The Role of Exercise in Rehabilitation after Uncomplicated Myocardial Infarction

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REVIEW PAPER

The Role of Exercise in Rehabilitation after Uncomplicated Myocardial Infarction Jennifer M Finlayson Key Words Uncomplicated myocardial infarction, exercise, cardiac rehabilitation.

Summary Literature is reviewed on the role of exercise in cardiac rehabilitation (CR) for patients after uncomplicated post myocardial infarction (MI). Exercise plays a role in each of the four phases of CR. Meta-analysis demonstrated a 20% reduction in mortality following an exercise programme but no significant reduction in recurrence of MI. Physiological benefits include increased aerobic capacity with reduced exercise heart rate and blood pressure, reduced angina and ST segment depression, increased levels of high density lipoprotein and sometimes increased myocardial contractility. The extent of these changes depends on the amount of exercise undertaken. Depression and anxiety, where diagnosed, may be reduced by exercise although other factors such as group support may contribute. Recent studies report benefits following two to four months exercise starting three to six weeks after MI. Non-exercising controls generally reach a similar stage at one year after MI. The role of exercise in such programmes may be one of encouraging motivation to exercise rather than to achieve significant increases in aerobic capacity. Home exercise programmes, correctly prescribed, are a real possibility for suitable low-risk patients and may facilitate long-term adherence to exercise. Strategies to reduce drop-out from CR and encourage underrepresented groups to participate should be formulated.

Introduction ‘Ischaemic heart disease remains the commonest cause of death in Western societies and the highest rates in the world are found in parts of the British Isles’ (Horgan et al, 1992, page 412). With the Government initiative t o reduce morbidity and mortality from coronary heart disease launched in 1992, cardiac rehabilitation is continuing to expand and develop to meet this demand (DOH, 1992). As part of the multi-disciplinary team, physiotherapists have a significant part to play in this expanding field. Cardiac rehabilitation (CR) comprises a multifactorial programme of regular physical exercise, advice and education on risk factor modification and stress management. This type of approach gives optimum benefit to a wide variety of cardiac patients as it provides opportunity for physical, psychological, social and vocational needs t o be

addressed (Roviaro et al, 1984; Stern et al, 1983; Ewart et al, 1983).Due to the breadth of the topic of cardiac rehabilitation it is not possible to review all aspects of rehabilitation within this paper. This literature review has been limited to the role of exercise in cardiac rehabilitation for patients recovering from uncomplicated myocardial infarction (MI),ie patients who have suffered an MI but have no subsequent evidence of congestive heart failure, unstable angina, significant arrhythmias and less than 35% of the left ventricle affected by ischaemia (DeBusk et al, 1979, 1986, 1994). Other criteria that exclude patients from this category are the physical limitations imposed by severe obesity, orthopaedic and peripheral vascular disease, stroke, chronic lung disease and low exercise tolerance. The review aims to identify the role of exercise in the rehabilitation of patients after uncomplicated MI from phase 1 to phase 4 of rehabilitation. The benefits of physical exercise will be reviewed. Different types of exercise programme will be discussed, together with the amount of exercise required t o be of benefit. Four phases of cardiac rehabilitation may be identified which vary in length depending on the rate of recovery of individual patients. They are described by Coats et al (1995) as phase 1 - inpatient stay; phase 2 - convalescent period a t home; phase 3 - intermediate post-discharge and phase 4 - long-term maintenance. Phases 1and 2 involve gradual mobilisation of patients within their own limitations. Generally they would be able t o climb stairs a t about five to seven days post MI. Over the next two to six weeks (phase 2) patients are encouraged t o walk progressively further until a daily walking distance of two miles is achieved. During phase 3 patients may attend a formal, supervised out-patient programme of exercise and participate in various psycho-social interventions that may include relaxation, counselling or continued education and advice on risk factor modification. The exercise should be prescribed for each patient following a graded exercise test. This will ensure a safe and effective level of physical activity. As patients progress into phase 4, they should be encouraged to undertake more unsupervised exercise of a suitable frequency, intensity and duration to maintain the increased fitness achieved in the supervised programme.

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Benefits of Exercise Early randomised controlled trials of exercise based CR showed a trend in reduction of mortality and non-fatal recurrence of MI, although results failed t o reach statistical significance because samples were too small (Roman et all 1983; Shaw 1981; Wilhelmsen et al, 1975). Meta-analyses of exercise based CR showed a significant reduction of 20% in mortality up to three years after an acute cardiac event but no significant change in morbidity (O’Connor et al, 1989; Oldridge et al, 1988). The authors of these metanalyses also suggest that the results may not be entirely due to exercise as some of the programmes included in the studies involved education and advice as well as prescribed physical activity. As huge numbers of patients are required t o demonstrate statistically significant changes in morbidity and mortality, more recent research has measured specific variables, such as maximal oxygen consumption (VO,max), sub-maximal heart rate and blood pressure (Worcester et all 1993; Leizorovicz et all 1991; Froelicher et all 19841, contractile force of myocardium (Ehsani et al, 19861, angina (Bethell and Mullee, 1990; DeBusk et al, 1979) and lipid levels (Blumenthal, Rejeski et al, 1988; Ehsani et al, 1986; Heath et all 1983). Other authors have measured psychological status (Newton et all 1991; Van Dixhoorn et all 1990; Taylor et al, 1986).

