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REHABILITATION FROM HEART DISEASE: A GUIDE TO THE REHAB PROGRAMS
Cardiac rehabilitation involves restoring patients to the best possible cardiac health, which includes the ability to perform physical activities; reduce risk factors for coronary heart disease; and encourage the best possible social, psychological and vocational functioning. In practice, this means enabling patients to do the physical and social activities that they would like to be able to do, without symptoms, and to minimize any psychological distress that may come from having had a recent cardiac event.
Traditional rehabilitation programs usually emphasize the exercise component. They usually involve supervised, or at least guided, programs of approved regular physical activity, done at an intensity that is believed to be safe. Isotonic exercise involves using large muscle groups such as the legs or arms to move the body through space. Activities such as walking, jogging, swimming and bicycling are examples of isotonic exercise. If done frequently enough (three or more times per week) and long enough (thirty minutes or longer), this type of exercise will increase cardiovascular fitness. Fitness is the ability to do physical activity and derives from increased efficiency on the part of exercising muscles. The heart does not actually become stronger with regular activities, but the body, and especially the exercising muscles, can learn to use the blood and oxygen provided by the heart more efficiently with training. Exercise produces impressive gains with only a moderate amount of effort, provided that the exercise is of sufficient duration and frequency to get a training effect. Heart patients do not need to become competitive athletes in order to benefit from exercise programs; rather, they need to have the desire and the will to maintain a program that can be of surprisingly low intensity (for example, modestly brisk, continuous walking) and that is often pleasurable (think of a walk through your neighborhood, in a nearby park, with the companionship of a loved one or a friend, or perhaps a pet), and can lead to increases in well-being. Even patients with very poor heart function, so-called heart failure, will derive some benefit from physical activity, allowing them to do more, with less distress, although they may not be restored to complete heart health.
Another recommended form of exercise is isometric exercise, performed by straining or pushing against resistance. This includes lifting weights; calisthenics such as sit-ups; and floor exercises such as gymnastics, yoga or tai chi. In all of these forms of exercise work, muscles are made to contract against resistance, and thereby become stronger; although it used to be thought that such forms of exercise might be dangerous for heart patients, we now know that they can increase strength, endurance, flexibility and well-being even in elderly patients with severe heart disease. Of course, this type of exercise needs to be done with proper technique and only after instruction from an expert.
These activities need not be done at an intensity that is painful or uncomfortable. The adage “no pain, no gain” is sometimes used by athletes training for competitive events. This is definitely not true for cardiac patients; in fact, the kinds of activities that can lead to a training effect and increase well-being are often gentle enough to be enjoyable and pleasurable while producing only minimum fatigue or shortness of breath. What is crucial for patients embarking on these programs is to learn to enjoy the feeling of exercising the body and the feeling of movement that goes along with the particular activity.
Another important component of rehabilitation programs is modifying behavior to minimize the impact of risk factors for heart disease, and educating patients about their illness and how to reduce their chances of having future events. Risk factors known to predispose to coronary heart disease (hardening of the arteries), or to the likelihood of a recurrent event, are by now well known to most readers, and include high cholesterol in the blood, cigarette smoking, diabetes, high blood pressure, obesity, certain kinds of personality or behavioral style, and genetic or inherited predispositions. The good news is that risk factors, other than genetic ones, can be changed, with behavior modification or with medication, or both, and that changing these risk factors can undoubtedly have a beneficial impact on the risk of future events as well as on well-being.
Although changing one’s attitude and behavior on one’s own definitely can modify some of these risk factors, especially those involving diet, stopping smoking and exercise, for most patients professional help, and often medications, are required.
A detailed discussion of the importance of and different kinds of cholesterol (the “good,” the “bad” and the “ugly”) is beyond the scope of this book. It is very important to remember, however, that most individuals find lowering their blood cholesterol through diet alone extremely difficult. In our experience, achieving a change in diet is more a matter of changing your philosophy toward eating than of knowing what foods to eat and what foods to avoid, or “dieting,” in the sense of depriving yourself of food. This includes learning how to enjoy the flavor of low-fat foods, for example, spices, herbs, fruits and vegetables, and learning to listen carefully to the signals of hunger and fullness by which your body tells you whether it is time to eat or not. Our North American lifestyle, with television watching, spectator sports and social activities centered around drinking alcohol and eating high-fat foods, is not conducive to heart-healthy habits. In this sense, the best steps to improving your diet may be to watch less television and to engage in more outdoor activities, where you are less likely to snack.
Drugs to lower cholesterol are very effective, are known to prolong life and are quite safe, although they may be a nuisance to take regularly and are not inexpensive. There should be no shame in taking medications to lower cholesterol, since even extraordinarily strict diets achieve only modest cholesterol lowering in most patients. Similarly, high blood pressure and diabetes respond well to drug treatment but cannot be cured (although they can be helped) by diet and exercise. An active decision to work with your doctors and caregivers to follow a treatment plan is very important, both since it will help you achieve your goals and since a positive attitude toward your treatment will be, in and of itself, beneficial.
Probably the most important, but often ignored, aspect of cardiac rehabilitation is increasing knowledge so that patients understand precisely what is happening to their bodies, and the benefits of the changes that they, together with their doctors, can bring about. Understanding the benefits (the why) as well as the details (the what) of rehabilitation can change it from “work,” like a school assignment, to a pleasurable activity that is done for its own sake as well as to improve heart health. Your most important task as a heart patient is to come to terms with this need to understand your heart, your body and your mind, and to work on this attitude, which requires you to see yourself not as a victim, but as a mind/body system that can powerfully influence your heart’s future. If there is any aspect of your heart health that you do not understand, be sure to ask it of your caregivers, and accept an answer only if you understand it completely.
Rehabilitation is not something that you just do for a few weeks or a few months after a heart event. Unfortunately, coronary artery disease can never be completely reversed. You therefore need to continue on your journey indefinitely, always aware that you have some small risk of a repeat heart event, but that this risk can be managed and controlled by continuously taking care of yourself and keeping up a vigilant attitude. Remember that it took twenty or thirty years for the hardening of the arteries to develop, and that your habits of living have evolved slowly since your childhood. Don’t be too hard on yourself, therefore, and don’t expect that you can change either your heart vessels or your heart habits overnight. As you gradually learn new habits, they will become second nature. Nevertheless, much in the way that anything in life that is worth having requires dedication and effort, maintaining heart-healthy habits requires a continuous and conscientious commitment. This need not be painful or distressing, but maintaining a positive attitude and beneficial changes in your diet and activity will not happen automatically. This is especially true with respect to your attitude toward yourself and your illness. Much as anger obstructs your path to recovery, and passivity leads to paralysis, equanimity combined with a realistic but determined attitude can help you deal with the inevitable frustrations of everyday life that all of us face.
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