The purpose of this book is to introduce the concepts embedded in quality function
deployment (QFD) and Lean-Six Sigma to help Public Health professionals implement quality improvement within their agencies. The tools and techniques of QFD and Lean-Six Sigma are designed to augment a robust PDCA or PDSA problem-solving process, not replace it.
The tools and techniques of QFD and Lean-Six Sigma can help problemsolving teams by providing insight into customer needs and wants, design and development of customer-centric processes, and mapping value streams. Both QFD and Lean-Six Sigma focus on doing the most with the resources we have.
Each of these megatools supports efforts to expand our community support programs
and to increase the effectiveness of internal capacities. This dual external/ internal focus offers an excellent partnership of quality improvement tools for
Public Health.
The tools and techniques of QFD and Lean-Six Sigma can help a problemsolving team make breakthrough improvements by building in customer requirements early in the problem-solving process as well as setting the stage for future improvements. You will fi nd that the QFD process ensures that the voice of the customer (VOC) drives all activities associated with designing or redesigning a product or service for internal or external customers. Lean-Six Sigma uses the same VOC inputs to align every activity within the Public Health department (PHD) directly with stated needs of the community and its stakeholders. These two methodologies will help improve quality, costs, and timeliness of products and services, which in for-profi t businesses translates into increased profi tability.
In Public Health, having lower costs can mean more can be done with existing budget dollars.
The objectives of QFD and Lean-Six Sigma are as follows:
• Provide higher-quality products and services to customers.
• Achieve customer-driven design of these products and services by
converting user needs into design parameters.
• Provide documentation and tracking system for future design endeavors
• Develop delivery processes that are effi cient and effective
• Involve suppliers early in the process
• Require data-driven decision making and incorporate a comprehensive set of quality tools under a powerful framework for effective problemsolving
• Provide tools for analyzing process fl ow and delay times at each activity in a process
The early results of the use of QFD in the United States included a reduction in the cycle time for design work, a defi ning of quality early in the design stage, a decrease in quality problems during manufacturing, a way to objectively benchmark
against the competition on improvements, reduced warranty claims, and an improvement in cross-functional team work.
In this book we will modify the QFD process and Lean-Six Sigma methodology so they are aligned with the needs and differences in Public Health design and delivery of products and services. When we make modifi cations we will point this out so readers will understand the change from what might be seen in an industrial or healthcare application of the same concepts.
As the Public Health community expands its use of quality improvement (QI), there is often confusion about how all the tools, techniques, methodologies, models, and approaches fi t together.1 Available techniques include basic and advanced tools of quality improvement as well as several QI models including quality function deployment, Lean-Six Sigma, daily management, mobilizing for action through planning and partnerships (MAPP),2 turning point,3 Baldrige,4 and state quality award models. At times, these models are introduced as competing techniques and processes. The models are not tied together into a system by which they complement one another. This chapter provides an overview showing how various QI techniques and improvement models are related to one another and can be used in compatible ways. The Public Health community would benefit from an overall approach that completely integrates QI into its management practices. Continuous improvement is one component of an integrated system of performance management by which an organization meets and exceeds the needs and expectations of its multiple customer, client, and stakeholder communities.
Some of the ways in which performance management can positively influence a Public Health agency are:
• Better return on dollars invested in health
• Greater accountability for funding and increases in the public’s trust
• Reduced duplication of efforts
• Better understanding of Public Health accomplishments and priorities among employees, partners, and the public
• Increased sense of cooperation and teamwork
• Increased emphasis on quality, rather than quantity
• Improved problem solving5
Autores:The Public Health Quality Improvement Handbook,
by Ron Bialek, Grace L. Duffy, and John W. Moran
Pesquisar neste blogue
terça-feira, 1 de junho de 2010
5 whys and 5 hows
What It Is
•The five whys and five hows constitute a questioning process designed to drill down into the details of a problem or a solution and peel away the layers of symptoms.
•The technique was originally developed by Sakichi Toyoda. He states “that by repeating why five times, the nature of the problem as well as its solution becomes clear.”
•The five whys are used for drilling down into a problem and the five hows are used to develop the details of a solution to a problem.
•Both are designed to bring clarity and refinement to a problem statement or a potential solution and get to the root cause or root solution.
•Edward Hodnet, a British poet, observed, “If you don’t ask the right questions, you don’t get the right answers. A question asked in the right way often points to its own answer. Asking questions is the ABC of diagnosis. Only the inquiring mind solves problems.”
When to Use It
•When we want to push a team investigating a problem to delve into more details of the root causes, the five whys can be used with brainstorming or the cause-and-effect diagram.
•The five hows can be used with brainstorming and the solution-and-effect diagram to develop more details of a solution to a problem under consideration.
•Both methods are techniques to expand the horizon of a team searching for answers. These two techniques force a team to develop a better and more detailed understanding of a problem or solution.
How to Use It
•Draw a box at the top of a piece of flip chart paper and clearly write down the problem or solution to be explored.
•Below the statement box draw five lines in descending order.
•Ask the “Why” or “How” question five times and write the answers on the lines drawn from number one to five.
•It may take less or more than five times to reach the root cause or solution.
Examples of five whys and five hows are below.
Five whys of less vigorous exercise:
Too much TV and video games
Why?
Few community-sponsored recreation programs
Why?
No family recreational activities
Why?
No safe play area
Why?
Lack of resources
Why?
Five hows of more vigorous exercise:
Less TV and video games
How?
More community-sponsored recreation programs
How?
More family recreational activities
How?
Safe play areas
How?
Additional resources
How?
Excerpted from Ron Bialek, Grace L. Duffy, and John W. Moran, The Public Health Quality Improvement Handbook (Milwaukee, WI: ASQ Quality Press, 2009), pages 168–170.
•The five whys and five hows constitute a questioning process designed to drill down into the details of a problem or a solution and peel away the layers of symptoms.
•The technique was originally developed by Sakichi Toyoda. He states “that by repeating why five times, the nature of the problem as well as its solution becomes clear.”
•The five whys are used for drilling down into a problem and the five hows are used to develop the details of a solution to a problem.
•Both are designed to bring clarity and refinement to a problem statement or a potential solution and get to the root cause or root solution.
•Edward Hodnet, a British poet, observed, “If you don’t ask the right questions, you don’t get the right answers. A question asked in the right way often points to its own answer. Asking questions is the ABC of diagnosis. Only the inquiring mind solves problems.”
When to Use It
•When we want to push a team investigating a problem to delve into more details of the root causes, the five whys can be used with brainstorming or the cause-and-effect diagram.
•The five hows can be used with brainstorming and the solution-and-effect diagram to develop more details of a solution to a problem under consideration.
•Both methods are techniques to expand the horizon of a team searching for answers. These two techniques force a team to develop a better and more detailed understanding of a problem or solution.
How to Use It
•Draw a box at the top of a piece of flip chart paper and clearly write down the problem or solution to be explored.
•Below the statement box draw five lines in descending order.
•Ask the “Why” or “How” question five times and write the answers on the lines drawn from number one to five.
•It may take less or more than five times to reach the root cause or solution.
Examples of five whys and five hows are below.
Five whys of less vigorous exercise:
Too much TV and video games
Why?
Few community-sponsored recreation programs
Why?
No family recreational activities
Why?
No safe play area
Why?
Lack of resources
Why?
Five hows of more vigorous exercise:
Less TV and video games
How?
More community-sponsored recreation programs
How?
More family recreational activities
How?
Safe play areas
How?
Additional resources
How?
Excerpted from Ron Bialek, Grace L. Duffy, and John W. Moran, The Public Health Quality Improvement Handbook (Milwaukee, WI: ASQ Quality Press, 2009), pages 168–170.
6 steps for implement lean
This practical, how-to book clearly and succinctly takes the reader through six proven “success steps” for implementing lean in any healthcare environment:
1. Create physician flow
2. Support physician value-added time
3. Visually communicate patient status
4. Standardize everyone’s work
5. Lay out the clinic for minimal motion
6. Change the care delivery model
Why go through such a transformation? Because it works. Tell a doctor that he can see the same number of patients, offering the same high quality and personal care, and have an extra 90 minutes at the end of his clinic day – and that means something. Tell the staff that they can look forward to actually ending on time, with satisfied patients, no backlog, and having focused their attention completely on quality patient care – and they will listen.