Physiological Effects of Cardiac Rehabilitation Programmes Lower HR and BP A reduced heart rate and blood pressure for a given work intensity in MI patients have been demonstrated (Leizoroviczet al, 1991; Bethell and Mullee, 1990). Studies by Blumenthal, Rejeski et a1 (1988) and Worcester et a1 (1993) also reported reductions in exercise heart rate and systolic blood pressure for a given workload following three to four months of regular exercise training. Blumenthal, Rejeski et at (1988), and Ehsani et a1 (1986) also found a reduction in resting heart rate. The rate pressure product (RPP - heart rate x systolic blood pressure), an indication of myocardial oxygen consumption, fell in a group of 100 MI patients following a three-month controlled exercise programme (Bethell and Mullee, 1990). A control group showed no change in rate pressure product (RPP). Conversely, a trial by Leizorovicz et a1 (1991) found no significant fall in RPP with exercise. They suggest this might show an habituation effect of exercise rather than an aerobic training effect. Their exercise programme lasted only six weeks, however, which might have been too short to allow a training effect to develop.

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After one year of exercise training, Froelicher et a1 (1984) found a reduction in heart rate and blood pressure at a given work load. This was partly due to a direct improvement in ventricular function. Subjects were selected individuals with stable coronary heart disease. V0,max was increased and myocardial perfusion also improved. The increased myocardial perfusion was most prevalent in those subjects with angina whose stroke volume and cardiac output fell with increasing intensity of exercise. This makes interpretation of results difficult, but lends support for including patients at high risk of a cardiac event in rehabilitation programmes. Ehsani et a1 (1981, 1986) demonstrated a 37% improvement in V0,max with significant reductions in exercise heart rate, blood pressure and ST segment depression. The results were achieved following a year of regular aerobic activity, the last nine months of which was performed four or five times weekly at 70 t o 80% of a patient’s V0,max. Sophisticated measurement techniques showed a n increase in left ventricular ejection fraction reflecting a direct improvement in ventricular contractile function. However only 25 patients were included in the study and not all of these were included in the statistical analysis. Patients were selected for the study and were on average 11 months post MI. Generalisations to the larger cardiac population should therefore be made with caution. Other studies demonstrate more modest but significant improvements in physical work capacity (PWC) following three o r four months exercise training beginning six t o eight weeks after MI (Worcester et al, 1993; Leizorovicz et al, 1991; Bethell and Mullee, 1990). Authors studying the effects of short-term exercise programmes soon after MI consider improvements in PWC to be largely due to skeletal muscle adaptation (Gattiker et al, 1992; Bethell and Mullee, 1990). This is based on work by Detry et a1 (1971) who found an increase in V0,max of 22.6% in a group of 12 patients with coronary heart disease following three months exercise training. The stroke volume during sub-maximal exercise was unchanged and the exercise heart rate reduced. The arteriovenous oxygen difference was increased implying that increased peripheral oxygen extraction was the reason for improved PWC. Clausen (1976) suggests that this is due to the increased enzyme activity in the trained muscles that was demonstrated by Gollnick et a1 (1973). Increased enzyme activity enables muscle mitochondria to produce a higher respiratory rate, thereby increasing local aerobic capacity, and reducing demands on the myocardium (Clausen, 1976).

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Reduced Angina Exercise training can also reduce angina. DeBusk et al(1979) reported reduced angina after eight weeks training soon after MI but did not use a standardised form of evaluation. Bethel1 and Mullee (1990) found a 10% reduction after three months training compared to a 60% increase in a non-exercising group. Angina was also reduced in some of the patients studied by Ehsani et a l (1986) following 12 months training. This may be due t o peripheral adaptation or improved myocardial function or both.

Lipid Levels High density lipo-proteins (HDL)are recognised to have a protective influence against heart disease whereas low density lipo-proteins may accelerate atherosclerosis (Gordon et al, 1977; Miller et al, 1977). Studies by Ehsani et al(1986) and Blumenthal, Rejeski et al(1988) demonstrate increases in HDL following 12 and three months’ training respectively. Heath et a1 (1983) fotind an 8% reduction in total cholesterol, a 9% reduction in low density lipoproteins and 11%increase in high density lipoproteins. However, this study included only ten patients exercising a t high intensity for six months.

Effects of Early Short-term Programmes Some authors have found that untrained groups have caught up with short-term trained groups when cardiovascular function has been re-evaluated six months to one year after an acute cardiac event (Worcester et al, 1993; Goble et al, 1991; Stern et a l , 1983). The role of exercise in early, short-term cardiac rehabilitation programmes could therefore be questioned. Worcester et a1 (1993) propose t h a t the role of exercise in such programmes is primarily to motivate patients to resume their previous levels of activity. This implies that the amount of exercise undertaken is less important than the patients’ psychological attitude towards activity during the recovery period. However, increasing the rate of recovery and restoring patients to a fuller life earlier should allow them to enjoy a better quality of life for longer and, if appropriate, an earlier return to work. A five-year study carried out by Hedback and Perk (1987) did show continued benefit to an exercise grdup compared with a non-exercise group. However, the exercise group continued with a monthly supervised exercise session which may have provided the motivation to maintain increased fitness.

