capacity for this age group, and was taken as basis for calculating the percentage of the patients’ capacity. 2. A group consisting of 193 male patients with coronary heart disease (coronary insufficiency and/or state of post myocardial infarction), continued working although they were not rehabilitated. The mean physical working capacity of this group was 74.5W which is 66 per cent of the mean physical working capacity for healthy subjects of this age group. The mean submaximal consumption was 1031 cm3/min. Forty patients of the ambulatory group returned to their previous jobs, mostly on a full time basis. From the dormitory groups, 12 out of 15 patients, and 8 out of 11 patients in the welfare subgroup returned to work. Only three patients out of 67 suffered occasional angina1 pain. Three patients died. For the patients in the ambulatory group, the return to their original occupations on a full-time basis presented no problem, because these patients were working mainly in sedentary professions and the rehabilitation program had significantly improved their physical work capacity. Not only were they able to continue working,
820
JANJ.
I(ELLERMANN
et
al.
but they also were able to participate in physical activities, prolonged walking, some housework and gardening. The return to work of the patients from the dormitory group proved a more complex problem. Nine of the 11 patients who did not work before their acceptance to the program, returned to a sedentary or moderate activity. Two continued not to work. Twelve patients in this group, who worked in part time jobs in professions requiring 24 cal/min (i.e. clerks, chemists, bookbinders, light mechanical workers, basket weavers, electricians, building contractors) returned to their original job on a full time basis, and three changed to physical activity requiring more than 4 cal/min (2 gardeners, 1 carpenter). We were helped by a social worker and a placement officer of the Ministry of Labour in placing the 11 formerly unemployed. Despite the three patients who achieved a physical working capacity of 90 per cent of the normal instead of the mean of 64 per cent after rehabilitation, there was no significant correlation between the physical working capacity achieved at the end of the program and the return to work at physical occupations. DISCUSSION The
purpose of this study was to improve the patient’s physical working capacity and return him to an appropriate occupation. The control group of coronary patients show a mean of 66 per cent as compared with healthy people, while the ambulatory group had a mean physical working capacity of 58 per cent on admission. This difference is not of great significance and probably reflects the difference in the working habits of both groups. As mentioned previously, the ambulatory group consisted mainly of professional people, not used to physical work, while the control coronary group was more disparate and included a large percentage of manual workers, before and after their illness. The physical working capacity of the dormitory group is much lower.and again reflects the lack of any systematic physical activities during previous years. The very low physical working capacity of the welfare group who had not worked at all in the past 1-7 yr should be stressed. The difference between the physical working capacity of the dormitory group (44-30 per cent) and that of the control group-coronary and ambulatory-(66-58 per cent) is significant. The results obtained after rehabilitation are highly significant (P=O.OOl) in all groups. This difference probably represents greater self-confidence and freedom from angina1 pains, as well as a feeling of general well-being. This allowed a better performance of work and was especially pronounced in the dormitory group, where patients could be sent to work for the first time after several years of inactivity. In conclusion, it could be demonstrated-despite the short follow-up time (33 yr) that it is possible to restore coronary patients to work by a short, planned rehabihtation program of four months, even after 7 yr of inactivity. Furthermore, it is possible to improve significantly the submaximal working capacity of those patients who returned to work by themselves, by gradual physical training. [l, 21 SUMMARY
Seventy patients with coronary
heart disease (status after myocardial infarction
Rehabilitation
of Coronary
Patients
821
and/or coronary insufficiency) have been rehabilitated by gradual physical training program. Forty-four patients underwent this program as ambulatory groups (gymnastics lessons three times weekly), and 26 were accepted to a dormitory next to the hospital. The program for both groups was of four months’ duration. The procedures of the rehabilitation are described. All rehabilitated patients were examined by a spiroergometric multistage test for determination of the submaximal physical working capacity. The test procedure and the results obtained before and after rehabilitation are presented, and the results compared to similarly examined healthy adults and coronary control group. Acknowledgemen&-The for technical assistance. statistical evaluation.
