Role of physiotherapy in cardiovascular disease prevention

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Cardiovascular diseases (CVDs) are a group of disorders of the heart and blood vessels and include coronary artery disease, cerebrovascular disease - disease of the blood vessels supplying the brain, peripheral arterial disease – disease of blood vessels supplying the arms and legs, rheumatic heart disease – damage to the heart muscle and heart valves from rheumatic fever, caused by streptococcal bacteria, congenital heart disease - malformations of heart structure existing at birth deep vein thrombosis and pulmonary embolism – blood clots in the leg veins, which can dislodge and move to the heart and lungs.

CVDs are the number one cause of death globally: more people die annually from CVDs than from any other cause. An estimated 17.1 million people died from CVDs in 2004, representing 29%of all global deaths. Of these deaths, an estimated 7.2 million were due to coronary heart disease and 5.7 million were due to stroke. Low- and middle-income countries are disproportionally affected: 82% of CVD deaths take place in low- and middle-income countries and occur almost equally in men and women. By 2030, almost 23.6 million people will die from CVDs, mainly from heart disease and stroke. These are projected to remain the single leading causes of death. The largest percentage increase will occur in the Eastern Mediterranean Region. The largest increase in number of deaths will occur in the South-East Asia Region (WHO, 2011).

The human toll and economic impact of CVD are difficult to overstate. In the United States alone, $403 billion was estimated to be spent in 2006 on health care or in lost productivity as a result of CVD, compared with $190 billion for cancer and $29 billion for human immunodeficiency virus (HIV) (Haase et al 2006). In developing countries, heart disease has historically affected the more educated and higher socioeconomic groups, but this is rapidly changing (McKay et al 2004).

The risk factors for CVD include -

  1. Non Modifiable – Increasing age (above 65), male gender, heredity (family history)
  2. Modifiable – smoking, high cholesterol, high blood pressure, physical inactivity, obesity or overweight, diabetes mellitus. In addition to these, stress can also play an important role in enhancing the other risk factors. For example, people under stress may overeat, start smoking or smoke more than they otherwise would.

Prevention of CVD is paramount to the health of every nation. Even modest control could have an enormous impact. It is projected that a reduction in the death rate due to chronic diseases by just 2% over 1 decade would prevent 36 million deaths (Strong et al 2005). Whilst the Government needs to take up the responsibility of population based interventions and control, interventions in individual patients are key to reducing the incidence of CVD globally. Since physiotherapists act as first contact practitioners in many countries, it is obligatory that they share greater responsibility in preventative care as in curative care.

Physiotherapists can play a major role in the primary prevention of CVD through lifestyle interventions, as numerous well-conducted prospective observational studies have demonstrated that the least active and unfit people are at the greatest risk of developing a variety of chronic diseases, such as heart disease, diabetes and obesity, and all-cause mortality. This increased risk occurs independent of ethnicity, income, education, or body size and shape, and there is a dose - response across a wide range of activity and fitness levels (Haskell et al 2009).

Evidence based guidelines all over the world suggest that adults should do at least 150 min a week of moderate-intensity, or 75 min a week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate and vigorous-intensity aerobic physical activity. Aerobic activity should be performed in episodes of at least 10 min, preferably spread throughout the week. Additional health benefits are provided by increasing to 300 min a week of moderate-intensity aerobic physical activity, or 2 h and 30 min a week of vigorous-intensity physical activity, or an equivalent combination of both. Adults should also do muscle strengthening activities that involve all major muscle groups performed on 2 or more days per week (Kesaniemi et al 2010). It is the responsibility of the physiotherapists to provide education and advice to public to maintain their health and prevent the development of chronic effects of deconditioning and CVD.

People should maintain or lose weight through an appropriate balance of physical activity, caloric intake, and formal behavioral programs when indicated to maintain/achieve a BMI between 18.5 and 24.9 kg/m.

Encourage an optimal blood pressure of  120/80 mm Hg through lifestyle approaches such as weight control, increased physical activity, alcohol moderation, sodium restriction, and increased consumption of fresh fruits, vegetables, and low-fat dairy products. People should be made aware of optimal blood pressure and need to constant monitoring in at risk groups.

As a secondary prevention strategy, a comprehensive risk-reduction regimen, such as cardiovascular or stroke rehabilitation or a physiotherapist-guided home- or community-based exercise training program, should be recommended to people with a recent acute coronary syndrome or coronary intervention, new-onset or chronic angina, recent cerebrovascular event, peripheral arterial disease, or current/prior symptoms of heart failure.

Thus for any patients presenting to physiotherapy clinics, a generalised evaluation of CVD risk can be undertaken during routine history taking through the medical/ family history. If it is suspected, then the patient should be referred to a general physician for a detailed examination. Or else, information leaflets can be provided to make people aware of the risk factors and how to curb the risk of developing CVD.

In addition clinics can conduct weekly group classes to make people aware of the CVD, associated risk factors and prevention strategies. This will enhance discussion and also help promote other PT services. Even the use of basic information leaflets in clinics which people can pick and read and then decide that if they are at risk, they can consult the physiotherapist for prevention strategies can work out well for both groups.

The prevention strategy can be marketed as a unique service, which will enhance the client base and reach of the clinical practice. Group classes have an added advantage of greater numbers with the same time span and thus help increasing revenue for the physiotherapists.

What do you think? Are you doing your bit in educating patients about CVDs and preventing them? Are you using any innovative means to engage with your patients on this topic, feel free to comment below. 

References

Haase et al. Heart disease and stroke statistics--2006 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2006;113(6):e85-151.

Haskell WL, Blair SN, Hill JO. Physical activity: health outcomes and importance for public health policy. Prev Med 2009;49(4):280-2.

J Mackay, G Mensah, Atlas of Heart Disease and Stroke.  2004 World Health Organization. Geneva

Kesaniemi A, Riddoch CJ, Reeder B, Blair SN, Sorensen TI. Advancing the future of physical activity guidelines in Canada: an independent expert panel interpretation of the evidence. Int J Behav Nutr Phys Act 2010;741

Strong K, Mathers C, Leeder S, Beaglehole R. Preventing chronic diseases: how many lives can we save? Lancet 2005;366:1578 – 82.



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