Return to work is an important measure of successful CR for some individuals with CHD. Variables which contribute to a successful return to employment or being considered fit to work include shift patterns, self-efficacy, perception of control over work demands and physical job requirements (ACSM, 2001).

The process of assessment for exercise, the consequent advice and guidance, and the exercise prescription itself should contribute to a tailored return to work needs for appropriate patients. These discussions to establish realistic return to work plans should commence as early as possible in the rehabilitation process. The aims of the occupational assessment are:

• discuss job demands (physical and psychological) and concerns;

• provide provisional timelines for return to work based on job analysis;

• provide an individualised exercise prescription based on job analysis;

• consider whether specific occupational carrying or lifting tests should be used for prescription.

(Adapted from ACSM, 2001).

Occupation, work conditions and demands may also impact on patients' ability to commit to attending cardiac rehabilitation programmes. The clinician may need to consider adapting supervised sessions or creating flexibility within programmes to accommodate work commitments, or to involve, where possible, not only the patient but the employer or occupational health representative in planning a rehabilitation programme.

When considering occupation, level of physical effort, including arm versus leg work, carrying and lifting activities, sustained versus bouts of exertion and environmental conditions could influence the type of exercise prescribed for assisting return to work. Driving occupations often require re-licensing using strict criteria on ETT (DVLA, 2004). The CR clinician can use assessment information and rehabilitation to prepare the patient for ETT requirements or to ascertain whether attainment of the level of functional capacity required for re-licensing is realistic for that individual. A detailed discussion around occupation at baseline assessment will reveal whether the patient considers himself or herself ready for return to work. This discussion is important when setting and working towards patient-centred goals. Despite many patients reporting that their jobs are physically active, most occupations require an energy expenditure of less than 5 METs (ACSM, 2001).

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