Psychological Effects of Exercise Physical activity is reputed to reduce depression and anxiety and to enhance mood in general

(Newton et al, 1991; Taylor et al, 1986; Stern and Cleary, 1981). Stern et al(1983) compared three groups of MI subjects undergoing a n exercise programme, group counselling, or usual medical care by a physician. Subjects were all diagnosed with depression or anxiety. Results showed that a 12-week aerobic exercise programme reduced fatigue, anxiety and depression, promoted independence and sociability, and considerably increased work capacity. Group counselling over 12 weeks resulted in substantial reductions in depression, promoted sociability and facilitated coping with interpersonal relationships. The usual care group showed no changes in any of the measured parameters. It appears from this study that an exercise programme with its apparent combined physical and psychological benefits is the optimum feature of cardiac rehabilitation. However, at 12 months there were no significant differences between any of the groups as the psychosocial status of the usual care group had improved to a comparable level. Newton et al(1991) studied 22 MI subjects and the psychological effects of an exercise-based cardiac rehabilitation programme. Depression and mood status were assessed in all subjects at the beginning and end of a ten-week rehabilitation period. Compared with a control group of ‘usual medical care’ both groups improved their PWC but the exercise group also showed reduced depression. The authors suggest that an exercisebased programme appears t o have psychological benefits, but they also propound other possible reasons for this benefit. They suggest the effect of social interaction, peer support, or being supervised by professionals. Education and relaxation sessions included in the programme may also have contributed to the improved psychological status. Other studies contradict the psychological benefit of exercise. Taylor et a l (1986) studied uncomplicated MI subjects undergoing a n exercise programme. They concluded that such patients were not particularly psychologically disturbed initially and therefore showed no significant improvement in psychological scores after 26 weeks of exercise training. They comment that within this random sample, the incidence of psychosocial impairment was no greater than in the general population. Blumenthal, Emery et al (1988) came t o the same conclusion after extensive psychological testing of 70 MI subjects before and after a 12-week exercise programme. The only support for a psychological benefit of exercise was informal reporting by subjects of ‘feeling better’. Van Dixhoorn et a l (1990) looked at the psychological effect of five weeks of exercise plus or minus relaxation on 156 MI subjects. The

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authors concluded t h a t exercise alone did not have a psychological benefit but combined with relaxation, anxiety and feelings of invalidity were reduced, while feelings of well-being were increased.

Exercise Programmes As MI patients do not have a normal coronary supply the usual standard prescriptive methods to determine exercise levels cannot apply (McArdle et al, 1994; ACSM, 1991). Each subject must have a n individual prescription based on a symptom-limited graded exercise test.

Frequency Studies that have demonstrated a training effect included exercise at least three times a week (Blumenthal, Rejeski et a l , 1988; Roviaro et a l , 1984; Roman et al, 1983).Ehsani et a1 (1986) and Rechnitzer et a1 (1983) advocated four to five times weekly exercise. However, patients were selected for their commitment to exercise in the study by Ehsani et al (1986); and a drop-out of 45% was reported by Rechnitzer et a1 (1983) so that more patients had to be recruited to achieve the aims of the study, which extended over three years. An exercise frequency of four or five times weekly may pose a challenge for less committed patients or create conflict with their other interests. Some authors have prescribed twiceweekly formal exercise with daily walking on the remaining days (Hare et al, 1995; Worcester et al, 1993; Goble et a l , 1991). A few studies describe daily exercise regimes comprising home-based walking programmes (DeBusk et al, 1994; Kugler et al, 1990; Sivarajan et al, 1982). Though these studies a r e rather isolated in their approach, perhaps they deserve more consideration, particularly for patients who do not adhere well to a more formal exercise programme. Intensity Exercise intensity should be prescribed for each patient according to the results of a stress test to ensure t h a t t h e level is safe a n d effective. Blumenthal et a1 (1988) studied the effects of low (< 45% V0,max) uersus high intensity exercise (65-75% V0,max) in patients eight weeks after MI. After 12 weeks both programmes produced a similar increase in PWC. The authors concluded t h a t in t h e short term a low intensity exercise programme was a s effective a s a high one for increasing V0,max. Worcester et al (1993) came to a similar conclusion but at four months after MI recorded a marginally greater PWC in t h e high intensity group. This increased activity was not related to the intensity or frequency of t h e exercise, a n d t h e difference had disappeared at 12 months.

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Kugler et a1 (1990) describe a mainly home-based walking programme which proved comparable to a n entirely hospital-based cycle ergometry programme in terms of increased PWC. They do not describe the intensity of the walking, or report whether the home based exercise intensity was monitored for consistency. The results offer positive implications for financing of programmes and patient convenience in attending hospital only once a week. If similar benefits may result from a lower exercise intensity, it seems preferable to use this rather t h a n a higher intensity which carries greater risk of musculoskeletal injury, causes some patients considerable subjective discomfort, and h a s a n element of greater cardiovascular risk (Williams, 1994; Blumenthal, Rejeski et al, 1988).

