Physiotherapy management of patients with Coronary Artery Disease: a Report on current practice in South Africa

Correspondence to: Ronel Roos Cardiopulmonary lecturer Department of Physiotherapy School of Therapeutic Sciences University of the Witwatersrand 7 York Road Parktown 2193 E­mail: ronel.roos@wits.ac.za AbSTrAcT: Coronary artery disease (CAD) is a worldwide health problem with an increased prevalence in sub-Saharan Africa. Physiotherapists internationally are involved in the care of these patients from the acute stage following a cardiac event until phase III cardiac rehabilitation is completed. The purpose of this study was to determine the current physiotherapy management of patients with CAD in South Africa. An observational crosssectional study was conducted over two months with a questionnaire that was sent to the government and private health care sectors. Results showed that more cardiopulmonary physiotherapists provided care (62%) than those who didn’t (38%). Care was mostly provided in a hospital setting (81%) and outpatient phase III cardiac rehabilitation was lacking (11%). In-hospital physiotherapy treatment was mostly provided once daily. Deep breathing exercises (99%), circulatory exercises (95%) and manual chest clearance techniques (88%) were mostly used during physiotherapy. Evidence based practice was consistent regarding early mobilization but was inconsistent with regards to the use of manual chest clearance techniques.

ciencies to a predominance of chronic lifestyle diseases such as CAD.South Africa is said to be in the second and third stage of epidemiological transi tion as the prevalence of risk factors for CAD and the disease itself are increas ing in a more compressed time frame when compared to developed countries (Mensah 2008;Steyn et al 2005).In the Interheart Africa study the researchers demonstrated that hypertension, abdo minal obesity as reflected by waisthip ratio, current/former smoking status and stress levels were stronger predictors for acute myocardial infarction in the Africa study group compared to the global Interheart study (Steyn et al 2005).The presence of lifestyle risk factors for CAD is therefore clearly evi dent.Another component to be aware of specifically when looking at CAD in the African context is the effect that the human immunodeficiency virus (HIV) has on the prevalence of CAD.The risk for CAD is higher in people infected with HIV and occurs at an ear lier age (Currier et al 2003).Due to all these factors it is no wonder that CAD is projected to be one of the leading causes

INTRODuCTION
Coronary artery disease (CAD) is a health problem worldwide.It is the lead ing cause of death internationally and accounts for a third of deaths globally (Mackay and Menash 2004).Mortality from CAD in developed countries has declined due to improved prevention strategies, diagnosis and treatment (Mackay and Menash 2004).CAD was previously considered rare in sub Saharan Africa but due to epidemio logical transition (economic develop ment, industrialisation and urbanisation) this is no longer the case (Mensah 2008).Epidemiological transition results in the shift of major causes of death from infectious diseases and nutritional defi of death in developing countries by 2030 (Abegunde et al 2007).
Internationally, physiotherapists treat patients with CAD in the acute stage following a coronary event and/ or fol lowing coronary artery bypass graft (CABG) surgery.These patients are then subsequently followed up as out patients during cardiac rehabilitation in order to improve function and quality of life and to delay the occurrence of subsequent coronary events (Piotrowicz and Wolszakiewicz 2008;Martin 2007;Tucker et al 1996).The role of the South African physiotherapist in the care and rehabilitation of patients with CAD has not been investigated to date.It is not clear what treatment interventions South African physiotherapists use in their management of such patients.The aims of this study were to establish a) how many physiotherapists who work in the cardiopulmonary field of physiotherapy are involved in the care and rehabi li tation of patients with CAD; b) the cur rent physiotherapy interventions that are used in the management of patients with CAD; c) the clinical setting (acute care or outpatient care) in which patients Descriptive data analysis was used to describe the data.

