Jean Crowe

Effects on quality of life with comprehensive rehabilitation after acute myocardial infarction

Abstract This investigation was designed to determine the impact of a brief period of cardiac rehabilitation, initiated within 6 weeks of acute myocardial infarction (AMI), on both disease-specific and generic health-related quality of life, exercise tolerance and return to work after AMI. With a stratified, parallel group design, 201 low-risk patients with evidence of depression or anxiety, or both, after AMI, were randomized to either an 8-week program of exercise conditioning and behavioral counseling or to conventional care. Although the differences were small, significantly greater improvement was seen in rehabilitation group patients at 8 weeks in the emotions dimension of a new disease-specific, health-related Quality of Life Questionnaire, in their state of anxiety and in exercise tolerance. All measures of health-related quality of life in both groups improved significantly over the 12-month followup period. However, the 95% confidence intervals around differences between groups at the 12-month follow-up effectively excluded sustained, clinically important benefits of rehabilitation in disease-specific (limitations, −2.70, 1.40; emotions, −4.86, 1.10, where negative values favor conventional care and positive values favor rehabilitation) and generic health-related quality of life (time trade-off, −0.062, 0.052; quality of well-being, −0.042, 0.035) or in exercise tolerance (−38.5, 52.1 kpm/min); also, return to work was similar in the 2 groups (relative risk, 0.93; confidence interval, 0.71, 1.64). It is concluded that in patients with evidence of depression or anxiety, or both, exercise conditioning and behavioral counseling after AMI was associated with an accelerated recovery in some outcome measures at 8 weeks, but by 12 months similar improvements were seen in both diseasespecific and generic health-related quality of life and in other outcome measures when compared with conventional care in this community.

Economic evaluation of cardiac rehabilitation soon after acute myocardial infarction

Abstract Although there are extensive clinical evaluations of cardiac rehabilitation after acute myocardial infarction (AMI), no full economic evaluation is available. Patients with AMI and mild to moderate anxiety or depression, or both, while still in hospital were randomized to either an 8-week rehabilitation intervention (n = 99) or usual care (n = 102). Comprehensive costs and health-related quality of life, measured with the time trade-off preference score, were obtained in a 12-month trial, and together with survival data derived from published meta-analyses, cost-utility and cost-effectiveness of early cardiac rehabilitation were estimated. The best estimate of the incremental net direct 12-month costs for patients randomized to rehabilitation was

Quality of life after myocardial infarction

480 (United States, 1991)/ patient. During 1-year follow-up, rehabilitation patients had fewer “other rehabilitation visits” (p

Inspiratory muscle training in adults with chronic obstructive pulmonary disease: An update of a systematic review

The objective of this work was to develop and test a questionnaire to measure health-related quality of life for patients after myocardial infarction (MI). In a cross-sectional survey, 63 patients identified the most frequent and important problems following acute myocardial infarction. The Quality of Life after Myocardial Infarction (QLMI) instrument was developed on the basis of these most frequent and important problems. The QLMI was administered, along with instruments measuring health utilities, social function, and emotional function, in a randomized trial of rehabilitation versus conventional care. The most frequent and important problems fell into areas of symptoms, restriction, confidence, self-esteem, and emotions, each of which is represented in the 26-item QLMI. Effect sizes of the overall QLMI in differentiating between rehabilitation and control groups (0.35), and in detecting improvement over 12 months (1.22) were comparable or larger than any other instrument. The Pearsons correlation coefficient between QLMI administered at 8 and 12 months following AMI varied between 0.75 and 0.87 for the five domains and the overall score. We found substantial correlations of the QLMI with other measures with moderate concordance with predictions about how the instrument should behave if it is a valid measure of health-related quality of life. The QLMI demonstrates a high degree of reliability, and is more responsive than other questionnaires. Relations between the QLMI and other measures provide moderate to strong evidence of its validity in discriminating between patients following AMI according to their health-related quality of life, and in measuring changes in health-related quality of life over time.