Timing Duration of exercise sessions is closely linked to t h e frequency and intensity of exercise. With uncomplicaled MI a n exercise programme may begin as early as three weeks after t h e event (DeBusk et a l , 1994; Goble et a l , 1991). These early programmes generally consist of aerobic sessions of 30 minutes at a n individually prescribed heart rate. This is gradually progressed to 45 minutes and training is carried out three or four times a week (DeBusk et a l , 1994; Worcester et al, 1993; Roviaro et al, 1984). In exercise programmes starting soon after MI, most of the training effect occurs in the first six to eight weeks (ACSM, 1986; Miller et al, 1984). The minimum length of a programme may be six weeks (Hare et a l , 19951, but is generally eight weeks (Worcester et al, 1993; Goble et al, 1991), and some may last 12 weeks (Bethel1 and Mullee, 1990; Blumenthal, Emery et a l , 1988). A few studies report results after one year (Ehsani et al, 1986; Froelicher et a l , 1984). Leon et al (1990) recommend a minimum of two to three months supervised exercise and ideally a six-month period to gain maximum benefit. The longer-term studies have shown greater improvements in physical fitness but do demand considerable commitment from patients and require extensive facilities if all MI patients are to be accommodated for up to a year.

Mode of Exercise Hall et al (1984) suggest cardiac patients may benefit best from a circuit-interval type training in the early phase of rehabilitation, progressing to a continuous conditioning type after about three months. The advantage of circuit-interval training is t h a t patients get variety in modes of exercise, using cycle and arm ergometers, bench stepping and rowing machines, working on each

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piece of equipment for a few minutes. A rest period can follow each station if required and this may be particularly important in the early stages of recovery. Various authors have demonstrated significant improvements in PWC following circuit-interval training (Gobleet al, 1991;Bethel1 and Mullee, 1990; Roviaro et al, 1984). A further advantage of a circuit is that most large muscle groups of the body can be exercised. This is import a n t as exercise is task-specific. Therefore, t o enable patients t o gain optimum recovery and functional capacity, exercise of the arms should be incorporated, as many occupations and activities of daily living involve use of the upper limbs (McArdle et al, 1994; Hall et al, 1984). Whether training does specifically improve patients’ abilities to perform activities at home or in the work place has not been demonstrated. Continuous conditioning exercise further increases aerobic capacity. The patients perform one type of activity -usually walking, jogging or cycle ergometry - at a consistent intensity for a gradually increasing period. There is no rest until the exercise time is completed. Many programmes in America and Europe use this type of exercise conditioning, starting from as early as three weeks after MI (Leizorovicz et al, 1991; Blumenthal and Emery, 1988; Hedback and Perk, 1987; DeBusk e t al, 1985). However, using a single mode of exercise may become boring and lead t o poor adherence (Bethell, 1992; ACSM, 1991; Hall et at, 1984). To gain all-round fitness, strength training with resisted exercise should also be considered. Isometric work, generally associated with strengthening, is not recommended for cardiac patients because of the rise in blood pressure that accompanies the effort (ACSM, 1991; Hall et al, 1984). Isotonic muscle strengthening programmes have been shown to be safe and effective in small groups of cardiac patients fulfilling certain conditions. Keleman et aZ(1986) reported an average increase in muscle strength of 24% in 20 cardiac patients following ten weeks of training when compared to a similar group of aerobic exercisers. Most of these patients averaged 2.5 to 3.5 years in a CR programme prior t o the study. McCartney et al (1991) performed a similar study but subjects had previously completed five months in a CR programme. Muscle strength and endurance capacity on a cycle ergometer were significantly increased in the experimental group. Based on this evidence, recommendations are made that before strength training begins, four months should have elapsed since MI and patients should have spent a t least three months in a formalised CR programme and have an exercise capacity of seven metabolic equivalents (METS )

(Lillegard and Terrio, 1994).The effect of increased muscle strength on patients’ ability to perform activities of daily living has yet to be evaluated.

Location of Exercise Programmes CR programmes may be based in hospitals,

community centres o r a t home. DeBusk et a1 (1985,1994) suggest that for appropriate patients home-based exercise training at an individually prescribed intensity can be just as safe and effective as supervised exercise. DeBusk et at (1985) found that early post-MI patients participating in a medically directed home exercise programme increased their PWC as much as patients in a hospital based programme. In a randomised controlled trial of low risk MI subjects, DeBusk et a1 (1994) showed an increased work capacity of 0.9 METS in subjects who undertook prescribed exercise at home with monthly telephone contact with a cardiac nurse compared with a ‘usual care’ group. Low-risk patients are those who have had an uncomplicated MI and in whom the following signs are absent on a symptom-limited graded exercise test (SLGXT): ischaemic ST segment depression, angina, significant arrhythmias such as frequent premature ventricular complexes and exercise hypotension. In addition, patients’ PWC must be greater than 5 METS on the SLGXT (Bell et al, 1995; Kavanagh, 1995; Kallio 1995; DeBusk et al, 1985). Home-based exercise programmes are an attractive option in the present economic climate and offer advantages t o patients in terms of convenience, abolition of travelling costs, and the opportunity t o become independent and responsible for regaining their own fitness (Wenger, 1992). They may also facilitate progress to phase 4 of rehabilitation. It is important that opportunity for education and advice on risk factor modification is not lost as a result of home-based exercise. Some patients and their relatives will also gain significant benefit from peer group support of a formalised CR programme (Wenger, 1992).