RESuLTS
The questionnaire was mailed to 50 regional and tertiary government insti tutions and 137 electronic question naires were circulated.A total of 187 questionnaires were sent out and 142 were returned (76%

METHODOLOgy
An observational crosssectional study was conducted.A questionnaire was developed following a literature review of chest clearance and rehabilitation methods used in the management of patients with CAD.A review of cardiac procedures performed in individuals diagnosed with CAD was also done.The questionnaire was developed in English as it is the language of medical science (nationally and internationally).The questionnaire was discussed with a peer group to verify its contents, to establish the time required to complete the questionnaire, to establish if the questions addressed the aims of the study and if all questions were understandable to the participant.Minor changes were made to the questionnaire.The question naire, informed consent form and infor mation sheet were mailed to the physio therapy heads of department (HOD) of govern ment hospitals (identified through the Department of Health web page) throughout South Africa that have intensive care units.The HOD was asked to invite his/her staff who worked in a cardiopulmonary setting to participate in the study.The questionnaires were then either faxed back to the researcher or mailed back in the enclosed prepaid addressed envelope.
Secondly, the South African Society of Physiotherapy (SASP) directory was reviewed to determine which private physiotherapy practices provided car diopulmonary care to patients.These practices were contacted telephonically to determine if they were willing to participate in the study.On agreement each participant's email address was obtained and the questionnaire, informed consent form and information sheet were then circulated electronically to them.Thirdly, an information letter of the study was sent to the chairperson of the Cardiopulmonary Rehabilitation Special Interest Group (CPRG) of the SASP.The letter requested that the researcher be permitted access to the CPRG mem bers' email addresses in an attempt to circulate the questionnaire to them.All documents were then emailed to the CPRG members of the SASP.The pri vate practitioners and CPRG members had the option of returning the question naire via email as an attachment or to fax it back to the researcher.All study participants had a two month period (June & July 2009) in which to return the questionnaire to the researcher and reminder strategies (telephone calls and email) were used to remind participants of the submission deadline.Permission to conduct this study was obtained from the University of the Witwatersrand Human Research Ethics committee.or private practice where they worked.
Most patients received treatment in hospital once or twice daily (Table 1).Physiotherapists who did provide phy sio therapy interventions to patients in an outpatient capacity did so once weekly (Table 1).
Figure 2 illustrates that patients were most commonly seen in hospital prior to and following CABG surgery and after myocardial infarction (MI).Fewer physiotherapists treated patients follow ing admission for chest pain/angina or angioplasty intervention (Figure 2).The reason for referral of these patients to physiotherapy is unknown.Few physio therapists continued with patient care following discharge from the hospital.

REASONS fOR NOT PROVIDINg REHA-BILITATION TO PATIENTS WITH CAD
The most common reasons listed for not providing rehabilitation care to patients with CAD in the private sector included a lack of equipment, space and time.It was mentioned that patients often received information from nursing staff members concerning living a healthy lifestyle and from dieticians concerning an appropri ate diet.Some private practitioners did provide outpatient rehabilitation but this was discontinued mostly due to poor patient adherence or changes in doctors' referral patterns.It was also noted that patients often lived far away from the specialised center where their coronary event was managed.Followup of these patients was therefore not possible.In the public sector these patients were often not referred to the physiotherapy department or they were transferred to a more specialised hospital.It was also noted that intervention in these patients depended on the patient's clinical con dition e.g. the presence of post operative complications or if they were medically stable.