Anxiety and depression after acute myocardial infarction

The purpose was to update an original systematic review to determine the effect of inspiratory muscle training (IMT) on inspiratory muscle strength and endurance, exercise capacity, dyspnea and quality of life for adults with chronic obstructive pulmonary disease (COPD). The original MEDLINE and CINAHL search to August 2003 was updated to January 2007 and EMBASE was searched from inception to January 2007. Randomized controlled trials, published in English, with adults with stable COPD, comparing IMT to sham IMT or no intervention, low versus high intensity IMT, and different modes of IMT were included. Nineteen of 274 articles in the original search met the inclusion criteria. The updated search revealed 17 additional articles; 6 met the inclusion criteria, all of which compared targeted, threshold or normocapneic hyperventilation IMT to sham IMT. An update of the sub-group analysis comparing IMT versus sham IMT was performed with 10 studies from original review and 6 from the update. Sixteen meta-analyses are reported. Results demonstrated significant improvements in inspiratory muscle strength (PI(max), PI(max) % predicted, peak inspiratory flow rate), inspiratory muscle endurance (RMET, inspiratory threshold loading, MVV), exercise capacity (Ve(max), Borg Score for Respiratory Effort, 6MWT), Transitional Dyspnea Index (focal score, functional impairment, magnitude of task, magnitude of effort), and the Chronic Respiratory Disease Questionnaire (quality of life). Results suggest that targeted, threshold or normocapneic hyperventilation IMT significantly increases inspiratory muscle strength and endurance, improves outcomes of exercise capacity and one measure of quality of life, and decreases dyspnea for adults with stable COPD.

Inspiratory Muscle Training Compared with Other Rehabilitation Interventions in Adults with Chronic Obstructive Pulmonary Disease: A Systematic Literature Review and Meta-Analysis

OBJECTIVES To assess the following: (1) symptoms of anxiety and depression in hospitalized patients who had acute myocardial infarction (AMI); (2) the association between sex, infarct severity, history of previous AMI, and symptoms of anxiety and depression in hospitalized patients; (3) symptoms of anxiety and depression during the first year after AMI in a select group of patients; and (4) the association between educational and occupational status and symptoms of anxiety and depression at the time of hospitalization in a select group of patients. DESIGN Cross-sectional survey (objectives 1 and 2) and prospective trial with random assignment (objectives 3 and 4). SETTING Six university-affiliated hospitals in a Canadian city. PATIENTS Seven hundred eighty-five hospitalized patients with AMI, with 1-year follow-up of 201 selected patients from this sample. INSTRUMENTS State-Trait Anxiety Inventory and the short form of the Beck Depression Inventory. INTERVENTION Data collection was initiated in the hospital 3 days after AMI, and patients were followed-up 14, 24, 41, and 56 weeks after AMI. RESULTS Student t tests, analysis of variance, and descriptive statistics were used. When the patients were in the hospital the mean state (S-anxiety) and trait (T-anxiety) scores were 43 and 44, respectively. Ten percent had S-anxiety scores and 14% had T-anxiety scores that were higher than the mean scores reported for psychiatric patients. During the 1-year follow-up in the select group of subjects, the mean S-anxiety and T-anxiety scores were both 48 in-hospital, and decreased to 42 and 46, respectively, by 14 weeks and remained at these levels for the remainder of the year. During the course of the year, 16% of the patients had State-Trait Anxiety Inventory scores consistent with psychiatric conditions. The in-hospital Beck Depression Inventory mean score was 3, and 9% of the patients had scores consistent with moderate to severe depression. During the first 24 weeks, symptoms of moderate to severe depression were reported by 10% of the select group of patients. No associations were found between anxiety and depression and sex, creatine phosphokinase level, previous AMI, education, or occupational status. CONCLUSIONS Symptoms of anxiety were prevalent among hospitalized patients who had an AMI, whereas depressive symptoms were rare. There was no association between anxiety and depression and sex, infarct severity, history of previous AMI, or educational or occupational status.