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. ::: 14.
authors wish to thank Mrs. T. LEVANON(R.N.) and Mrs. P. NACHUM(R.N.) We are indebted to Miss CH. BIRENBAUMand Mr. I. WINTNER for the
REFERENCES HELLERSTEIN, H. D. : Rehabilitation of patients with heart disease, Postgrad. Med. 15,265, 1964. REINDELL,H.: Herz Kreislaufkrankheiten und Sport, Johann Ambr. Barth, Muenchen, 1960. STRANDELL,T.: Circulatory studies on healthy old men, Acta med. stand. Suppl. 414, Stockholm, 1964. ASTRAND,P. 0. : Experimental studies of physical working capacity in relation to sex and age, Kopenhagen, 1952. BENGTSON,E.: The working capacity in normal children evaluated by submaximal exercise on the bicycle ergometer and compared with adults, Acta med. stand. 154, 359, 1956. BICKELMAN,A. G. : The responses of the normal and abnormal heart to exercise, Circulation 28, 000. 1963. BIOERCK,G. : The return to work of patients with myocardial infarction, Acta med. stand. 175, 000,1964. HOLMANN, W.: Der Arbeits und Trainingseinfluss auf Kreislauf und Atmung. Eine klinische und physiologische Betrachtung. Steinkopf, Darmstadt, 1959. SJOESTRAND, T. : The relationship between the S.V. of the heart and the capacity of the vascular system. Acta physiul. scan. 42, Suppl. 145, 1957. TAYLOR,H. L., BUSKIRK,E. and HENSCHEL:Maximal oxygen intake as an objective measure of cardiorespiratory perform, Appl. Physiol. 8, 73, 1955. ASTRAND, I.: Aerobic work capacity in men and women with special reference to age, Acta phys. stand. 49, Suppl. 169, Stockholm, 1960. PASSMORE,R.: Human energy expenditure, Physiol. Rev. 35,801, 1955. BRUCE, B. A., BLACKMAN,J. R., JONES,J. W. and STRAIT,G.: Exercise testing in adult normal subjects and cardiac patients, Pediatrics 32, Suppl. October 1963. LYTHGOE,R. J.: The pulse rate and oxygen intake during the early stages of recovery from severe exercise, Proc. R. Sot. 98, 468, 1925.
REHABILITATION JAN J.
KELLERMANN,
M.D.,
Press Ltd. Printed in Great Britain
OF CORONARY
MOSHE
LEVY, M.D.,
ITZHAK KARIv,
PATIENTS*
SALOMON FELDMAN, M.D.
and
M.D.
Tel Hashomer Government Hospital, Tel Hashomer, Israel
(Received 25 October 1966; in revised form 25 May 1967; further revised 13 July 1967) THE REHABILITATION of coronary patients has become important in recent years, owing to the growing numbers of patients with myocardial infarction and angina pectoris. [I] Some of the main and, as yet, unsolved problems are: When should the patient return to work? What limits should be imposed on his physical activities? What kind of work can he perform? Are conditioning measures needed in order to enable him to resume his previous employment or some other work? Four years ago we started with a rehabilitation program of coronary patients, in two parallel groups, both suffering from coronary insufficiency and/or post myocardial infarction state.
Dormitory group
Patients were hospitalized in quarters close to the main hospital during the week and were permitted to spend weekends at home. The criteria for acceptance into this group were inability to return to work after recovery from the acute phase of myocardial infarction due to angina pectoris. Ambulatory group
Patients visit the hospital three times a week for gradual physical training. Patients accepted to this group were active in their professions (predominantly sedentary occupations), mostly on a part-time basis, and complained of angina pectoris. These patients were afraid of increasing physical activity. Both groups were accepted for a period of four months. In this communication an attempt is made to describe the programs of rehabilitation and to assess their effect. MATERIAL
The coronary patients in this study represent various professional groups with different time intervals of inactivity after the acute onset. The age range is between 40 and 60. The upper limit of age of 60 yr was chosen because, practically, only a few patients beyond this age return to active work. [2, 31 The patients of the ambulatory group represented mainly members of the free *Supported by Grant No. ISR 17-62 of the Vocational of Health, Education and Welfare, Washington, D.C. 815
Rehabilitation
Administration,
Department
816
JAN J. KELLERMAN et al.