These Lean principles and success steps work in clinics ranging from orthopedics to neurology to cardiac care—the specialty doesn’t matter. They work in small practices and large hospital settings. Lean methodology provides the tools to address the frustrations patients and doctors alike experience in the clinic process.
Included throughout the book is a case study showing the lean transformation undertaken at the Orthopedic Center at Children’s Hospital of Wisconsin, with numerous quotes and insights from those actually involved. This transformation resulted in patient wait times being reduced by more than 70 percent, the clinic being able to see 25 percent more patients in less space, patient satisfaction scores sometimes reaching 100 percent, and staff satisfaction scores improving by more than 25 percent.
1. Create physician flow: This centers on the idea of the physician as a “shared resource”—a pacemaker in the process—who should never have down time due to missing information or lack of clear priorities. Everything except the physician’s consultation with the patient is essentially changeover and should be done as
efficiently as possible to set the doctor up for the best possible patient interaction.
2. Support physician value-added time: In order for the physician to maintain a state of flow and not experience undue downtime, she needs a high level of coordination of clinic processes. This step calls for the creation of a team leader position, whose primary responsibility is to make sure the doctor’s time is used effectively.
The team leader is usually a nurse who has leadership potential; the duties include tracking the status of each patient and “driving the bus” to direct the clinic.
3. Visually communicate patient status: Visual communication is the Lean concept of using visible markers, signals, and signs to communicate the status of a given process so that anyone walking into the work
environment can tell what’s in process, what’s working, and where the problems are. With this step, I describe a seemingly simple, powerful tool in the clinic setting: the Patient Status Whiteboard.
4. Standardize everyone’s work: Standard work is a tool of Lean that provides process stability and a mechanism for formal process improvement. In this step the care team creates standard work for their processes to find immediate improvement opportunities, achieve predictable outcomes, and clarify their roles in the care process. Creating standard work also formalizes changes made so far and helps the Lean system become an integral part of the practice’s culture.
5. Lay out the clinic for minimal motion: This step focuses on examining how to change the physical layout of a clinic or other healthcare environment to improve patient flow and staff communication. It uses the tools of spaghetti mapping and 5S to look at individual workstations, and discusses the flow of care and communication throughout the clinic. Some of the Lean improvements discussed here are simple ones: creating supply and material carts, moving commonly used forms and supplies inside the exam rooms, organizing paperwork at the front desk, and establishing “pull” by creating a kanban card system. Architectural improvements, such as U-shaped cell designs, help develop an enhanced team space to improve patient safety, staff communication, and patient handoffs.
6. Change the care delivery model: This means rethinking the clinic processes to focus relentlessly on patient flow. The idea of focusing on flow is central to Lean, because organizing work in departments simply does not work. Support departments—such as radiology, casting, physical therapy, labs, echo, and pharmacy—should be rethought and broken into decentralized mini-departments, where feasible. The previous steps—managing the physician’s time, visually controlling patient status, standardizing the individual tasks in the care process—lay a stable foundation so that larger process changes do not create chaos.
Autores: Aneesh Suneja with Carolyn Suneja
Lean Doctors A Bold and Practical Guide to Using Lean Principles to Transform Healthcare Systems,One Doctor at a Time , ASQ Quality Press Milwaukee, Wisconsin
1. Create physician flow
2. Support physician value-added time
3. Visually communicate patient status
4. Standardize everyone’s work
5. Lay out the clinic for minimal motion
6. Change the care delivery model
Why go through such a transformation? Because it works. Tell a doctor that he can see the same number of patients, offering the same high quality and personal care, and have an extra 90 minutes at the end of his clinic day – and that means something. Tell the staff that they can look forward to actually ending on time, with satisfied patients, no backlog, and having focused their attention completely on quality patient care – and they will listen.
These Lean principles and success steps work in clinics ranging from orthopedics to neurology to cardiac care—the specialty doesn’t matter. They work in small practices and large hospital settings. Lean methodology provides the tools to address the frustrations patients and doctors alike experience in the clinic process.
Included throughout the book is a case study showing the lean transformation undertaken at the Orthopedic Center at Children’s Hospital of Wisconsin, with numerous quotes and insights from those actually involved. This transformation resulted in patient wait times being reduced by more than 70 percent, the clinic being able to see 25 percent more patients in less space, patient satisfaction scores sometimes reaching 100 percent, and staff satisfaction scores improving by more than 25 percent.
1. Create physician flow: This centers on the idea of the physician as a “shared resource”—a pacemaker in the process—who should never have down time due to missing information or lack of clear priorities. Everything except the physician’s consultation with the patient is essentially changeover and should be done as
efficiently as possible to set the doctor up for the best possible patient interaction.
2. Support physician value-added time: In order for the physician to maintain a state of flow and not experience undue downtime, she needs a high level of coordination of clinic processes. This step calls for the creation of a team leader position, whose primary responsibility is to make sure the doctor’s time is used effectively.
The team leader is usually a nurse who has leadership potential; the duties include tracking the status of each patient and “driving the bus” to direct the clinic.
3. Visually communicate patient status: Visual communication is the Lean concept of using visible markers, signals, and signs to communicate the status of a given process so that anyone walking into the work
environment can tell what’s in process, what’s working, and where the problems are. With this step, I describe a seemingly simple, powerful tool in the clinic setting: the Patient Status Whiteboard.
4. Standardize everyone’s work: Standard work is a tool of Lean that provides process stability and a mechanism for formal process improvement. In this step the care team creates standard work for their processes to find immediate improvement opportunities, achieve predictable outcomes, and clarify their roles in the care process. Creating standard work also formalizes changes made so far and helps the Lean system become an integral part of the practice’s culture.
5. Lay out the clinic for minimal motion: This step focuses on examining how to change the physical layout of a clinic or other healthcare environment to improve patient flow and staff communication. It uses the tools of spaghetti mapping and 5S to look at individual workstations, and discusses the flow of care and communication throughout the clinic. Some of the Lean improvements discussed here are simple ones: creating supply and material carts, moving commonly used forms and supplies inside the exam rooms, organizing paperwork at the front desk, and establishing “pull” by creating a kanban card system. Architectural improvements, such as U-shaped cell designs, help develop an enhanced team space to improve patient safety, staff communication, and patient handoffs.
6. Change the care delivery model: This means rethinking the clinic processes to focus relentlessly on patient flow. The idea of focusing on flow is central to Lean, because organizing work in departments simply does not work. Support departments—such as radiology, casting, physical therapy, labs, echo, and pharmacy—should be rethought and broken into decentralized mini-departments, where feasible. The previous steps—managing the physician’s time, visually controlling patient status, standardizing the individual tasks in the care process—lay a stable foundation so that larger process changes do not create chaos.
Autores: Aneesh Suneja with Carolyn Suneja
Lean Doctors A Bold and Practical Guide to Using Lean Principles to Transform Healthcare Systems,One Doctor at a Time , ASQ Quality Press Milwaukee, Wisconsin
sábado, 22 de maio de 2010
Entorse da tíbio-társica
As entorses do tornozelo estão entre as lesões musculoesqueléticas mais comuns. A entorse da tíbio-társica resulta do estiramento/rotura de ligamentos, devido a uma distensão excessiva por torção do pé (Prentice & Voight, 2003).
Uma das lesões mais frequentes da região do tornozelo é a entorse que ocorre durante a inversão.
Visto que a cápsula articular e os ligamentos são mais fortes na face medial da tíbio-társica, a entorse por inversão envolvem estiramento ou ruptura dos ligamentos laterais são muito mais comuns que as entorses por eversão dos ligamentos mediais, que também são protegidos pelo maléolo lateral (Gubiani, 2003).
Grau I
Dor e moderada a forte, presença de edema;
Rigidez articular.
Grau III
Ruptura total do ligamento;
Grande instabilidade;
Inicialmente, presença de dor forte, seguida de pouca ou nenhuma dor em virtude da ruptura total das fibras nervosas.