DISCuSSION
Coronary artery disease is projected to be the leading cause of death in develop ing countries by 2030 (Abegunde 2007).This study investigated the current level of involvement of cardiopulmonary physiotherapists in the management of patients with CAD in South Africa.
It was encouraging to note that more cardiopulmonary physiotherapists pro vided care to patients living with CAD than those who did not.Primary pre vention strategies such as education concerning living a healthy lifestyle and secondary management for re occurrence of a cardiac event such as cardiac rehabilitation are important components in attempting to decrease the burden of CAD (Mensah 2008;Piotrowicz and Wolszakiewicz 2008).Education consisting of postoperative precautions of CABG (wound care and temporary restrictions in physical   Tucker et al (1996) and Martin (2007) as techniques commonly used by physiotherapists in the manage ment of patients undergoing CABG surgery in Australia and the United Kingdom.There is however conflicting evidence in the literature concerning the effectiveness of DBE following CABG and for the purpose of this dis cussion the treatment technique will be divided into positive pressure related and nonpressure related deep breathing exercises.
Westerdahl et al ( 2005) conducted a randomised controlled trial (level 1b) in patients following CABG and found that implementing DBE with a fluctuating positive pressure device e.g.blowbottle improved the patients' pulmonary func tion.CTscans of these patients' chests revealed less areas of atelectasis in the intervention group.It is important to note that the DBE in this study was per formed in a sitting position.It is well known that an upright position is more adventitious compared to the supine posi tion when attempting to improve lung volumes in a cardiopulmonary patient (Pryor and Prasad 2008;Frownfelter and Dean 2006).Intermittent positive pressure breathing (IPPB) was used by 31 physiotherapists in the current study.Romanini et al (2007) reported that IPPB was effective in managing hypoxemia in CABG patients in the first few days fol lowing surgery.However, Westerdahl et al ( 2001) reported that DBE performed with a blow bottle device was more effective in preventing a decline in lung function in patients after CABG than DBE alone or IPPB.Brasher et al (2003) on the other hand showed that if DBE was removed from an early mobilisation program for patients after CABG there was no significant difference between the control and intervention groups relating to the patients' lung function results.In this and Westerdahl's studies the patients were mobilised out of bed on day one post surgery but the position ing and repetitions during DBE were different.In Westerdahl's study (2005) all DBE were done in sitting and the repetitions of DBE per hour were greater compared to the latter study where participants were positioned in supine or sitting during DBE and performed fewer repetitions.
With reference to nonpressure related DBE, the effect of IS was compared to other prophylactic physiotherapy tech niques on postoperative pulmonary complications (PPC) following CABG in a Cochrane review (Freitas et al 2007) (level 1a evidence).A total of four randomised controlled trials met the inclusion criteria for this review.The reviewers found no differences in PPC when using IS or a pressure device such as IPPB for patients after CABG surgery.Worse pulmonary function and arterial oxygen levels were reported with the use of IS when compared with pressure devices (Freitas et al, 2007).Even though the evidence is contradictory in nature regarding the use of chest clearance techniques such as DBE, IS, blowbottle and IPPB postoperatively, patients who undergo CABG surgery have significant pulmonary dysfunction four days post operatively which can persist up to four months following surgery (Westerdahl et al, 2003).Intervention strategies used by physiotherapists for the improvement of pulmonary function following CABG is therefore still justified.
Manual techniques were frequently used by physiotherapists in the current study.A literature search in Pubmed, Cochrane Database for Systematic Reviews and Scopus however found no evidence to support the use of this treat ment modality in the care of patients with CAD.Postural drainage (PD) was also commonly used.Headdown PD is considered a relative contraindication in patients with severe cardiovascular disease (Hough 1997) In this study, patients with CAD were most commonly seen by physio therapists once or twice daily while in hospital.This finding is similar to the frequency of treatment provided by physiotherapists working in the United Kingdom when treating patients post cardiac surgery (Martin 2007).When reviewing treatment frequency Van der Peijl et al (2004) reported no difference in hospital length of stay or postopera tive complications between patients seen once or twice daily by physiotherapists after cardiac surgery.They did note that the twice daily group reached functional milestones sooner and was more satis fied with the physiotherapy service.
A group of patients that was not so frequently managed by physiothera pists was that undergoing angiogram and angioplasty interventions.It is well known that these patients are less physically active than patients who have had CABG (Reid et al 2006).The role of education in the form of risk factor modification and the importance of exercise is essential for such patients as the rate of angiography interventions is increasing (Reid et al 2006).

CONCLuSION
The study confirmed that most physio therapists working in the cardiopulmo nary field in South Africa are involved in the management of patients with CAD during hospitalisation.However the use of evidence based interventions in the clinical care of patients with CAD was inconsistent.There is currently limited involvement of physiotherapists in out patient cardiac rehabilitation in South Africa.Considering the potential burden of this disease on the economy of South Africa, the focus of physiotherapists should be on prevention of risk factors such as hypertension through education and exercise as well as implementation of programmes (cardiac rehabilita tion) for the longterm management of indi viduals diagnosed with CAD.
Physiotherapy practice in this arena could be enhanced by evidencedbased workshops to clinicians, improved com munication between professionals [refer rals], creating a data base of healthcare professionals providing phase three car diac rehabilitation and outpatient follow up of patients to enhance patient care.

ACkNOWLEDgEMENTS
The researcher would like to thank all the government and private sector physio therapists who participated in this study.

Figure 1 :
Figure 1: interventions used in management of cAD patients.