professions (doctors, lawyers, journalists, managers), who returned to work, but continued to suffer from moderate to severe angina, or had been unable to take a full-time job because of low physical capacity and weariness. Many of them suffered either from professional competition-feeling themselves unable to compete with healthy and younger co-workers-or from depression, with subsequent complete indifference to their work and future. The dormitory group consisted of patients who did not return to work at all after the initial attack, sometimes owing to misguided medical instructions. Some of them lived on welfare allowances or sent their wives and children to work, some did not believe that they could ever take up active, productive work again. Severe social problems resulted from this long incapacity, some of the patients having been out of work for as long as 7 yr. Both groups were free of intractable angina pectoris, severe arrhythmia, heart failure or diastolic blood pressure over 115 mm Hg. Twenty-six patients of the dormitory group and 44 patients of the ambulatory group form the material of this communication. In all these patients typical ECG findings of old myocardial infarction and/or coronary insufficiency have been found. METHODS
The hospitalized patients were attended by a house matron, who remained with them from late afternoon until morning. They had their meals in the hospital dining room (three times a day). Work performed by patients was supervised by trained hospital personnel, upon instructions of the medical staff as to the time and range of work permitted for each individual. Treatment was based on a gradual progressive physical program. At first, patients performed light tasks twice a day for 15 min, and attained an average of 7 hr of work at the end of the program-after four months of rehabilitation. They began by walking to and from the dining room, place of work and ward (a total of 2800 m). Patients started with light gardening (sprinkling, etc.) twice a day for 15 min, and occupational therapy for 15 min twice a day. At the end of the first month the working periods (garden, workshops) were gradually prolonged to 1 hr, in addition to 1 hr of occupational therapy. Thus, the patients were kept busy (with gardening and other work) from7.30a.m.to12.00p.m.andfrom3.30p.m.to5.00p.m.bytheendoftheprogram. Gymnastics lessons were held three times a week and the duration of the lesson was 40-60 min. Twice a month patients took walks to a distance of 6 km, at a speed of 3 km/hr, with several short rest periods. By the end of the treatment, the distance of 10 km, at a speed of 4 km/hr, with one or two rest periods, was reached. The ambulatory group par?icipated only in a gradual physical training, which was based on breathing exercises, muscle relaxation, and gymnastics. Effort was gradually increased within the four months of treatment. This was done under medical supervision of the program by a physician and a nurse. It should be noted that care was taken to discourage any competition among the patients, either at work or during physical training. Smoking was prohibited. Patients were kept on a low calorie and low salt diet. Medication was permitted at the beginning of the program and then gradually stopped. By the end of the second month, most of the patients gave up medication of their own accord. In hot weather, time
Rehabilitation
of Coronary
Patients
817
schedules of work and training were revised in such a way thatthe morning sessions began at an earlier hour, and afternoon sessions at a later hour. Caloric requirements of the various efforts are shown in Tables 1 and 2. The gradual increase in work during the four months of training is summarized in Table 3. TABLE1. HOUSEHOLD CHORES Bed-making
Cal/min 3.7-4.5
Shower Dress Simple House-cleaning OCCUPATIONAL THERAPY ACTIVITIES Light Carpentry, Sanding, Polishing, Basket Weaving Light Mechanics WALKING Walking (3 km per day at the rate 2 km/hr) Excursions (at the rate 3.5 km/hr) Excursions (at the rate 5.0 km/hr)
2.1 2.1 1.9-3.5 2.5-3.5 2.0-3.5 2.0-2.5 2.5-3.0 3.54.0
TABLE2. GARDENING Watering by Hose Spading Raking Sowing (Flowers and Vegetables) Picking (Flowers and Vegetables) Watering by Can (6 I.) Hoeing (2.5 kg Hoe with a 1.5 m handlelight to medium soil) Pruning
Cal/min 1.5-2.0 1.5-2.1 1.7-2.5 2.0-3.0 2.1-3.5 2.2-2.5 3.0-5.0 3.0-3.5
TABLE3. AVERAGE CALORICREQUIREMJNI-S CALORIC REQUIREMENT DURING From the 1st until the 14th day From the 14th day until 1 month During the 1st and 2nd month At the end of the 3rd month At the end of the 4th month
WORK 150 300 450 650-750 750-loo0
After recording a detailed history of the patient, with special attention to his physical activities, a routine physical examination, ECG, and X-ray of the chest were performed. If there were no signs of acute cardiac or coronary insufficiency, severe arrhythmia, or diastolic blood pressure above 115 mm, and the patient was not suffering from intractable angina pectoris, a spiroergometric test was performed for determination of submaximal physical working capacity. [4-lo] For this purpose, an electric bicycle ergometer and a spirometer “Pulmotest”, both from the Goddart Company, were used. The multistage spiroergometric and ergometric test used at our institute were based on steady state measurements of various parameters (Sjoestrand, Bengtson, Astrand, Reindell). More than 2000 examinations have been performed so far. Our evaluation and later proposition for proper work is based on