Presença de edema bastante demarcada, tornando a articulação muito rígida.
Requer imobilização da articulação
Cirurgia - Rupturas Completas
Geralmente nas rupturas completas, o ligamento lateral do tornozelo é reparado cirurgicamente. Contudo, conforme Kisner e Colby (1998), a cirurgia pode também ser indicada nos casos de grande instabilidade do tornozelo, sendo que os procedimentos cirúrgicos podem ser realizados com a re-oposição e sutura do ligamento destruído, ou através da substituição deste por uma porção do tendão do fibular curto.
Hurwitz, Ernst e Hy (citado por Gubiani, 2003), descrevem que a reconstrução dos ligamentos laterais do tornozelo pode ser realizada através de dois tipos básicos: anatómica e não-anatómica. A reconstrução anatómica repara as lesões crónicas no ligamento do tornozelo mediante restauração directa dos ligamentos, anos após a lesão. Os procedimentos não-anatómicos envolvem a contribuição do tendão curto peroneal. A técnica requer um enxerto do curto peroneal, com espessura total direccionando-o através do peróneo para substituir o ligamento talofibular anterior, mas não substitui anatomicamente o ligamento calcaneofibular (Hurwitz; Ernst; Hy, citado Por Gubiani, 2003).
Kisner e Colby (1998) relatam que um bom resultado pós-operatório promove estabilidade lateral à articulação do tornozelo, mas pode ocorrer uma leve perda da inversão de aproximadamente 10 graus.
A técnica artroscópica para actuação cirúrgica no tornozelo é relativamente nova e veio acrescentar uma opção de tratamento das lesões dessa articulação (Souza, 1997).
A cirurgia artroscópica para o tornozelo veio permitir visão directa de toda a articulação e das suas estruturas intra-articulares, aumentando a capacidade diagnóstica e simplificando a execução das técnicas para correcções cirúrgicas. A baixa morbidade e a rápida recuperação dos pacientes foram factores que definitivamente vieram privilegiar a indicação da técnica artroscópica em contraposição à cirurgia aberta (Souza, 1997).
Hoje, a artroscopia cirúrgica do tornozelo é largamente aceita como procedimento para diagnóstico e como modalidade válida e efectiva no tratamento de várias lesões intra-articulares nessa articulação. As principais indicações para a cirurgia artroscópica do tornozelo são (Souza, 1997):
• Avaliação de sintomas em um tornozelo pós-traumático sem diagnóstico preciso;
• Retirada de corpos livres articulares ou calcificações, quer de origem traumática ou em decorrência de doença articular;
• Recessões de fragmentos em fracturas osteocondrais nos estágios II, III, e IV, seguidas de perfurações ou abrasão nas áreas cruentas;
• Recessões de osteófitos, exostoses e calcificações decorrentes de doença degenerativa do tornozelo ou associados com condições pós-traumáticas;
• Outras indicações que ainda não foram bem avaliadas a longo prazo, como: cirurgias para reconstrução de instabilidade crónica lateral do tornozelo e cirurgias de erosão na doença degenerativa grave.
Reabilitação
Os principais objectivos na fase inicial da reabilitação do tornozelo são reduzir o edema, a hemorragia e a dor, além de proteger o ligamento já em recuperação. Em todas as lesões musculoesqueléticas agudas, os esforços do tratamento inicial, devem ser direccionados para diminuir o edema. O controlo do edema inicial é a medida mais importante a ser adoptada durante todo o processo de reabilitação. Este controlo, inclui gelo, compressão, elevação, repouso e protecção (PRICE). (Prentice & Voight, 2003)
O ligamento lesado deve ser mantido em posição estável para que a recuperação possa ocorrer. Assim sendo, durante o período de protecção máxima, que se segue à lesão, o paciente deve permanecer sem sustentar o peso ou, apoiá-lo parcialmente, usando as canadianas. Este tipo de apoio parcial ajuda a controlar várias complicações que podem surgir durante a recuperação. (Prentice & Voight, 2003)
A atrofia muscular, a perda proprioceptiva, a estase circulatória e o aparecimento de contracturas nos tendões são minimizadas quando o apoio da carga é limitado uniformemente (Prentice & Voight, 2003)
À medida que o edema é controlado e a dor diminui, indica que os ligamentos estão suficientemente recuperados para tolerar carga (se bem que limitada) e que a reabilitação pode tornar-se mais agressiva (Prentice & Voight, 2003).
Bibliografia
ALMEIDA, L. - Estudo comparativo das técnicas de manipulação osteopática e mobilização no tratamento do entorse crônico de tornozelo em inversão. Trabalho de obtenção de bacharel em Fisioterapia da Faculdade Assis Gurgacz, 2005.
ANDREWS, M. et al – Reabilitação Física das Lesões Desportivas. 2ªedição. Editora Guanabara Koogan: Brasil, 2000;
CAILLET, R. – Dor no Pé e no Tornozelo – 3ª Edição. Editora Artmed: Porto Alegre, 2005
GUBIANI, M. - Estudo comparativo das técnicas de manipulação osteopática e mobilização oscilatória no tratamento da entorse de tornozelo em inversão. Trabalho de Conclusão de Curso de Fisioterapia da Universidade Estadual do Oeste do Paraná, 2004.
KISNER, C.; COLBY, L. – Exercícios Terapêuticos: Fundamentos e Técnicas. 3ª Edição. Editora Manole: São Paulo, 2003;
KOTTKE, F. e LEHMANN, J. – Tratado de Medicina Física e Reabilitação de Krusen. 4ª Edição, Volume 2, Editora Manole: São Paulo, 1994;
LINCOLN, N. e EDMANS, J. - A shortened version of the Rivermead Perceptual Assessment Battery. Clinical Rehabilitation, Volume 3, 1989;
SOUZA, J. - Cirurgia artroscópica do tornozelo. Revista Brasileira Ortopedia, Vol. 32, Nº 4, 1997.
Uma das lesões mais frequentes da região do tornozelo é a entorse que ocorre durante a inversão.
Visto que a cápsula articular e os ligamentos são mais fortes na face medial da tíbio-társica, a entorse por inversão envolvem estiramento ou ruptura dos ligamentos laterais são muito mais comuns que as entorses por eversão dos ligamentos mediais, que também são protegidos pelo maléolo lateral (Gubiani, 2003).
Como já foi referido, a entorse por inversão é a lesão mais comum, e quase sempre resulta numa lesão dos ligamentos laterais, sendo o ligamento perónio – astragalino anterior o mais frequentemente lesado, de entre os três feixes. A lesão ocorre em situações de inversão, flexão plantar e rotação interna. Os ligamentos perónio – calcaneano e perónio – astragalino posterior também tendem a sofrer entorses por inversão à medida que a força aumenta. (Prentice & Voight, 2003).
Os sinais e sintomas das lesões ligamentares do tornozelo variam de acordo com o mecanismo da lesão, com a gravidade, os tecidos acometidos e a extensão do seu acometimento. No geral, são evidentes diferentes graus de dor, tumefacção, hipersensibilidade localizada e incapacidade funcional (Andrews & Harreison & Wilk, 2000). 
Após um traumatismo por inversão ou por eversão, os exames radiográficos da articulação e da estrutura óssea são de grande importância. As lesões ósseas devem ser excluídas antes de poder serem tomadas decisões acerca do tratamento apropriado para a lesão (Andrews & Harreison & Wilk, 2000).
Tabela - Diferentes graus de gravidade da entorse (Andrews & Harreison & Wilk, 2000)
Estiramento das fibras ligamentares;
Pouca ou nenhuma instabilidade;
Dor leve e ligeiro edema;
Rigidez articular.
Grau II
Ruptura e separação das fibras ligamentares;
Instabilidade moderada;Dor e moderada a forte, presença de edema;
Rigidez articular.
Grau III
Ruptura total do ligamento;
Grande instabilidade;
Inicialmente, presença de dor forte, seguida de pouca ou nenhuma dor em virtude da ruptura total das fibras nervosas.
Presença de edema bastante demarcada, tornando a articulação muito rígida.
