Effects of a Multidimensional Cardiopulmonary Rehabilitation Program on Psychosocial Function Kathleen Dracup, RN, DNSC, Debra K. Moser, RN, MN, Celine Marsden, RN, MN, Shelley E. Taylor, PhD, and Peter M. Guzy, MD, PhD

The effects of participation in a structured, outpatient cardiac rehabilitation program on psychosocial function after acute myocardiai infarction or coronary artery bypass surgery, or both, were evaluated prospectively in 141 patients who were married or living with “a significant other” (89% men, mean [* standard deviation] age 63 f 9 years old). Forty-one patients who were participants in a 3-month cardiac rehabiiitation program were compared with 166 patients who did not participate in a formal program. On average, patients in both groups were well educated, older Caucasians who had minimal cardiac dysfunction (New York Heart Association class I or ii). Patients in the 2 groups were not different at baseline in sociodemographic or ciinieai characteristics or in any of the dependent measures of anxiety, depression, psychosocial adjustment to illness or marital adjustment. six months after initial testing, patients who attended cardiac rehabilitation were significantly less anxious (F[ 1,139] = 5.09, p = 0.03), fess depressed (F[l,l39] = 8.39, p = 0.004), had better psychosocial adjustment (F[1,139] = 5.87, p = 0.02), and were more satisfied with their marriages (F[l,l39] = 8.6, p = 0.004) than nonparticipants. The findings support the effectiveness of group cardiac rehabilitation for this subgroup of patients in faciiiWing their psychosocial recovery after an acute cardiac event. (Am J Cardid lSS1;68:31-34)

atient participation in an exercise-basedcardiac rehabilitation program may minimize the physical and emotional disability associatedwith myocardial infarction and coronary artery bypass surgery, but controversyexistsover the exact nature of the benefits of such programs and their value in relation to their cost.re5Recent reviews and meta-analyses of experimental data have documented the following benefits: reduced mortality, improved functional capacity, improved symptom-limited maximal oxygen uptake and reduced cardiac risk factors.4-6However, many studies have not supported the commonly held belief that participation in a cardiac rehabilitation program improves psychological well-being.7-10In general, the programs subjectedto systematic assessmenthave focusedon exercise training and excluded education and counseling components.7J1This study compares the psychosocial adaptation of patients who participated in a multidimensional cardiac rehabilitation program with that of patients who did not.

P

METHODS

Patients: Patients were recruited during the 4 years betweenMay 1985 and April 1989 from 6 large metropolitan area hospitals in Los Angeles County as part of an ongoing study to test the effects of teaching cardiopulmonary resuscitation to family members of cardiac patients. Patients receivedno intervention as part of the cardiopulmonary resuscitation study. Patients were included if they had the following: (1) a myocardial infarction or coronary artery bypass surgery within the past 12 months, (2) were literate in English, (3) aged 25 to 80 years, and (4) living with a spouseor significant other. Patients were excluded if they had a significant chronic illness other than heart diseaseor a history of psychiatric illness. The so&demographic and clinical characteristics of the patient sample are summarized in Table I. On average,patients were older CauFrom the Schoolsof Nursing and Medicine, and the Department of casian men (mean f standard deviation age 63 f 9 Psychology, University of California, Los Angeles, California. This years old, range 33 to SO),well educated,with minimal study was supportedby Grant RO 1 HL32 171 from the National Heart, Lung, and Blood Institute, Bethesda,Maryland. Manuscript received cardiac symptoms and with supportive spouses. December 31, 1990;revised manuscript received March 4, 1991,and Cardiac rehabilitation: Forty-one patients particiacceptedMarch 6. pated in a structured outpatient cardiac rehabilitation Addressfor reprints: Kathleen Dracup, RN, DNSc, UCLA School of Nursing, 10833Le Conte Avenue, Los Angeles, California 90024- program. The remaining 100 patients, who servedas a 6918. comparison group, were largely patients discharged CARDIAC REHABILITATION AND PSYCHOSOCIAL STATUS

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TABLE I Comparison of Group Characteristics

TABLE II Comparison of Psychosocial Function Between

Cardiac No Cardiac Rehabilitation Rehabilitation p Value No. of subjects Gender Male (%I Female (%) Marital status Married (%) Single t%) Work status Employed t%) Unemployed (%I Sick leave (%) Retired (%I Income O-$9,999 (%) $10,000-39,999 (%) > $40,000 (%) No answer (%I Cardiac diagnosis* Myocardial infarction (%I Cardiac bypass surgery (%) Angina t%)

Cardiac Rehabilitation (n = 41) and Noncardiac Rehabilitation (n = 100) Groups Cardiac Rehabilitation

NS 38 (93) 3 (7)

88 (88) 12 (12)

39 (95) 2 (5)

97 (97) 3 (3)

16 (39) 2 (5) 3 (7) 20 (49)

46 (46) 4 (4) 5 (5) 45 (451

0 (0)

1 (1) 26 (26) 60 (60) 8 (8)

Baseline NS

NS

No Cardiac Rehabilitation

6 Months Baseline

6 Months

Anxiety 72-4 524 7&5 724 Depression 12 -+ 7 827 13 f 7 13 2 7 Psychosocial adjustment 42 _’ 9 36 k 8 44211 42211 Marital adjustment 115 f 20 121 +- 16 114 2 17 111 2 18 Anxiety: higher scores indicate increased anxiety; depression: higher scoras indicate increased depression; psychosocial adjustment: higher scores indicate poorer adjustment; marital adjustment: higher scores indicate betteradjustment.

