Physiotherapy Management of Patients with Coronary Artery Disease: A Report on Current Practice in South Africa

Abstract

Introduction Coronary artery disease (CAD) is a global health problem and remains a major cause of morbidity and mortality internationally. South Africa has a high prevalence of CAD, with many patients requiring medical, surgical and physiotherapy management. Physiotherapists play an important role in providing cardiac rehabilitation to CAD patients in the hospital and out-patient settings. The last report on physiotherapy management of patients with CAD was published in 2011. Objectives This study aimed to establish the number and years of experience of physiotherapists who work in the cardiopulmonary field and are currently involved in the care and rehabilitation of patients with CAD; determine the current physiotherapy interventions and outcome measures used in the management of patients with CAD; identify the referral systems used for referring patients with CAD to physiotherapy rehabilitation within the acute care and out-patient settings; identify the clinical settings (e.g. acute care or outpatient clinic) in which physiotherapy rehabilitation interventions for patients with CAD currently take place, the frequency of these interventions (acute and chronic phase), physiotherapists’ involvement in providing structured phase three cardiac rehabilitation programmes in an outpatient setting, and outcome measurement tools used in patient care. Methodology A descriptive cross-sectional study using a survey questionnaire was performed. The authors of the 2011 report provided permission to use a modified version of their questionnaire for this survey. The modified questionnaire underwent content and face validation, and the final version of the questionnaire was captured on REDcap. Ethical clearance was obtained through the University of Witwatersrand Human Research Ethics (Medical) Committee before commencement of the survey (Clearance Certificate Number M220313). The link to the questionnaire was electronically distributed via the secretariate of the SASP to their physiotherapy members in South Africa. Responses from physiotherapists involved in rehabilitation of patients with CAD in the acute care or out-patient setting were included in analysis whereas responses received from physiotherapy students, assistants or technicians were excluded from analysis. Descriptive statistics were used to summarise the data as numbers and percentages (categorical data) and means and standard deviations (normally distributed continuous data) or median and interquartile ranges (non-normally distributed continuous data) and range (minimum and maximum). An inductive approach to coding was used to analyze the qualitative responses to the open-ended questions. Codes were identified and grouped into themes to build a comprehensive image of the collective responses of the participants. Questionnaires with more than 50% of incomplete responses were not included in the data analysis. iii Results Forty-six questionnaires were submitted to REDcap of which 37 were included in the final analysis. Results showed that most physiotherapists working in the hospital setting, in private practice (n=28, 76%) provided care to patients with CAD. Most physiotherapists working in a cardiopulmonary capacity had an average of 10 years of experience and were treating patients in the medical ICU (n=26, 70%) and surgical wards (n=26, 70%) post coronary artery bypass graft (CABG) surgery (n=21, 72%) and post myocardial infarction (MI) (n=21, 72%). Patients with CAD were mostly referred to physiotherapy by a specialist or surgeon in both the in-hospital and out-patient settings. In-hospital treatment was mostly provided twice daily (n=20, 67%). ACBT (n=25, 81%), DBE (n=23, 74%), incentive spirometry (n=21, 68%), manual techniques (n=22, 71%), circulatory exercises (n=25, 80%), graded mobilisation (n=26, 84%), and home exercise guidelines (n=23, 74%) were mostly used in the hospital setting. In the out-patient setting, strengthening exercises (n= 15, 50%), home exercise programmes consisting of specific exercises (n= 15, 50%), graded mobilisation (n=14, 47%), home exercises guidelines (n=12, 40%) and ACBT (n=12, 40%) were commonly used, however, many physiotherapists did not provide out-patient care to CAD patients (n=14, 47%). Of those who did provide out-patient care, (n=11) 38% reported providing this service once a week. Presence of secretions (n=23, 82%), incentive spirometry (n=18, 64%), VAS pain scale (n=17, 61%), and the 6MWT (n=17, 61%) were the most common outcome measurements used. The provision of phase three cardiac rehabilitation remains insufficient at (n=7, 23%), similar to the findings of the 2011 study. Conclusion Results of the present study were similar to that of the 2011 report. Treatment interventions such as breathing exercises and early mobilisation were in line with the literature. South African physiotherapists still mostly provide manual techniques as part of patient care. Phase two and three cardiac rehabilitation programmes are scarce despite a large population of CAD patients requiring rehabilitation. This study lays the foundation for further research in this field. Physiotherapy management of CAD patients in the public healthcare setting should be explored using the survey. Future research should include reporting on the clinical profiles of patients undergoing CABG surgery in South Africa, as well as the effect that physiotherapy has on their outcomes. Barriers and facilitators to physiotherapy provision of CAD patients should be explored.