Previous Medical History And Comorbidity

This is possibly the most important non-CHD assessment factor that influences exercise prescription in CR. As the patient population within phase III cardiac rehabilitation expanded and became more inclusive for those with more limited exercise ability, either through age or complex medical history, so our assessment had to expand to consider a diverse and substantial number and combination of orthopaedic, neurological, respiratory, vascular and musculoskeletal conditions. A survey carried out by Thow, et al. (2003) looked at non-cardiac patient interventions within eight cardiac rehabilitation programmes in the West of Scotland. Of the 701 interventions carried out over a two-month period, 72% of these were to adapt exercise programmes in light of non-cardiac conditions or to give advice on the same. This highlights the importance both of individualising exercise prescription in the presence of co-morbidity and of having suitably trained exercise professionals to assess, advise patients and deliver phase III cardiac rehabilitation.

The increase in participants with co-morbidity presents the exercise professional in cardiac rehabilitation with prescription and programme management challenges that will be further discussed in Chapter 4.

Limitation of functional capacity will often be attributable not to coronary heart disease but to co-morbid conditions. This may mean that functional capacity assessed by means of walking is both ineffective and inappropriate. Can we, therefore, effectively prescribe exercise to accommodate this diversity, and can we implement outcomes to measure the effectiveness of our interventions?

Unfortunately, there does not appear to be a gold standard for measuring physical functioning, either by performance-based or self-report measures (Pepin, et al., 2004), especially in the older patient. As with most aspects of CR it is likely that a variety of measures will need to be considered on an individual patient basis.

In addition, there are proposals of a link between co-morbidity and risk during exercise. Zoghbi, et al. (2004) attempted to apply the traditional risk stratification tables of the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR, 1999) to a patient population. They also applied a co-morbidity index (CMI) which 'predicts short and long-term mortality rates for a specific medical condition'. This CMI index has been shown to indicate a 'progressive 10-fold increase in mortality as the score increases', with common co-morbid conditions given a weighted score. The researchers concluded that the traditional tool (AACVPR, 1999), but interestingly also the CMI, are independent predictors of risk of events during exercise, giving preliminary evidence of a link between co-morbidity and risk during exercise.

However, they also noted that the AACVPR (1999) guidelines were more accurate in predicting high-risk status and events in men, and that the CMI

was the significant predictor in women in their study. They suggested that the traditional risk stratification tables may not be sufficient to assess risk across the genders, and that their use should be supplemented with not only risk factor assessment, as proposed in the Canadian (Stone, et al., 2001) tool discussed at the beginning of this chapter, but also with a detailed co-morbidity assessment. They also underline the importance, as did Thow, et al. (2003), of staff competency to manage the multitude of non-cardiac co-morbidity among CR participants.

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