NS 9 (22) 26 (63) 6 (15)

in a variety of psychological and social dimensionsas a result of a physical illness.14-17Organized into a 46NS item self-report questionnaire, the scale reflects 7 di28 (68) 70 (70) mensions: health care orientation, vocational environ24 (56) 66 (66) 30 (73) 71 (71) ment, domestic environment, sexual relations, extended family relations, social environment and psychologi63 2 8 632 10 NS Age (yrs) Time from cardiac cal distress. Marital adjustment was measured by the 523 41-3 event (mos) NS Spanier Dyadic Adjustment Scale.i8 The 32-item quesYears of education 14 2 3 15 r 3 NS 1 2 0.3 NYHA functional class 1 +- 0.3 NS tionnaire was designed for use with either married or Mean values are ? standard deviation. unmarried cohabiting couples.The scalemeasuresmar*Categories not mutually exclusive. NS = difference not statistically significant; NYHA = New York Heart Association ital adjustment along the 4 dimensionsof marital satisfaction, dyadic cohesion, consensusand affection. All questionnaires have established reliability and validity from hospitals that did not have cardiac rehabilitation and have been used in a variety of clinical populations, programs. Four cardiac rehabilitation programs were including patients with cardiac disease. Data analysis: Baseline group characteristics were represented,Although they were in different locations, they shared a number of similarities; all were nurse- compared to identify any differences between the 2 supervised,with patients attending 3 monitored exercise study groups by using independent t tests and chisessionsper week for 12 weeks.All programs included square. Comparison of baselinevalues of the dependent a detailed health evaluation of the patient, initial pa- variables between the groups was accomplished by tient-spouse interview and mutual goal-setting, stress analysis of variance. The hypothesis that the 2 groups management classes,risk factor counseling and educa- differed for the dependentvariables of anxiety, deprestion. The philosophy of the programs emphasizedpa- sion, total psychosocialadjustment and marital satisfaction was examined by using multivariate analysis of tient responsibility and accountability. Instmments: Psychosocialfunctioning was assessed variance with post hoc comparisonby univariate analyby measuring levels of anxiety, depression,marital ad- sis of variance to identify sourcesof difference. Statistijustment and overall psychosocialadjustment to illness. cal significance was set at a p value of 0.05. Continuous Data were collected at baseline and at 6 months data are presentedas mean f standard deviation. through 3 mailed questionnaires. The Multiple Affect Adjective Checklist was used to measure the state of RESULTS There were no significant differences between the It consistsof 132 alphabetianxiety and depression.r2y13 cardiac rehabilitation group and the group not attendcally arranged adjectives with instructions to check ing cardiac rehabilitation in so&demographic and clinwords that describe feelings over the previous week. Scores for anxiety range from 0 to 21. For anxiety, ical characteristics (Table I) or in baselinepsychosocial scoresof 57 are within normal range. Scores for de- states (Table II). However, there were significant difpressionrange from 0 to 40, with 11 consideredmoder- ferencesbetweenthe 2 groups over time for the dependent variables (F[4,136] = 4.32, p = 0.02) using Pillais’ ate clinical depression. The PsychosocialAdjustment to Illness Scale is de- criterion. Results of the evaluation of assumptions of signed to measurethe changesa personhas experienced normality and homogeneity of variance-covariancema-

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JULY 1, 1991

trixes were satisfactory. Post hoc comparisonsby univariate analysis of variance revealed that patients who participated in a cardiac rehabilitation program were significantly less anxious (F[1,139] = 5.09, p = 0.03) less depressed(F[1,139] = 8.39, p = 0.004), had better psychosocial adjustment (F[1,139] = 5.87, p = 0.02), and were more satisfied with their marriages (F[1,139] = 8.6, p = 0.004) at 6 months follow-up than patients who did not participate in formal cardiac rehabilitation (Table II). Although patients did not receive any intervention as part of the cardiopulmonary resuscitation training study from which the subjects for this study were recruited, we used participation in the cardiopulmonary resuscitation intervention group as a factor in the analysis to eliminate the possibility that family assignment offers a competing explanation of patient group differences.There was no significant difference between the groups, whether or not family members had learned cardiopulmonary resuscitation (F[12,423] = 0.56, p = 0.87). DISCUSSION Although these findings are limited by the nonrandomized design, participation in an outpatient, monitored cardiac rehabilitation program resulted in improved psychosocialfunction at 6-month follow-up. Patients who participated in the cardiac rehabilitation program were significantly less anxious and less depressed,had better psychosocialadjustment and greater marital satisfaction than patients who did not participate. A possible explanation for these positive findings is that the programs tested in this trial used a multidimensional approach to recovery. Previous investigators have suggestedthat specific psychologically oriented interventions are required to reap positive psychological benefits. For example, in a study of 106 postmyocardial infarction natients randomized to either a LOUD counseling program or an exercise training program, exercise training significantly reduced fatigue, increasedexercise work capacity and promoted feelings of independence.tg Patients in the group receiving a counseling intervention were significantly less anxious and depressedat 6 months than patients in the group receiving an exercise training intervention. The mechanism usually proposedfor the positive psychological effect of exercise training is that increased levels of fitness lead to enhanced self-esteem;however, in several studies the changes in emotional- functioning that were associated with participation in an aerobic training class were independent of actual changesin fitness.20l21 Thus, exercise alone may not be powerful enough to alter the psychological and social recovery of patients after a cardiL