Conclusion Regular physical exercise can reduce mortality up t o three years after MI. Following an exercise programme PWC is increased, sub-maximal heart rate, blood pressure and angina are reduced and high density lipo-protein levels may be increased. In selected patients, exercise of sufficiently high intensity and frequency over a year can increase myocardial contractility and stroke volume. Many shorter-term exercise programmes attribute improvements in PWC t o musculoskeletal adaptation.. These types of programmes serve

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to accelerate the rate of recovery but non-CR patients will reach a similar PWC after one year. Anxiety and depression, where specifically diagnosed, may be reduced after a n exercise programme. This may be partly due to the effect of working in a group setting under supervision. Exercise should be specifically prescribed for each patient in terms of frequency, intensity and duration t o ensure safety and efficacy. This does not have to be at a high level to have beneficial effects although greater physiological benefits will be achieved with more exercise. Most trials can demonstrate objective improvements in patients after an exercise-based CR programme. How these translate into improvements in patients’ quality of life is less clear. Investigation into whether patients experience as great a subjective benefit from exercise as they do objectively may clarify problems of drop-out or poor adherence. The effect of exercise on the ability to perform activities of daily living or leisure pursuits is not well documented. This must relate to patients’ quality of life and therefore the motivation to exercise or not may depend on how patients perceive exercise to contribute to their quality of life. Exercise must be continued on a long-term basis if benefits accrued during a formalised programme are to be maintained. Issues of how t o increase patients’ motivation to continue to exercise unsupervised and how t o encourage those who may have dropped out of formal programmes to return to physical activity need t o be addressed. The efficacy of exercise after MI in people who have not been well represented in controlled trials should be considered. That is, those over 65 years old, women, unemployed people and nonCaucasians. Indications are that these groups can benefit from exercise but may be excluded or fail to take up or complete CR (Pel1 et al, 1996; Lavie and Milani, 1995a, b; Cannistra et al, 1995). With the current economic constraints on services, home-based exercise programmes may become more popular. As exercise is individually prescribed, it would lend itself to a home-based programme for suitable, uncomplicated MI patients. This would free facilities for supervised exercise for higher-risk patients. However, any decisions must be based on correct identification of low-risk patients through clinical assessment and discussion with relevant members of the multi-disciplinary team. Other components of the CR programme such as stress management or dietary advice are essential t o ensure a n holistic approach t o achieving and maintaining a healthy lifestyle. Education of patients and relatives to encourage a change in

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attitude towards healthy living is very important if phase 4 of CR is to be successful. This includes developing a positive attitude towards regular exercise. Therefore, a CR programme must include this encouragement even if exercise is home-based. Author and Address for Correspondence Miss Jennifer M Finlayson MSc MCSP is a lecturer in the Department of Physiotherapy,School of Health Sciences, University of Liverpool, Thompson Yates Building, Quadrangle, Brownlow Hill, Merseyside L69 3GB. This article was received on April 15, 1996, and accepted on April 21, 1997.

References American College of Sports Medicine (ACSM) (1991). Guidelines for Exercise Testingand Prescription, Lea and Febiger, London, 4th edn. Bell, J, Coats, A J S and Hardman, A E (1995). ‘Exercisetesting and prescription’ in: Coats, A, McGee, H, Stokes, H and Thompson, D (eds) British Association of Cardiac Rehabilitation Guidelinesfor Cardiac Rehabilitation,Blackwell Science, Oxford. Bethell, H J N (1992). ‘Exercise in post infarct rehabilitation’, British Journal of Clinical Practice, 46, 2, 11 6 122. Bethell, H J N and Mullee, M A (1990). ‘A controlled trial of community-basedcoronary rehabilitation’, British Heart Journal, 64,370375, Blumenthal, J A and Emery, C F (1988). ‘Rehabilitation of patients following myocardial infarction’, Journal of Consulting and Clinical Psychology,56,3, 374-381. Blumenthal, J A, Emery, C F and Rejeski, W J (1988). ‘The effects of exercise training on psychosocial functioning after myocardialinfarction’,Journal of Cardiopulmonary Rehabilitation, 8, 5, 183-1 93. Blumenthal, J A, Rejeski, J, Walsh-Riddle, M, Emery, C F, Miller, H, Roark, S, Ribisl, P M, Morris, P B, Brubaker, P and Sander Williams, R (1988). ‘Comparison of high and low intensity exercise training early after acute myocardial infarction’, American Journal of Cardiology,61, 1, 26-29. Cannistra, L B, OMalley, C J and Balady, G J (1995). ‘Comparison of cardiac rehabilitation in black women and white women’, American Journal of Cardiology,75, 14, 890-893. Clausen, J P (1976). ‘Circulatory adjustments to dynamic exercise and effect of physical training in normal subjects and in patientswith coronary artery disease’, Progress in Cardiovascular Diseases, XVIII, 6, 459-495. Coats, A, McGee, H, Stokes, H and Thompson, D (eds) (1995). British Association of Cardiac Rehabilitation Guidelines for Cardiac Rehabilitation, Blackwell Science, Oxford. DeBusk, R F, Blomqvist, C G, Kouchoukos, N T, Luepker, R V, Miller, H S, Moss, A J, Pollock, M L, Reeves, T J, Selvester, R H, Stason, W B, Wagner, G F and Willman, V L (1986). ‘Identification and treatment of low risk patients after acute myocardial infarction and coronary artery bypass surgery’, New England Journal of Medicine, 314, 3, 161-166,. DeBusk, R F, Haskell, W L, Miller, N H, Berra, K and Taylor, C B (1985). ‘Medically directed at-home rehabilitation soon after clinically uncomplicated acute myocardial infarction: A new model for patient care’, American Journal of Cardiology,55,4,251-257. DeBusk, R F, Houston, N, Haskell, W, Fry, G and Parker, M (1979). ‘Exercisetraining soon after myocardialinfarction’,Arnerican Journal of Cardiology,44,7, 1223-29. DeBusk, R F, Miller, N H, Superko, R, Dennis, C, Thomas, R J, Lew, H T, Berger, W E, Heller, R S, Rompf, J, Gee, D, Kraemer H C, Bandura, A, Ghandour, G, Clark, M, Shah, R V, Fisher, L and Barr Taylor, C (1994). ‘A case-management system for