Requer imobilização da articulação
Cirurgia - Rupturas Completas
Geralmente nas rupturas completas, o ligamento lateral do tornozelo é reparado cirurgicamente. Contudo, conforme Kisner e Colby (1998), a cirurgia pode também ser indicada nos casos de grande instabilidade do tornozelo, sendo que os procedimentos cirúrgicos podem ser realizados com a re-oposição e sutura do ligamento destruído, ou através da substituição deste por uma porção do tendão do fibular curto.
Hurwitz, Ernst e Hy (citado por Gubiani, 2003), descrevem que a reconstrução dos ligamentos laterais do tornozelo pode ser realizada através de dois tipos básicos: anatómica e não-anatómica. A reconstrução anatómica repara as lesões crónicas no ligamento do tornozelo mediante restauração directa dos ligamentos, anos após a lesão. Os procedimentos não-anatómicos envolvem a contribuição do tendão curto peroneal. A técnica requer um enxerto do curto peroneal, com espessura total direccionando-o através do peróneo para substituir o ligamento talofibular anterior, mas não substitui anatomicamente o ligamento calcaneofibular (Hurwitz; Ernst; Hy, citado Por Gubiani, 2003).
Kisner e Colby (1998) relatam que um bom resultado pós-operatório promove estabilidade lateral à articulação do tornozelo, mas pode ocorrer uma leve perda da inversão de aproximadamente 10 graus.
A técnica artroscópica para actuação cirúrgica no tornozelo é relativamente nova e veio acrescentar uma opção de tratamento das lesões dessa articulação (Souza, 1997).
A cirurgia artroscópica para o tornozelo veio permitir visão directa de toda a articulação e das suas estruturas intra-articulares, aumentando a capacidade diagnóstica e simplificando a execução das técnicas para correcções cirúrgicas. A baixa morbidade e a rápida recuperação dos pacientes foram factores que definitivamente vieram privilegiar a indicação da técnica artroscópica em contraposição à cirurgia aberta (Souza, 1997).
Hoje, a artroscopia cirúrgica do tornozelo é largamente aceita como procedimento para diagnóstico e como modalidade válida e efectiva no tratamento de várias lesões intra-articulares nessa articulação. As principais indicações para a cirurgia artroscópica do tornozelo são (Souza, 1997):
• Avaliação de sintomas em um tornozelo pós-traumático sem diagnóstico preciso;
• Retirada de corpos livres articulares ou calcificações, quer de origem traumática ou em decorrência de doença articular;
• Recessões de fragmentos em fracturas osteocondrais nos estágios II, III, e IV, seguidas de perfurações ou abrasão nas áreas cruentas;
• Recessões de osteófitos, exostoses e calcificações decorrentes de doença degenerativa do tornozelo ou associados com condições pós-traumáticas;
• Outras indicações que ainda não foram bem avaliadas a longo prazo, como: cirurgias para reconstrução de instabilidade crónica lateral do tornozelo e cirurgias de erosão na doença degenerativa grave.
Reabilitação
Os principais objectivos na fase inicial da reabilitação do tornozelo são reduzir o edema, a hemorragia e a dor, além de proteger o ligamento já em recuperação. Em todas as lesões musculoesqueléticas agudas, os esforços do tratamento inicial, devem ser direccionados para diminuir o edema. O controlo do edema inicial é a medida mais importante a ser adoptada durante todo o processo de reabilitação. Este controlo, inclui gelo, compressão, elevação, repouso e protecção (PRICE). (Prentice & Voight, 2003)
O ligamento lesado deve ser mantido em posição estável para que a recuperação possa ocorrer. Assim sendo, durante o período de protecção máxima, que se segue à lesão, o paciente deve permanecer sem sustentar o peso ou, apoiá-lo parcialmente, usando as canadianas. Este tipo de apoio parcial ajuda a controlar várias complicações que podem surgir durante a recuperação. (Prentice & Voight, 2003)
A atrofia muscular, a perda proprioceptiva, a estase circulatória e o aparecimento de contracturas nos tendões são minimizadas quando o apoio da carga é limitado uniformemente (Prentice & Voight, 2003)
À medida que o edema é controlado e a dor diminui, indica que os ligamentos estão suficientemente recuperados para tolerar carga (se bem que limitada) e que a reabilitação pode tornar-se mais agressiva (Prentice & Voight, 2003).
Bibliografia
ALMEIDA, L. - Estudo comparativo das técnicas de manipulação osteopática e mobilização no tratamento do entorse crônico de tornozelo em inversão. Trabalho de obtenção de bacharel em Fisioterapia da Faculdade Assis Gurgacz, 2005.
ANDREWS, M. et al – Reabilitação Física das Lesões Desportivas. 2ªedição. Editora Guanabara Koogan: Brasil, 2000;
CAILLET, R. – Dor no Pé e no Tornozelo – 3ª Edição. Editora Artmed: Porto Alegre, 2005
GUBIANI, M. - Estudo comparativo das técnicas de manipulação osteopática e mobilização oscilatória no tratamento da entorse de tornozelo em inversão. Trabalho de Conclusão de Curso de Fisioterapia da Universidade Estadual do Oeste do Paraná, 2004.
KISNER, C.; COLBY, L. – Exercícios Terapêuticos: Fundamentos e Técnicas. 3ª Edição. Editora Manole: São Paulo, 2003;
KOTTKE, F. e LEHMANN, J. – Tratado de Medicina Física e Reabilitação de Krusen. 4ª Edição, Volume 2, Editora Manole: São Paulo, 1994;
LINCOLN, N. e EDMANS, J. - A shortened version of the Rivermead Perceptual Assessment Battery. Clinical Rehabilitation, Volume 3, 1989;
SOUZA, J. - Cirurgia artroscópica do tornozelo. Revista Brasileira Ortopedia, Vol. 32, Nº 4, 1997.
Ressecção da extremidade superior do fémur – Girdlestone
A artroplastia de Girdlestone foi realizada e documentada, pela primeira vez, por Schmalz (1817) e White (1821) para tratar crianças com tuberculose da articulação coxofemoral. Em 1928, Girdlestone descreveu resumidamente este procedimento utilizando-o para o tratamento da tuberculose da pélvs e mais tarde, em 1943, Girdlestone difundiu esta técnica mundialmente como uma solução para o tratamento das patologias sépticas e tuberculosas da pélvis. Em 1960, com o desenvolvimento da artroplastia de substituição do quadril, as artroplastias de recessão caíram em desuso. Actualmente, a artroplastia de recessão de Girdlestone (ARG) é utilizada como uma cirurgia alternativa para a falha e/ou infecção da prótese total da anca (PTA), sepsia grave da anca e falhas cirúrgicas prévias, sem condições ósseas para a realização de um procedimento cirúrgico que preserve a anatomia funcional articular. Hoje em dia, o termo Girdlestone é aplicado à condição em que se encontram os pacientes que removeram a prótese (YAMAMATO, et al, 2006).
O material protésico (cabeça femural metálica e cúpula acetabular plástica) é retirado e o espaço vazio será ocupado por tecido fibroso cicatricial. A articulação permanece muito instável, obrigando o paciente a utilizar canadianas durante a marcha, contudo, como contrapartida, existe grande mobilidade, facilitando o sentar, o sair de viaturas e mesmo baixar-se. Nestas circunstâncias, a própria condição é quase indolor. Caso ocorra rigidez, há maior estabilidade, mas também dor, e por vzes incapacitante (SERRA, 2001).
O principal objectivo desta técnica consiste em minimizar a recidiva de infecção e o alívio da dor, assim como, melhorar a função do paciente, e promover satisfação (FERRE, 2007).
No entanto, alguns autores afirmam que a cirurgia de Girdlestone é uma técnica funcionalmente pobre, pois altera o estilo de vida do paciente, leva a alterações posturais, à fadiga precoce proveniente do alto consumo de energia para a marcha, a instabilidade articular pós-operatória, o distúrbio da marcha com presença do sinal de Trendelemburg, a necessidade de suporte externo para locomoção e o encurtamento do membro afectado, constituindo uma séria desvantagem cirúrgica (YAMAMATO, et al, 2006).