I

ac event, whereas a program that operates on several levels simultaneously (i.e., physical, emotional, social) evokessuch changes. In most cardiac rehabilitation studies, patients enter a rehabilitation program with relatively normal scores of psychosocialmeasures,allowing little room for improvement.7~10Those investigators who enrolled patients with moderate to severe psychosocial disturbancesdid show differencesbetween experimental and control groups.t9 Although most patients in the present study also scoredwithin normal ranges at baseline, significant improvement in psychosocialstatus was documented in the rehabilitation group, whereasthe control group remained relatively unchanged. This result supports the effectiveness of the multidimensional approach to rehabilitation tested in the current study. All patients in the current study were married or living with a significant other. There is some evidence that family support of participation in cardiac rehabilitation is an important predictor of psychosocialrecovery.” Becauseall previous studies of the psychosocial effects of cardiac rehabilitation have used a sample of both married and single patients, the positive results in the current study may also reflect a synergistic effect between participation in a rehabilitation program and spousesupport.

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5. Oldridge NB, Guyatt GH, Fischer ME, Rimm AA. Cardiac rehabilitation after myocardial infarction: combinedexperienceof randomized clinical trials.

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7. Blumenthal JA, Emery CF, Rejeski WJ. The effects of exercisetraining on psychosocialfunctioning after myocardial infarction. J Cardiopul Rehab 1988; X:183-193. 8. Erdman RAM, DuivenvoordenHJ, Verhage F, Kazemier M, Hugenholtz PG. Predictability of beneficial effects in cardiac rehabilitation: a randomizedclinical trial of psychosocialvariables. J Cardiopul Rehab 1986;6:206-213. 9. Stern MJ, Cleary P. National exerciseand heart diseaseproject: psychosocial changes observed during a low-level exercise program. Arch Intern Med

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11. BurgessAW, Lerner DJ, D’Agostino RB, VokonasPS, Hartman CR, Gaccione P. A randomized control trial of cardiac rehabilitation. Sot Sci Med 1987;24:359-370.

12. Zuckerman M, Lubin B. Manual for the Multiple Affect Adjective Check List. San Diego, California: Educational and Industrial Testing Service, 1965. 13. Zuckerman M, Lubin B, Vogel L, Valerius E. Measurementof experimentally induced affects. J Consult Psycho1 1964;28:418-425. 14. Derogatis L. Scoringand proceduresmanualfor PAIS. Baltimore, Maryland: Clinical PsychometricResearch, 1976. 15. Morrow GR, Chiarello RJ, Derogatis LR. A new scalefor assessingpatients’ psychosocialadjustment to medical illness. Psycho1 Med 1978;8:605-610. 16. De-Nom AK. Psychosocialadjustment to illness scale (PAIS): a study of chronic hemodialysispatients. J Psychosom Res 1982;26:1l-17.

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17. Powers MJ, Jalowiec A. Profile of the well-controlled, well-adjustedhypertensive patient. Nurs Res 1987;36:106-110. 18. Spanier GB. Measuring dyadic adjustment: new scales for assessingthe quality of marriage and similar dyads. J Marr Fam 1976;38:15-28. 19. Stern MJ, German PA, Kaslow L. The group counselingv exercisetherapy study: a controlled intervention with subjectsfollowing myocardial infarction. Arch Intern Med 1983;143:1719-1725. 20. JasnoskiM, Holmes D. Influence of initial aerobic titness,aerobic training, and changesin aerobic fitness on personality functioning. J Psychosom Res 1981;25:553-556. 21. JasnoskiM, Holmes D, SolomonS, Aguiar C. Exercise,changesin aerobic capacity, and changesin self-perceptions:an experimental investigation. J Res Personal 1981;15:460-466.

JULY 1, 1991

Effects of a multidimensional cardiopulmonary rehabilitation program on psychosocial function.

The effects of participation in a structured, outpatient cardiac rehabilitation program on psychosocial function after acute myocardial infarction or ...
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