523

coronary risk factor modification after acute myocardial infarction’, Annals of Internal Medicine, 120, 9, 721-728.

Physical Medicine and Rehabilitation, (Chicago 11l ) , 71, 5, 322-325.

Department of Health (1992). The Health of the Nation: A strategy for health in England, HMSO.

Lavie, C J and Milani, R V (1995a). ‘Effects of cardiac rehabilitation and exercise training on exercise capacity, coronary risk factors, behavioural characteristics and quality of life in women’, American Journal of Cardiology,75, 340-343.

Detry, J R, Rousseau, M, Vandenbroucke, G, Kusumi, F, Brasseur, L A and Bruce, R A (1971). ‘Increased arteriovenous oxygen difference after physical training in coronary heart disease’, Circulation, XLIV, 109-1 18. Ehsani, A A, Biello, D R, Schultz, J, Sobel, B E and Holloszy, J 0 (1986). ‘Improvement of left ventricular contractile function by exercise training in patients with coronary artery disease’, Circulation, 74, 2, 350-358. Ehsani, A A, Heath, G W, Hagberg, J M, Sobel, B E and Holloszy, J 0 (1981). ‘Effects of twelve months of intense exercise training on ischaemic ST-segment depression in patients with coronary artery disease’, Circulation, 64, 6, 1116-24. Ewart, C K, Barr Taylor, C, Reese, L B and DeBusk, R F (1983). ‘Effects of early post myocardial infarction exercise testing on selfperception and subsequent physical activity’, American Journal of Cardiology, 51, 1076-80. Froelicher, V, Jensen, D, Genter, F, Sullivan, M, McKirnan, M D, Witzum, K, Scharf, J, Strong, M L and Ashburn, W (1984). ’A randomised trail of exercise training in patients with coronary heart disease’, Journal of the American Medical Association, 252,10,1291-97. Gattiker, H , Goins, P and Dennis, C (1992). ‘Cardiac rehabilitation: Current status and future directions’, Western Journal of Medicine, 156, 2, 183-188. Goble, A J, Hare, D L, MacDonald, P S, Oliver, R G, Reid, M A and Worcester, M C (1991). ‘Effect of early programmes of high and low intensity exercise on physical performance after transmural acute myocardial infarction’, British Heart Journal, 65, 126-1 31. Gollnick P D, Armstrong, R B, Saltin, B, Saubert, C W, Sembrowich, W L and Shepherd, R E (1973).‘Effects of training and enzyme activity on fibre composition of human skeletal muscle’, Journal of Applied Physiology, 34, 1, 107-1 11. Gordon, T, Castelli, W P, Hjortland, M C, Kannel, W B and Dawber, T R (1977). ‘High density lipoprotein as a protective factor against coronary heart disease’, American Journal of Medicine, 62, 707-71 4. Hall, L K, Meyer, G C and Hellerstein, H K (eds) (1984). Cardiac Rehabilitation:Exercise testing and prescription, La Crosse Exercise and Health Series, Life Enhancement Publications, Illinois. Hare, D L, Fitzgerald, H, Darcy, F, Race, E and Goble, A J (1995). ‘Cardiac rehabilitation based on group light exercise and discussion: An Australian hospital model’, Journal of Cardiopulmonary Rehabilitation, 15, 3, 186-192. Heath, G W, Ehsani, A A, Hagberg, J M, Hinderliter, J M and Goldberg, A P (1983). ‘Exercise training improves lipoprotein lipid profiles in patients with coronary artery disease’, American Heart Journal, 105,6,889-895. Hedback, B and Perk, J (1987). ‘Five-year results of a comprehensive rehabilitation programme after myocardial infarction’, European Heart Journal, 8,234-242. Horgan, J, Bethell, H, Carson, P, Davidson, C, Julian, D, Mayou, R A and Nagle, R (1992). ‘Working party report on cardiac rehabilitation’,British Heart Journal, 67, 412-418. Kallio, V (1995). ‘Selecting patients for rehabilitation and rehabilitation for patients’ in: Jones, D and West, R (eds) Cardiac Rehabilitation, BMJ Publishing Group, London, page 111. Kavanagh, T (1995). ‘The role of exercise training in cardiac rehabilitation’ in: Jones, D and West, R (eds) Cardiac Rehabilitation, BMJ Publishing Group, London, page 68. Keleman, M H, Stewart, K, Gillilan, R E, Ewart, C, Valenti, S A, Manley, J D and Keleman, M D (1986). ‘Circuit weight training in cardiac patients’, Journal of the American College of Cardiology, 7, 1, 38-42. Kugler, J, Dimsdale, J E, Hartley, H and Sherwood, J (1990). ‘Hospital supervised vs home exercise in cardiac rehabilitation: Effects on aerobic fitness, anxiety and depression’, Archives of