Na universidade da Flórida, 21 pacientes foram submetidos a ARG após o diagnóstico de PTA infectada e foram reavaliados depois do procedimento. Os resultados destes pacientes sugeriram que a artroplastia de recessão pós PTA infectada provê piores resultados funcionais. De Laat concluiu que a artroplastia de acordo com Girdlestone, em alguns casos, constitui a única solução para garantir uma boa qualidade de vida para pacientes com patologias na articulação do quadril, porém, McElwaine e Colville afirmam que uma das grandes desvantagens deste procedimento é a alteração no estilo de vida desses pacientes (YAMAMATO, et al, 2006).
Bibliografia
FERRE, J. Estudio experimental de la cicatrización en la artroplastia de resección de la cadera. Tese para título de Doutoramento em Medicina e Cirúrgia, da Universidade de Barcelona, 2007.
O’SULLIVAN, S. e SCHIMITZ, T. – Fisioterapia: Avaliação e Tratamento. 2ª Edição. Editora Manole: São Paulo, 1993;
PALMER, M. e EPLER M. – Fundamentos das Técnicas de Avaliação Musculo Esquelética. 2ª Edição. Guanabara – Koogan: Rio de Janeiro, 1992;
YAMAMATO, et al. Avaliação da função e qualidade de vida em pacientes submetidos à artroplastia de resseção tipo Girdlestone. Acta Ortopédica Brasileira, 15 (4:214-217, 2007).
O material protésico (cabeça femural metálica e cúpula acetabular plástica) é retirado e o espaço vazio será ocupado por tecido fibroso cicatricial. A articulação permanece muito instável, obrigando o paciente a utilizar canadianas durante a marcha, contudo, como contrapartida, existe grande mobilidade, facilitando o sentar, o sair de viaturas e mesmo baixar-se. Nestas circunstâncias, a própria condição é quase indolor. Caso ocorra rigidez, há maior estabilidade, mas também dor, e por vzes incapacitante (SERRA, 2001).
O principal objectivo desta técnica consiste em minimizar a recidiva de infecção e o alívio da dor, assim como, melhorar a função do paciente, e promover satisfação (FERRE, 2007).
No entanto, alguns autores afirmam que a cirurgia de Girdlestone é uma técnica funcionalmente pobre, pois altera o estilo de vida do paciente, leva a alterações posturais, à fadiga precoce proveniente do alto consumo de energia para a marcha, a instabilidade articular pós-operatória, o distúrbio da marcha com presença do sinal de Trendelemburg, a necessidade de suporte externo para locomoção e o encurtamento do membro afectado, constituindo uma séria desvantagem cirúrgica (YAMAMATO, et al, 2006).
Na universidade da Flórida, 21 pacientes foram submetidos a ARG após o diagnóstico de PTA infectada e foram reavaliados depois do procedimento. Os resultados destes pacientes sugeriram que a artroplastia de recessão pós PTA infectada provê piores resultados funcionais. De Laat concluiu que a artroplastia de acordo com Girdlestone, em alguns casos, constitui a única solução para garantir uma boa qualidade de vida para pacientes com patologias na articulação do quadril, porém, McElwaine e Colville afirmam que uma das grandes desvantagens deste procedimento é a alteração no estilo de vida desses pacientes (YAMAMATO, et al, 2006).
Bibliografia
FERRE, J. Estudio experimental de la cicatrización en la artroplastia de resección de la cadera. Tese para título de Doutoramento em Medicina e Cirúrgia, da Universidade de Barcelona, 2007.
O’SULLIVAN, S. e SCHIMITZ, T. – Fisioterapia: Avaliação e Tratamento. 2ª Edição. Editora Manole: São Paulo, 1993;
PALMER, M. e EPLER M. – Fundamentos das Técnicas de Avaliação Musculo Esquelética. 2ª Edição. Guanabara – Koogan: Rio de Janeiro, 1992;
YAMAMATO, et al. Avaliação da função e qualidade de vida em pacientes submetidos à artroplastia de resseção tipo Girdlestone. Acta Ortopédica Brasileira, 15 (4:214-217, 2007).
terça-feira, 18 de maio de 2010
Guidelines for cardic rehabilitation
Cardiovascular disease remains the leading cause of death in Australia. In 1995, it
accounted for 46% of all deaths, with 24% being attributed to coronary heart disease.
However, while age-adjusted certified deaths from coronary heart disease are falling,
increasing numbers of patients are being discharged alive from hospitals after acute
cardiac events and interventions. These patients constitute the major pool of those
eligible to attend cardiac rehabilitation and secondary prevention programs.
Cardiac rehabilitation programs were originally introduced to facilitate recovery from acute cardiac events. In both the USA and Australia, work classification or cardiac rehabilitation units were set up in the 1950’s and 1960’s to encourage return to work among those with physical or psychological disabilities. In Australia, hospital-based programs were established in the mid 1970’s. Since that time, many programs have been established in metropolitan and rural hospitals throughout Australia, and more recently, in community settings. Australia now has a large network of programs, particularly in Victoria.
As well as facilitating recovery, cardiac rehabilitation programs function as launching pads for secondary prevention of cardiovascular disease. Education, counselling and behavioural interventions to promote lifestyle change and modify risk factors have become an increasingly important part of cardiac rehabilitation programs.
In 1993, the National Heart Foundation of Australia produced a document to establish
minimal standards for cardiac rehabilitation to guide health care providers and policy makers. The purpose of these new Best Practice Guidelines is to provide optimal standards for cardiac rehabilitation and secondary prevention programs, particularly those conducted during convalescence. The recommendations contained within these Guidelines apply to cardiac rehabilitation programs not only in Victoria, but also elsewhere in Australia and in other countries.
The Guidelines examine evidence for the effectiveness of exercise training, education, counselling and behavioural interventions upon physical, psychological, social, occupational and behavioural outcomes, risk factors, morbidity and mortality.
Recommendations for best practice are based upon a comprehensive review of the
scientific literature. However, where scientific evidence from clinical trials and
observational studies is lacking, recommendations are based upon expert opinion and
consensus statements derived from surveys and focus groups with practitioners in the
field.
These Best Practice Guidelines do not duplicate the contents of the Clinical Practice
Guideline of the US Agency for Health Care Policy and Research (AHCPR), which
was published in 1995. Whereas the major part of that document deals with evidence
concerning exercise training, these Best Practice Guidelines focus equally on
education, counselling and behavioural interventions, as well as other aspects of
cardiac rehabilitation which were not extensively addressed in the AHCPR Clinical
Practice Guideline. Reference is also made to the findings of studies published since
the production of the AHCPR Clinical Practice Guideline.
Exercise Training
There has been extensive research into the benefits of exercise training in patients
with cardiovascular disease, particularly after acute cardiac events. Physical and
functional outcome measures have been well defined and it is clear that exercise
training produces definite physical, quality of life and secondary prevention benefits.
Available evidence confirms that exercise training produces definite improvements in
physical performance (exercise tolerance, muscular strength and symptoms),
psychological functioning (anxiety, depression, well-being), and social adaptation and functioning. Further, exercise training produces a demonstrable reduction in
mortality, morbidity, recurrent events and hospital readmissions.
In general, psychosocial outcomes have been less well studied than physical and
functional effects of exercise training. Conclusions concerning psychosocial benefits, widely claimed by patients and endorsed by practitioners, have been much less well documented scientifically. It is likely that many of the psychosocial benefits of exercise training are attributable to group activities, peer support and access to professional advice rather than to the exercise itself.
It is probable that exercise training has a favourable impact upon other outcomes,
including modification of risk factors. These benefits are mostly apparent when
exercise is provided as part of a comprehensive program including education,
counselling, behavioural interventions and support. Further, evidence indicates that
for such beneficial lifestyle changes to be sustained, continued physical activity and support are required.