Is inspiratory muscle training effective for individuals with cervical spinal cord injury? A qualitative systematic review

The purpose of this systematic review was to determine the effect of inspiratory muscle training (IMT) (alone or combined with exercise and/or pulmonary rehabilitation) compared to other rehabilitation interventions such as: exercise, education, other breathing techniques or exercise and/or pulmonary rehabilitation among adults with chronic obstructive pulmonary disease (COPD). A systematic review of the literature on IMT and COPD was conducted according to the Cochrane Collaboration protocol. Inclusion criteria for the review included randomized controlled trials, published in English, comparing IMT or combined IMT and exercise/pulmonary rehabilitation with other rehabilitation interventions such as general exercise, education, other breathing techniques or exercise/pulmonary rehabilitation among adults with COPD. 274 articles were retrieved, and 16 met the inclusion criteria. Seven meta-analyses were performed that compared targeted or threshold IMT to exercise (n = 3) or to education (n = 4). Results showed significant improvements in inspiratory muscle strength and endurance, and in the dyspnea scale on a quality of life measure, for participants in the IMT versus education group. In other instances where meta-analyses could not be performed, a qualitative review was performed. IMT results in improved inspiratory muscle strength and endurance compared to education. Further trials are required to investigate the effect of IMT (or combined IMT) compared to other rehabilitation inventions for outcomes such as dyspnea, exercise tolerance, and quality of life.

Effects of inspiratory muscle training in cystic fibrosis: a systematic review

Objective: To perform a systematic review to determine the effect of inspiratory muscle training (IMT) in adults with cervical spinal cord injury (CSCI). Design: A systematic search of the literature on IMT and CSCI according to the Cochrane Collaboration protocol was performed. We searched electronic databases up to August 2003 including MEDLINE and CINAHL, searched reference lists from pertinent articles and books, made personal contact with authors, and hand searched targeted journals to identify potential studies for inclusion. Study selection: Inclusion criteria for the review included randomized controlled trials published in English comparing IMT with another comparison group among adults with CSCI. Data extraction: Two reviewers abstracted relevant data from included studies. Methodological quality of the studies was assessed using criteria developed by Jadad et al. We also assessed whether the comparison groups were similar at baseline and whether an intention-to-treat analysis was performed. Results: Forty articles were retrieved and three met the inclusion criteria. All studies used inspiratory resistance muscle trainers for at least 15 min, twice daily, five to seven days per week for six to eight weeks. Meta-analysis could not be performed due to differences in study design and outcomes. Only one study reported a positive effect of IMT compared to control for measures of dyspnoea and pulmonary function. Conclusion: Literature on the effect of IMT among adults with CSCI is scarce and an overall effect could not be confirmed.

Cardiorespiratory Physical Therapy for Patients with Acute Medical Conditions: Qualitative Systematic Review

Objective: We performed a systematic review to determine the effect of inspiratory muscle training (IMT) on inspiratory muscle strength and endurance, exercise capacity, dyspnoea and quality of life for adolescents and adults living with cystic fibrosis. Data sources: MEDLINE, EMBASE and CINAHL electronic databases were searched up to January 2008. Review methods: We performed a systematic review using the methodology outlined in the Cochrane Collaboration protocol. Articles were included if: (1) participants were adolescents or adults with cystic fibrosis (>13 years of age); (2) an IMT group was compared to a sham IMT, no intervention or other intervention group; (3) the study used a randomized controlled trial or cross-over design; and (4) it was published in English. Data were abstracted and methodological quality was assessed independently by two reviewers. Results: The search strategy yielded 36 articles, of which two met the inclusion criteria. Both studies used a targeted or threshold device for IMT. Meta-analyses were limited to forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC), which showed no difference in effect between the IMT group and the sham and/or control group. Individual study results were inconclusive for improvement in inspiratory muscle strength. One study demonstrated improvement in inspiratory muscle endurance. Conclusion: The benefit of IMT in adolescents and adults with cystic fibrosis for outcomes of inspiratory muscle function is supported by weak evidence. Its impact on exercise capacity, dyspnoea and quality of life is not clear. Future research should investigate the characteristics of the subgroup of people with cystic fibrosis that might benefit most from IMT.

QUALITY OF LIFE AFTER MYOCARDIAL INFARCTION

Cardiorespiratory physical therapy interventions included postural drainage, coughing, huffing, percussion, vibration, positioning, turning and hyperinflation. Studies evaluated physical therapy in a range of acute conditions (atelectasis, pneumonia, pneumothorax, pleural effusion, deep vein thrombosis, acute myocardial infarction and mechanically ventilated patients). Measured outcomes included pulmonary and cardiorespiratory measures, mortality and length of hospital stay.