Lavie, C J and Milani, R V (1995b). ‘Effects of cardiac rehabilitation programmes on exercise capacity, coronary risk factors, behavioural characteristics and quality of life in a large elderly cohort‘, American Journal of Cardiology,76, 3, 177-179. Leizorovicz, A, Saint-Pierre, A, Vasselon, C and Boissel, J P (1991). ‘Comparison of a rehabilitationprogramme, a counselling programme and usual care after an acute myocardial infarction: Results of a long-term randomised trial’, European Heart Journal, 12,612-616. Leon, A S, Certo, C, Comoss, P, Franklin, B A, Froelicher, V, Haskell, W L, Hellerstein, H K, Marley, W P, Pollock, M L, Reis, A, Sivarajan, E F and Smith, L K (1990). ‘Position paper of the American Association of Cardiovascular and Pulmonary Rehabilitation- Scientific evidence of the value of cardiac rehabilitation services with emphasis on patients following myocardial infarction - Section 1: Exercise conditioning component’, Journal of CardiopulmonaryRehabilitation, 10, 79-87. Lillegard, W A and Terrio, J D (1994). ‘Appropriate strength training’, Medical Clinics of North America, 78, 2, 457-477. McArdle, W D, Katch, F I and Katch, V L (1994). Essentials of Exercise Physiology, Lea and Febiger, London, chapter 10. McCartney, N, McKelvie, R S, Haslam, D R S and Jones, N L (1991). ‘Usefulness of weightlifting in improving strength and maximal power output on coronary artery disease’, American Journal of Cardiology,67, 939-945. Miller, N H, Haskell, W L, Berra, K and DeBusk, R F (1984). ‘Home versus group exercise training for increasing functional capacity after myocardial infarction’, Circulation,70, 4, 645-649. Miller, N E, Thelle, D S, Forde, 0 H and Mjos, 0 D (1977). ‘The Tromso heart study - High density lipoprotein and coronary heart disease: A prospective case-control study’, Lancet, 2, 965-968. Newton, M, Mutrie, N and McArthur, J D (1991). ‘The effects of exercise in a coronary rehabilitation programme’, Scottish Medical Journal, 36, 38-41. O’Connor, G T, Buring, J E, Yusuf, S, Goldhaber,S Z, Olmstead, E M, Paffenbarger, R S and Hennekens, C H l(1989). ‘An overview of randomised trials of rehabilitation with exercise after myocardial infarction’, Circulation, 80, 2, 234-244. Oldridge, N 6, Guyatt, G H, Fischer, M E and Rimm, A A (1988). ‘Cardiac rehabilitation after myocardial infarction - Combined experience of randomised clinical trials’, Journal of the American Medical Association, 260, 7, 945-950. Pell, J, Pell, A, Morrison, C, Blatchford, 0 and Dargie, H (1996). ‘Retrospective study of influence of deprivation on uptake of cardiac rehabilitation’, British Medical Journal, 313, 267-268. Rechnitzer, P A, Cunningham, D A, Andrew, G M, Buck, C W, Jones, N L, Kavanagh,T, Oldridge, N 8, Parker, J 0, Shephard, R J, Sutton, J R and Donner, A P (1983). ‘Relation of exercise to the recurrence rate of myocardial infarction in men’, American Journal of Cardiology,51, 1, 65-69. Roman, 0, Gutierrez, M, Luksic, I, Chavez, E, Camuzzi, A L, Villalon, E, Klenner, C and Cumsille, F (1983). ‘Cardiac rehabilitation after acute myocardialinfarction’, Cardiology,70, 223-231. Roviaro, S, Holmes, D S and Holmsten, R D (1984). ‘Influence of a cardiac rehabilitation programme on the cardiovascular, psychologicaland social functioning of cardiac patients’, Journal of Behavioural Medicine, 17, 1, 61-81. Shaw, L W (1981). ‘Effects of a prescribed supervised exercise programme on mortality and cardiovascular morbidity in patients after a myocardial infarction‘, American Journal of Cardiology, 48, 39-46. Sivarajan, E S, Bruce, R A, Lindskog, B D, Almes, M J, Belanger, L and Green, B (1982). ‘Treadmill test responses to an early exercise program after myocardial infarction: A randomised study’, Circulation,65, 1420-28.