Studies have now confirmed that high intensity and low intensity exercise programs
produce similar benefits. Nevertheless, some patients may prefer high intensity
exercise. Those returning to heavy manual jobs may benefit from more intensive
exercise training. For the majority of patients, however, low intensity exercise is
sufficient. Further, low intensity exercise has some important practical advantages. It is more suitable for a broader population, including older men and women and
patients with functional impairments, and it is more likely to be sustained in the
longer term. Because low intensity programs do not require such careful supervision
and use less technology and equipment, they can be conducted at low cost. Clinical
rather than technological methods can be used for risk stratification, assessment and
monitoring, with considerable cost savings. Exercise conducted in groups also
significantly reduces costs.
Further research is needed to determine best practice with regard to the frequency of
exercise sessions and the duration of exercise programs. On the basis of both evidence and expert opinion, it is apparent that twice weekly group exercise programs are as effective as thrice weekly. While twice weekly group exercise is recommended, there is some evidence that once weekly supervised group exercise may achieve similar benefits to twice weekly group exercise, provided it is accompanied by an additional daily home walking program.
There is no scientific evidence to indicate the preferred duration of exercise cardiac rehabilitation programs. On the basis of expert opinion, most of the aims of
ambulatory cardiac rehabilitation programs conducted during convalescence should be achieved with a twice weekly program lasting four to eight weeks.
It should be emphasised that individual patients vary considerably in their need for a group exercise program. Thus, it is essential to provide flexible programs to meet
particular needs.
Recommendations
Exercise programs for cardiac patients should:
• be based on low to moderate intensity exercise
• be suitable for a broad population
• be tailored to individual needs while being conducted in groups
• be preferably conducted twice per week
• be accompanied by a home walking program
• be continued for four to eight weeks
• have a ratio of no more than 10 patients to one staff member
• be designed by a physiotherapist or exercise specialist
• be conducted by a physiotherapist, exercise specialist or an additionally trained
nurse or occupational therapist
Education, Counselling and Behavioural Interventions
Scientific evidence concerning the benefits of education, counselling and behavioural
interventions is less conclusive than that concerning exercise training. Much of the
research in these areas has been poorly designed. Further, the evidence base is
confounded by markedly differing interventions, duration of programs and outcome
measures. In some areas, evidence is nonexistent or scanty. For example, the application of behavioural approaches to modify risk factors has not been extensively
tested to date in cardiac rehabilitation.
Despite these qualifications, there is now some good evidence to support the
effectiveness of education, counselling and behavioural interventions in cardiac
rehabilitation, whether combined with, or provided independently of, an exercise
program. Available evidence confirms that education, counselling and behavioural
interventions increase patient knowledge and enhance psychosocial functioning.
Further, favourable effects have been demonstrated upon reduction of smoking, lipid
levels and stress. However, increases in knowledge do not necessarily lead to improved health behaviours. More emphasis upon teaching patients the necessary skills for making lifestyle changes is required. Further research is needed to develop interventions which produce measurable improvements in health behaviours and
modification of risk factors.
Recommendations
Education and counselling for cardiac patients should:
• be conducted in groups
• be preferably conducted twice per week
• be conducted over four to eight weeks
• be supplemented by individual counselling as required
• follow adult learning principles and encourage interactive discussion
• apply behavioural principles, including goal setting and monitoring, to promote
lifestyle changes
• involve psychologists and other appropriately trained specialists to teach patients
skills for making lifestyle changes
• provide information relevant to the needs of particular patients or groups of
patients
• provide scientifically accurate information
• be delivered by a multidisciplinary team of appropriately trained facilitators
Psychosocial Interventions
Cardiac patients and spouses commonly experience psychological distress following an acute cardiac event. Unfortunately, there appears to be less emphasis upon psychosocial than physical and functional aspects of cardiac rehabilitation.
Participation in group exercise and education programs enhances psychological
functioning. Such groups also provide social support. Cardiac rehabilitation programs
conducted in groups have significant advantages over individually based programs
(such as home programs) in these important respects. Stress management programs,
relaxation therapy, psychosocial counselling groups and spouse groups can also
facilitate psychosocial recovery. Evidence from well designed studies to support the
value of such interventions is generally lacking, although a few recent studies have
shown favourable effects from stress management and relaxation therapy. Individual
counselling of patients and spouses has also been shown to be effective.
Recommendations
Psychosocial rehabilitation should offer:
• brief screening to detect patients and spouses requiring special assistance
• individual counselling by a social worker, psychologist, or other trained counsellor,if required
• participation in a group to provide social support
• additional modules, such as stress management or relaxation therapy, if required
Vocational Rehabilitation
There is limited evidence demonstrating that cardiac rehabilitation, as currently
practised, has a favourable impact upon occupational outcomes. One possible
explanation for this lack may be that resumption of work appears to have been set
aside or forgotten as a major aim of cardiac rehabilitation in recent years. Further
studies are required to test strategies to increase rates of return to work and to
promote better occupational adjustment among those who successfully resume work.
Recommendations
Vocational rehabilitation should include:
• supervision by the occupational therapist
• discussion at entry assessment of employment plans and development of
appropriate vocational goals
• identification of any physical and psychological barriers to resumption of work
• modules offering tailored vocational programs, including work hardening and
simulated work testing
• adequate liaison between patient, doctor and employer
Organisational Issues
There is considerable evidence to support the need for improved referral procedures,
discharge planning and liaison between health care providers so that greater
participation in cardiac rehabilitation programs can be achieved. Attention to such
process issues has been inadequate in the past and now requires a greater focus.
Assistance with transport and the provision of more locally based programs are also
recommended.
The practice of automatic referral to programs is strongly recommended. If medical
contraindications exist in individual cases, the doctor should indicate in the patient’s hospital record that the patient should not be referred to a program.
The delivery of a structured cardiac rehabilitation program involves the need for
multiple skills. Such expertise is usually beyond the capacity of one or few health
professionals and in several areas, specific training is required. Thus, a
multidisciplinary team is recommended. A designated co-ordinator is essential. Any
team member with adequate organisational and interpersonal skills and sufficient
time may fulfil this role. An important function of the program co-ordinator is to
ensure adequate communication between different team members, and especially with
general practitioners. One health professional may suffice for small programs in
poorly resourced rural or local communities, provided there is adequate back-up support.
A key principle of contemporary cardiac rehabilitation programs is flexibility. Thus,
while nearly all patients should be encouraged to attend exercise and education
groups, the duration of their attendance and the nature and amount of rehabilitation
required will vary considerably, according to individual need.
Some patients will require slow progress and support through a gradual program of
increasing activity, while others with little impairment of cardiac function or fitness may progress rapidly. Psychological and social support may also vary markedly in degree. While some patients may have a good understanding of their illness or procedure and have clearly defined goals for achievement in a cardiac rehabilitation program, others may have little idea of the nature of their condition or of what may be achieved or desirable from such a program. It is therefore essential that the individual needs of each patient are understood and discussed between the patient and program staff. Patients should be able to see that their particular needs are being addressed at all times in the program.
A rehabilitation plan devised to suit the individual patient needs to be agreed upon at the entry assessment. Specific individual behavioural goals should also be decided so that progress can be monitored. For best practice, a variety of program components or modules should be available to patients. It is now apparent that certain patient groups, such as those who have undergone coronary angioplasty, require different kinds of programs. Some patient groups, such as those of aboriginal background, have rarely attended cardiac rehabilitation programs. Moreover, very little research has been conducted to identify their specific needs. Tailored programs for different patient populations need to be devised and evaluated.
The need for flexibility in the provision and delivery of services also arises from
recommendations that programs should be offered to a broad range of patients,
including those with considerable physical and functional limitations. It is further
advocated that family members should also attend cardiac rehabilitation programs
which can offer them an opportunity for primary prevention of cardiovascular disease.
Recommendations
Cardiac rehabilitation and secondary prevention programs should:
• develop efficient referral procedures
• develop effective strategies to maximise program attendance and completion
• offer programs which are accessible
• provide flexible, multifactorial programs consisting of several modules
• offer programs which suit a broad range of patient groups as well as family members
• be delivered by a multidisciplinary team with a designated co-ordinator
• ensure adequate communication between hospital staff, program staff and general
practitioners
Evaluation
Evaluation is becoming an increasingly important aspect of cardiac rehabilitation and
secondary prevention programs. There are some suitable measures available to assess
functional, quality of life and behavioural outcomes. However, there is a definite need for further research to test the applicability of some generic tools to cardiac
rehabilitation and to devise more sensitive measures. Outcome indicators have been
included in the Best Practice Guidelines because it is difficult to monitor a number of outcomes which require longterm follow-up. Further testing of the recommended
process and outcome indicators is required to identify suitable benchmarks. More
detailed costings of best practice model programs are also required. Qualitative
research is required to obtain a better understanding of patient attitudes and
responses in areas which are less well understood.
