Cardiovascular Rehabilitation (dedikált példány) [antikvár]

PREFACE Observant physicians have, for decades, espoused and practiced many of the principles utilized in cardiovascular rehabilitation. It is known widely that patients do better when encouraged to become physically active as early as medically appropriate than if permitted to remain bedridden, or sedentary. Early has become earlier and earlier, but what constitutes appropriate physical activity seems unclear to many. Should patients walk, jog, run, swim, or engage in other forms of exercise? When, how, for how long, and at what intensity should exercise be prescribed remain questionable to most physicians. Most physicians would agree that avoidance of depression, fears, anxiety, and what may be called emotional stress is good. Most busy physicians recognize, however, that it is difficult to deal effectively with the majority of these common disorders in an office practice. Few, if any, physicians would deny that a good diet, proper nutrition, and an ideal body weight are good for their patients, but how does the physician advise the patient? People do not adhere to prescribed, restrictive diets for long. If the patient is on a diet, the entire family must be on the same diet, or more than one kitchen is required. Most physicians are aware that widely publicized and promoted, or advertised, diets are faddish and temporary, soon replaced by the most recent and more highly promoted diet. Physicians are busy, and one would think that they would willingly turn their patients over to a facility that provided the right kind of exercise, took care of the psychological and nutritional problems, and did not lure patients away from them in terms of long-term care. Extensive research on the effects of exercise has been published. Volumes have been written about the psychology of the cardiac patient, and nutrition advice abounds. Many convinced pioneers have formulated programs to provide exercise programs for patients. A lesser number have combined psychological and nutritional counseling as well. Why then, in 1983, did an editor of a recent book write, "Unfortunately, the information gathered thus far does not provide yet the desired scientific evidence that can validate the belief held by researchers in the field of the individual and social benefits they attribute to cardiovascular rehabilitation programs" (Blocker, W. P., Jr. Rehabilitation in Ischemic Heart Disease. S. P. Medical and Scientific Books, 1983, preface)? Why, in 1978, did Dr. Pollock say, "In his closing lecture following the 1970 Symposium on Coronary Heart Disease and Physical Fitness, Hansen concluded that large-scale application of physical conditioning in the prevention and therapy of patients with coronary heart disease could not be justified on the basis of irrefutable scientific evidence. Irrefutable evidence is still lacking and is not likely to be forthcoming in the near future" (Pollock, M. L., and Schmidt, D. H. Heart disease and Rehabilitation. Houghton-Mifflin, Boston, 1979, p. 694)? Why have so many dedicated cardiovascular rehabilitation services started and failed? Why do so relatively few physicians refer their patients to cardiovascular rehabilitation centers? Why have even some of the pioneers in the field become discouraged at the slow acceptance of dedicated cardiovascular rehabilitation? The health insurance industry has been cautious in its reimbursement practices. There is not a simple answer to these questions. The first assumption would be that convincing, demonstrated evidence has not been sufficient to establish a widely held view that dedicated cardiovascular rehabilitation facilities provide the claimed benefits. The second assumption is that most physicians do feel that they can provide adequate rehabilitation for their patients from their offices; thus, they are not compelled to refer these patients to dedicated centers. A third assumption is that there have been few, if any, standards or guidelines for cardiovascular rehabilitation centers; hence, the field is fair game for almost anyone with the desire to conduct an array of activities of widely varying quality. Reading and listening lead me to think that those with limited or even anecdotal experience speak out, both pro and con, as often as those who work extensively in the field. It is a field where freedom of speech has certainly not been suppressed. In many cases, there v