818
JAN
J. K~UERMANN et al.
the so-called “50 per cent load”. As BRODYexpressed it in his book (quoted from ASTRAND)[l l] Bioenergetics and Growth: “Machines are not usually run at more than 50% of their capacity and a similar safety margin should perhaps be allowed to men and animals, so as to avoid injury and untimely death”. Astrand came to the conclusion that the 50 per cent level should probably be considered as the upper limit, at least with work periods of longer duration than 1 hr. We use the 50 per cent load as a peak load for the work capacity and propose proper work in relation to the calorie requirement. [l 1, 121 As an example: a patient who had, under laboratory conditions a physical work capacity of 100 W (600 kg/mm), would need for this work under submaximal test conditions approximately 7 cal/min. In this case we would propose a proper work with a mean requirement of 3.5 cal/min. The energy requirements of the different occupations were estimated according to the table of PASSMORE and DURNIN. [ 121 The parameters recorded during the spiroergometric test were: 1. Pulse rate 2. Blood pressure 3. Oxygen consumption 4. Minute ventilation 5. ECG There data were collected at rest, at various workloads and after effort (recovery time). The workloads were measured in W/min or in kg/min. The submaximal physical work capacity is defined as the highest load at which the patient is able to perform in steady state. Steady state conditions are considered as being maintained if pulse rate TABLE 4. No. of cases
32 zd
:
Mean W.
% P.W.C.
02 Consumpt cm3
Healthy
100
112.5
100
1.500
A.S.H.D.
193
74.5
66
1031
Before _______ After
44
65.3
58
1083
44
93
84
1250
Before
15
50
44
830
After
15
72
64
1012
Before
11
34
30
11
62
54
.z E $
e,
_____
2 c-
-
d
After
-
NB: Age Group of all Cases: 40-60 yr
Rehabilitation
of Coronary
Patients
819
and oxygen consumption remain steady during the last 23 min of a 5-min effort. The tests were started generally with a load of 25 W (150 kg/min), and raised gradually by 25-50 W on a basis of 40 rev/min. Each phase of effort was of 5 min duration. The test was interrupted if: 1. Steady state was not reached 2. The heart rate exceeded 150 beats/min 3. Further pathological ECG changes appeared (“ST” depressions, arrhythmias, etc.) 4. Angina1 pain occurred. RESULTS
A. Dormitory group of 26 patients, 11 of them welfare patients. The 15 nonwelfare patients had, at admission, a mean physical work capacity of 5OW, which is 44 per cent of the normal physical work capacity obtained in a healthy control group of the same age, and a mean oxygen consumption of 830 cmS/min. These patients increased their physical work capacity after rehabilitation to 72W (64 per cent) and 1012 cm3/min submaximal oxygen consumption. The 11 patients who had been referred to our unit through the welfare organization and who had stopped working l-7 yr prior to their rehabilitation had, at the initial examination, a physical work capacity of 34W (30 per cent) and achieved, after rehabilitation, a physical working capacity of 61W (54 per cent). B. The ambulatory group consisting of 44 patients who had a mean physical working capacity of 65.3W and a submaximal oxygen consumption of 830 cm3/min before rehabilitation. After rehabilitation this group achieved a mean physical working capacity of 94W which is 84 per cent of the normal, and the oxygen consumption rose to 1250 cm3/min. The results of the rehabilitated groups have been compared with the spiroergometric examination of two control groups: 1. 100 healthy males, age group 40-60, had a mean physical working capacity of 112.5W and a mean submaximal oxygen consumption of 1500 cm3/min. This had been considered as the normal (100 per cent) physical working capacity for this age group, and was taken as basis for calculating the percentage of the patients’ capacity. 2. A group consisting of 193 male patients with coronary heart disease (coronary insufficiency and/or state of post myocardial infarction), continued working although they were not rehabilitated. The mean physical working capacity of this group was 74.5W which is 66 per cent of the mean physical working capacity for healthy subjects of this age group. The mean submaximal consumption was 1031 cm3/min. Forty patients of the ambulatory group returned to their previous jobs, mostly on a full time basis. From the dormitory groups, 12 out of 15 patients, and 8 out of 11 patients in the welfare subgroup returned to work. Only three patients out of 67 suffered occasional angina1 pain. Three patients died. For the patients in the ambulatory group, the return to their original occupations on a full-time basis presented no problem, because these patients were working mainly in sedentary professions and the rehabilitation program had significantly improved their physical work capacity. Not only were they able to continue working,
820
JANJ.
I(ELLERMANN
et
al.