It should be emphasised that multifactorial, comprehensive cardiac rehabilitation
programs combining exercise training with education, counselling and behavioural
interventions produce significantly greater benefits to patients than programs
providing either exercise or education alone. Many of the studies reviewed contain
education, counselling or behavioural interventions as well as exercise training and
demonstrated favourable outcomes. However, it is difficult to determine which
ingredients of multifactorial programs produce these benefits.
Recommendations
All programs should:
• undergo outcome evaluation to determine their effectiveness upon patient outcomes
• undergo process evaluation to identify inadequacies, to assure program quality and
to improve program delivery
• be evaluated following professional advice regarding appropriate evaluation methods
Cost, Cost Saving and Cost Effectiveness
There is marked variation in the cost of programs throughout the world. Costs depend
largely on the program duration, frequency of attendance and the intensity of
rehabilitation exercise. Low cost programs are feasible provided that high intensity
exercise is avoided, thereby obviating the need for technology in risk stratification and monitoring. The major cost is then related to the salaries of program staff. With a well attended program, approaching optimal size for exercise and education groups and for both group and individual counselling and support, it appears that the aims of the program may be generally achieved with twice weekly (possibly once weekly) sessions of group work lasting two hours per session over a period of six weeks. This type of twice weekly program can be reasonably conducted at a mean cost of approximately $40 per session per patient and a total cost of $480 per patient completing the program. The cost of a once weekly program would probably approach $300 per patient.
There is now evidence that significant cost saving may be achieved through cardiac
rehabilitation and secondary prevention programs. These savings are largely from
reduced subsequent hospital admissions and reduced costs of medical care. There are
additional savings that arise through pension, retirement and sickness benefits, provided that work resumption and remaining in work is achieved. These cost savings may be very large in an ageing population prone to development of preventable heart failure.
While cost benefit and effectiveness studies are so far not widely reported, it is
apparent that cardiac rehabilitation programs have benefits and effectiveness similar
to other successful interventions in the treatment of cardiac and vascular disease.
Recommendations
Cardiac rehabilitation and secondary prevention programs should:
• Avoid high intensity exercise to assure low cost
• Assure educational and behavioural contents are sufficient for secondary prevention, thereby reducing future medical and hospital costs
• Encourage continuation in gainful employment, thereby reducing pension,
retirement and social security costs
• Be directed to assure the above and, further, to improve other patient outcomes,
including longer life expectancy and improved quality of life such that the gains
are apparent relative to the cost.
Although the primary focus of these Best Practice Guidelines has been upon producing recommendations for outpatient programs conducted during convalescence, much of the literature cited in support of recommendations was based upon longterm maintenance programs. It should be emphasised that behaviour change is a process which requires considerable time. Thus, participation in ongoing community based programs is recommended to encourage maintenance of behaviour change and modification of risk factors.
accounted for 46% of all deaths, with 24% being attributed to coronary heart disease.
However, while age-adjusted certified deaths from coronary heart disease are falling,
increasing numbers of patients are being discharged alive from hospitals after acute
cardiac events and interventions. These patients constitute the major pool of those
eligible to attend cardiac rehabilitation and secondary prevention programs.
Cardiac rehabilitation programs were originally introduced to facilitate recovery from acute cardiac events. In both the USA and Australia, work classification or cardiac rehabilitation units were set up in the 1950’s and 1960’s to encourage return to work among those with physical or psychological disabilities. In Australia, hospital-based programs were established in the mid 1970’s. Since that time, many programs have been established in metropolitan and rural hospitals throughout Australia, and more recently, in community settings. Australia now has a large network of programs, particularly in Victoria.
As well as facilitating recovery, cardiac rehabilitation programs function as launching pads for secondary prevention of cardiovascular disease. Education, counselling and behavioural interventions to promote lifestyle change and modify risk factors have become an increasingly important part of cardiac rehabilitation programs.
In 1993, the National Heart Foundation of Australia produced a document to establish
minimal standards for cardiac rehabilitation to guide health care providers and policy makers. The purpose of these new Best Practice Guidelines is to provide optimal standards for cardiac rehabilitation and secondary prevention programs, particularly those conducted during convalescence. The recommendations contained within these Guidelines apply to cardiac rehabilitation programs not only in Victoria, but also elsewhere in Australia and in other countries.
The Guidelines examine evidence for the effectiveness of exercise training, education, counselling and behavioural interventions upon physical, psychological, social, occupational and behavioural outcomes, risk factors, morbidity and mortality.
Recommendations for best practice are based upon a comprehensive review of the
scientific literature. However, where scientific evidence from clinical trials and
observational studies is lacking, recommendations are based upon expert opinion and
consensus statements derived from surveys and focus groups with practitioners in the
field.
These Best Practice Guidelines do not duplicate the contents of the Clinical Practice
Guideline of the US Agency for Health Care Policy and Research (AHCPR), which
was published in 1995. Whereas the major part of that document deals with evidence
concerning exercise training, these Best Practice Guidelines focus equally on
education, counselling and behavioural interventions, as well as other aspects of
cardiac rehabilitation which were not extensively addressed in the AHCPR Clinical
Practice Guideline. Reference is also made to the findings of studies published since
the production of the AHCPR Clinical Practice Guideline.
Exercise Training
There has been extensive research into the benefits of exercise training in patients
with cardiovascular disease, particularly after acute cardiac events. Physical and
functional outcome measures have been well defined and it is clear that exercise
training produces definite physical, quality of life and secondary prevention benefits.
Available evidence confirms that exercise training produces definite improvements in
physical performance (exercise tolerance, muscular strength and symptoms),
psychological functioning (anxiety, depression, well-being), and social adaptation and functioning. Further, exercise training produces a demonstrable reduction in
mortality, morbidity, recurrent events and hospital readmissions.
In general, psychosocial outcomes have been less well studied than physical and
functional effects of exercise training. Conclusions concerning psychosocial benefits, widely claimed by patients and endorsed by practitioners, have been much less well documented scientifically. It is likely that many of the psychosocial benefits of exercise training are attributable to group activities, peer support and access to professional advice rather than to the exercise itself.
It is probable that exercise training has a favourable impact upon other outcomes,
including modification of risk factors. These benefits are mostly apparent when
exercise is provided as part of a comprehensive program including education,
counselling, behavioural interventions and support. Further, evidence indicates that
for such beneficial lifestyle changes to be sustained, continued physical activity and support are required.
Studies have now confirmed that high intensity and low intensity exercise programs
produce similar benefits. Nevertheless, some patients may prefer high intensity
exercise. Those returning to heavy manual jobs may benefit from more intensive
exercise training. For the majority of patients, however, low intensity exercise is
sufficient. Further, low intensity exercise has some important practical advantages. It is more suitable for a broader population, including older men and women and
patients with functional impairments, and it is more likely to be sustained in the
longer term. Because low intensity programs do not require such careful supervision
and use less technology and equipment, they can be conducted at low cost. Clinical
rather than technological methods can be used for risk stratification, assessment and
monitoring, with considerable cost savings. Exercise conducted in groups also
significantly reduces costs.
Further research is needed to determine best practice with regard to the frequency of
exercise sessions and the duration of exercise programs. On the basis of both evidence and expert opinion, it is apparent that twice weekly group exercise programs are as effective as thrice weekly. While twice weekly group exercise is recommended, there is some evidence that once weekly supervised group exercise may achieve similar benefits to twice weekly group exercise, provided it is accompanied by an additional daily home walking program.
There is no scientific evidence to indicate the preferred duration of exercise cardiac rehabilitation programs. On the basis of expert opinion, most of the aims of
ambulatory cardiac rehabilitation programs conducted during convalescence should be achieved with a twice weekly program lasting four to eight weeks.