Physiotherapy, October 1997, vol83, no 10

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Stern, M J and Cleary, P (1981). 'National exercise and heart disease project: Psychosocial changes observed during a lowlevel exercise program', Archives of fnternal Medicine, 141, 10, 1463-67. Stern, M J, Gorman, P A and Kaslow, L (1983). 'The group counselling versus exercise therapy study - A controlled intervention with subjects following myocardial infarction', Archives of lnternal Medicine, 143, 9, 1719-25. Taylor, C B, Houston-Miller, N, Ahn, D K, Haskell, Wand DeBusk, R F (1986). 'The effects of exercise training programs on psychosocial improvement in uncomplicated postmyocardial infarction patients', Journal of Psychosomatic Research, 30, 5, 581-587. Van Dixhoorn, J, Duivenvoorden, H J, Pool, J and Verhage, F (1990). 'Psychic effects of physical training and relaxation therapy

after myocardial infarction', Journal of Psychosomatic Research, 34,3, 327-337. Wenger, N K (1992). 'Supervised versus unsupervised exercise training following myocardial infarction and myocardial revascularisation procedures', Annals of the Academy of Medicine of Singapore, 21, 1, 141-144. Wilhelmsen, L, Sanne, H, Elmfeldt, D, Grimby, G, Tibblin, G and Wedel, H (1975). 'A controlled trial of physical training after myocardial infarction', Preventive Medicine, 4, 491-508. Williams, M A (1994). Exercise Testing and Training in the Elderly Cardiac Patient, Human Kinetics, Illinois. Worcester, M C, Hare, D L, Oliver, R G, Reid, M A and Goble, A J (1993). 'Early programmes of high and low intensity exercise and quality of life after myocardial infarction', British Medical Journal, 11, 1244-47.

in other journals Some of these journals may be available in your hospital library, or photocopies of specific articles may be obtained using inter-library facilities (ask your librarian for details). The CSP is also developing its own resource centre and special physiotherapy journals collection. In case of difficulty photocopies from physiotherapy journals may be supplied by the CSP on request (but please obtain them from libraries wherever possible). A charge will be made by the CSP for this service. Contact: Samantha Molloy, Information Assistant, Education Department, The Chartered Society of Physiotherapy.

Physiotherapy is a peer reviewed Journal which is indexed in Physiotherapy Index (AMED), ClNAHL and

Critical Reviews in Physical and Rehabilitation Medicine 1996, vol8, no 4 Exercise and Parkinson's disease. E J Protas, R K Stanley, J Jankovic. 253-266. The functional independence measure (FIMSMInstrument) and the functional independence measure for children (WeeFIM"' Instrument): Ten years of development. A Deutsch, S Braun, C Granger. 267-281. Aerobic exercise in the rehabilitation of individuals with chronic low back pain: A review. E J Protas. 283-295. A review of the management of upper-limb amputees. L E Jones, J Davidson. 297-322. Physical activity in prevention and rehabilitation of breast cancer. K Francis. 323-341.

EMBASE.

The figures at the end of each entry are the first and last page numbers.

Pediatric Physical Therapy 7997, vol9, no 1, Spring Advocacy. A F VanSant. 1. Examination and treatment of 17-year-old students with pain in the back, hips, and knees. A Kimming. 2-1 1.

Clinical Biomechanics 1997, vol 12, no 4, June A literature review of low back disorder surveillance measures and risk factors. S A Ferguson, W S Marras. 21 1-226. lntersegmental dynamics of standing from sitting. J Crosbie, R D Herbert, J T Bridson. 227-235. Analysis of the sit-stand-sit movement cycle in normal subjects. K M Kerr, J A White, D A Barr, R A B Mollan. 236-245.

Review of the effects of progressive resisted muscle strengthening in children with cerebral palsy: A clinical consensus exercise. J Dararh, J S W Fan, L C Chen et a/. 12-1 7. Functional outcome in osteogenesis imperfecta: Disability profiles using the PEDI. R H H Englebert, J W H Custers, J van der Net et a/. 18-22. Evaluation of the Denver II as applied to Alaska native children. C I Kerfeld, M R Guthrie, K B Stewart. 23-31.

No 2, Summer

Increased friction of animal joints by experimental degeneration and recovery by addition of hyaluronic acid. T Obara, K Mabuchi, T Iso, T Yamaguchi. 246-252.

The supported ambulation profile scale (SWAPS): Development of an outcome measure of locomotive status in children with cerebral palsy. F Malouin, C L Richards, C Menier et a/. 48-53.

Restriction of foot supination by ankle braces in sudden fall situations. S Podzielny, E M Hennig. 253-258.

An analysis of physical therapy practice AcQ: Implications for role release in educational settings. B Rainforth. 54-61.

The hybrid ring tubular external fixator: A biomechanical study. H Stein, R Mosheiff, F Baumgart eta/. 259-266.

lnterobserver agreement of a structured observation of motor performance in infants (SOMP-I). K Persson, F Rasmussen, E Hemgren. 62-67.

Patella position and biomechanical properties of the patellar tendon one year after removal of its central third. K-F Hanselmann, L Durselen, P Augat, L Claes. 267-271.

Physiotherapy, October 1997, vol83, no 10

Effects of physical therapy on postural control in children with cerebral palsy. J Jonsdottir, L Fetters, J Kluzik. 68-75.