but they also were able to participate in physical activities, prolonged walking, some housework and gardening. The return to work of the patients from the dormitory group proved a more complex problem. Nine of the 11 patients who did not work before their acceptance to the program, returned to a sedentary or moderate activity. Two continued not to work. Twelve patients in this group, who worked in part time jobs in professions requiring 24 cal/min (i.e. clerks, chemists, bookbinders, light mechanical workers, basket weavers, electricians, building contractors) returned to their original job on a full time basis, and three changed to physical activity requiring more than 4 cal/min (2 gardeners, 1 carpenter). We were helped by a social worker and a placement officer of the Ministry of Labour in placing the 11 formerly unemployed. Despite the three patients who achieved a physical working capacity of 90 per cent of the normal instead of the mean of 64 per cent after rehabilitation, there was no significant correlation between the physical working capacity achieved at the end of the program and the return to work at physical occupations. DISCUSSION The
purpose of this study was to improve the patient’s physical working capacity and return him to an appropriate occupation. The control group of coronary patients show a mean of 66 per cent as compared with healthy people, while the ambulatory group had a mean physical working capacity of 58 per cent on admission. This difference is not of great significance and probably reflects the difference in the working habits of both groups. As mentioned previously, the ambulatory group consisted mainly of professional people, not used to physical work, while the control coronary group was more disparate and included a large percentage of manual workers, before and after their illness. The physical working capacity of the dormitory group is much lower.and again reflects the lack of any systematic physical activities during previous years. The very low physical working capacity of the welfare group who had not worked at all in the past 1-7 yr should be stressed. The difference between the physical working capacity of the dormitory group (44-30 per cent) and that of the control group-coronary and ambulatory-(66-58 per cent) is significant. The results obtained after rehabilitation are highly significant (P=O.OOl) in all groups. This difference probably represents greater self-confidence and freedom from angina1 pains, as well as a feeling of general well-being. This allowed a better performance of work and was especially pronounced in the dormitory group, where patients could be sent to work for the first time after several years of inactivity. In conclusion, it could be demonstrated-despite the short follow-up time (33 yr) that it is possible to restore coronary patients to work by a short, planned rehabihtation program of four months, even after 7 yr of inactivity. Furthermore, it is possible to improve significantly the submaximal working capacity of those patients who returned to work by themselves, by gradual physical training. [l, 21 SUMMARY
Seventy patients with coronary
heart disease (status after myocardial infarction
Rehabilitation
of Coronary
Patients
821
and/or coronary insufficiency) have been rehabilitated by gradual physical training program. Forty-four patients underwent this program as ambulatory groups (gymnastics lessons three times weekly), and 26 were accepted to a dormitory next to the hospital. The program for both groups was of four months’ duration. The procedures of the rehabilitation are described. All rehabilitated patients were examined by a spiroergometric multistage test for determination of the submaximal physical working capacity. The test procedure and the results obtained before and after rehabilitation are presented, and the results compared to similarly examined healthy adults and coronary control group. Acknowledgemen&-The for technical assistance. statistical evaluation.
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. ::: 14.
authors wish to thank Mrs. T. LEVANON(R.N.) and Mrs. P. NACHUM(R.N.) We are indebted to Miss CH. BIRENBAUMand Mr. I. WINTNER for the
REFERENCES HELLERSTEIN, H. D. : Rehabilitation of patients with heart disease, Postgrad. Med. 15,265, 1964. REINDELL,H.: Herz Kreislaufkrankheiten und Sport, Johann Ambr. Barth, Muenchen, 1960. STRANDELL,T.: Circulatory studies on healthy old men, Acta med. stand. Suppl. 414, Stockholm, 1964. ASTRAND,P. 0. : Experimental studies of physical working capacity in relation to sex and age, Kopenhagen, 1952. BENGTSON,E.: The working capacity in normal children evaluated by submaximal exercise on the bicycle ergometer and compared with adults, Acta med. stand. 154, 359, 1956. BICKELMAN,A. G. : The responses of the normal and abnormal heart to exercise, Circulation 28, 000. 1963. BIOERCK,G. : The return to work of patients with myocardial infarction, Acta med. stand. 175, 000,1964. HOLMANN, W.: Der Arbeits und Trainingseinfluss auf Kreislauf und Atmung. Eine klinische und physiologische Betrachtung. Steinkopf, Darmstadt, 1959. SJOESTRAND, T. : The relationship between the S.V. of the heart and the capacity of the vascular system. Acta physiul. scan. 42, Suppl. 145, 1957. TAYLOR,H. L., BUSKIRK,E. and HENSCHEL:Maximal oxygen intake as an objective measure of cardiorespiratory perform, Appl. Physiol. 8, 73, 1955. ASTRAND, I.: Aerobic work capacity in men and women with special reference to age, Acta phys. stand. 49, Suppl. 169, Stockholm, 1960. PASSMORE,R.: Human energy expenditure, Physiol. Rev. 35,801, 1955. BRUCE, B. A., BLACKMAN,J. R., JONES,J. W. and STRAIT,G.: Exercise testing in adult normal subjects and cardiac patients, Pediatrics 32, Suppl. October 1963. LYTHGOE,R. J.: The pulse rate and oxygen intake during the early stages of recovery from severe exercise, Proc. R. Sot. 98, 468, 1925.