It should be emphasised that individual patients vary considerably in their need for a group exercise program. Thus, it is essential to provide flexible programs to meet
particular needs.
Recommendations
Exercise programs for cardiac patients should:
• be based on low to moderate intensity exercise
• be suitable for a broad population
• be tailored to individual needs while being conducted in groups
• be preferably conducted twice per week
• be accompanied by a home walking program
• be continued for four to eight weeks
• have a ratio of no more than 10 patients to one staff member
• be designed by a physiotherapist or exercise specialist
• be conducted by a physiotherapist, exercise specialist or an additionally trained
nurse or occupational therapist
Education, Counselling and Behavioural Interventions
Scientific evidence concerning the benefits of education, counselling and behavioural
interventions is less conclusive than that concerning exercise training. Much of the
research in these areas has been poorly designed. Further, the evidence base is
confounded by markedly differing interventions, duration of programs and outcome
measures. In some areas, evidence is nonexistent or scanty. For example, the application of behavioural approaches to modify risk factors has not been extensively
tested to date in cardiac rehabilitation.
Despite these qualifications, there is now some good evidence to support the
effectiveness of education, counselling and behavioural interventions in cardiac
rehabilitation, whether combined with, or provided independently of, an exercise
program. Available evidence confirms that education, counselling and behavioural
interventions increase patient knowledge and enhance psychosocial functioning.
Further, favourable effects have been demonstrated upon reduction of smoking, lipid
levels and stress. However, increases in knowledge do not necessarily lead to improved health behaviours. More emphasis upon teaching patients the necessary skills for making lifestyle changes is required. Further research is needed to develop interventions which produce measurable improvements in health behaviours and
modification of risk factors.
Recommendations
Education and counselling for cardiac patients should:
• be conducted in groups
• be preferably conducted twice per week
• be conducted over four to eight weeks
• be supplemented by individual counselling as required
• follow adult learning principles and encourage interactive discussion
• apply behavioural principles, including goal setting and monitoring, to promote
lifestyle changes
• involve psychologists and other appropriately trained specialists to teach patients
skills for making lifestyle changes
• provide information relevant to the needs of particular patients or groups of
patients
• provide scientifically accurate information
• be delivered by a multidisciplinary team of appropriately trained facilitators
Psychosocial Interventions
Cardiac patients and spouses commonly experience psychological distress following an acute cardiac event. Unfortunately, there appears to be less emphasis upon psychosocial than physical and functional aspects of cardiac rehabilitation.
Participation in group exercise and education programs enhances psychological
functioning. Such groups also provide social support. Cardiac rehabilitation programs
conducted in groups have significant advantages over individually based programs
(such as home programs) in these important respects. Stress management programs,
relaxation therapy, psychosocial counselling groups and spouse groups can also
facilitate psychosocial recovery. Evidence from well designed studies to support the
value of such interventions is generally lacking, although a few recent studies have
shown favourable effects from stress management and relaxation therapy. Individual
counselling of patients and spouses has also been shown to be effective.
Recommendations
Psychosocial rehabilitation should offer:
• brief screening to detect patients and spouses requiring special assistance
• individual counselling by a social worker, psychologist, or other trained counsellor,if required
• participation in a group to provide social support
• additional modules, such as stress management or relaxation therapy, if required
Vocational Rehabilitation
There is limited evidence demonstrating that cardiac rehabilitation, as currently
practised, has a favourable impact upon occupational outcomes. One possible
explanation for this lack may be that resumption of work appears to have been set
aside or forgotten as a major aim of cardiac rehabilitation in recent years. Further
studies are required to test strategies to increase rates of return to work and to
promote better occupational adjustment among those who successfully resume work.
Recommendations
Vocational rehabilitation should include:
• supervision by the occupational therapist
• discussion at entry assessment of employment plans and development of
appropriate vocational goals
• identification of any physical and psychological barriers to resumption of work
• modules offering tailored vocational programs, including work hardening and
simulated work testing
• adequate liaison between patient, doctor and employer
Organisational Issues
There is considerable evidence to support the need for improved referral procedures,
discharge planning and liaison between health care providers so that greater
participation in cardiac rehabilitation programs can be achieved. Attention to such
process issues has been inadequate in the past and now requires a greater focus.
Assistance with transport and the provision of more locally based programs are also
recommended.
The practice of automatic referral to programs is strongly recommended. If medical
contraindications exist in individual cases, the doctor should indicate in the patient’s hospital record that the patient should not be referred to a program.
The delivery of a structured cardiac rehabilitation program involves the need for
multiple skills. Such expertise is usually beyond the capacity of one or few health
professionals and in several areas, specific training is required. Thus, a
multidisciplinary team is recommended. A designated co-ordinator is essential. Any
team member with adequate organisational and interpersonal skills and sufficient
time may fulfil this role. An important function of the program co-ordinator is to
ensure adequate communication between different team members, and especially with
general practitioners. One health professional may suffice for small programs in
poorly resourced rural or local communities, provided there is adequate back-up support.
A key principle of contemporary cardiac rehabilitation programs is flexibility. Thus,
while nearly all patients should be encouraged to attend exercise and education
groups, the duration of their attendance and the nature and amount of rehabilitation
required will vary considerably, according to individual need.
Some patients will require slow progress and support through a gradual program of
increasing activity, while others with little impairment of cardiac function or fitness may progress rapidly. Psychological and social support may also vary markedly in degree. While some patients may have a good understanding of their illness or procedure and have clearly defined goals for achievement in a cardiac rehabilitation program, others may have little idea of the nature of their condition or of what may be achieved or desirable from such a program. It is therefore essential that the individual needs of each patient are understood and discussed between the patient and program staff. Patients should be able to see that their particular needs are being addressed at all times in the program.
A rehabilitation plan devised to suit the individual patient needs to be agreed upon at the entry assessment. Specific individual behavioural goals should also be decided so that progress can be monitored. For best practice, a variety of program components or modules should be available to patients. It is now apparent that certain patient groups, such as those who have undergone coronary angioplasty, require different kinds of programs. Some patient groups, such as those of aboriginal background, have rarely attended cardiac rehabilitation programs. Moreover, very little research has been conducted to identify their specific needs. Tailored programs for different patient populations need to be devised and evaluated.
The need for flexibility in the provision and delivery of services also arises from
recommendations that programs should be offered to a broad range of patients,
including those with considerable physical and functional limitations. It is further
advocated that family members should also attend cardiac rehabilitation programs
which can offer them an opportunity for primary prevention of cardiovascular disease.
Recommendations
Cardiac rehabilitation and secondary prevention programs should:
• develop efficient referral procedures
• develop effective strategies to maximise program attendance and completion
• offer programs which are accessible
• provide flexible, multifactorial programs consisting of several modules
• offer programs which suit a broad range of patient groups as well as family members
• be delivered by a multidisciplinary team with a designated co-ordinator
• ensure adequate communication between hospital staff, program staff and general
practitioners
Evaluation
Evaluation is becoming an increasingly important aspect of cardiac rehabilitation and
secondary prevention programs. There are some suitable measures available to assess
functional, quality of life and behavioural outcomes. However, there is a definite need for further research to test the applicability of some generic tools to cardiac
rehabilitation and to devise more sensitive measures. Outcome indicators have been
included in the Best Practice Guidelines because it is difficult to monitor a number of outcomes which require longterm follow-up. Further testing of the recommended
process and outcome indicators is required to identify suitable benchmarks. More
detailed costings of best practice model programs are also required. Qualitative
research is required to obtain a better understanding of patient attitudes and
responses in areas which are less well understood.
It should be emphasised that multifactorial, comprehensive cardiac rehabilitation
programs combining exercise training with education, counselling and behavioural
interventions produce significantly greater benefits to patients than programs
providing either exercise or education alone. Many of the studies reviewed contain
education, counselling or behavioural interventions as well as exercise training and
demonstrated favourable outcomes. However, it is difficult to determine which
ingredients of multifactorial programs produce these benefits.
Recommendations
All programs should:
• undergo outcome evaluation to determine their effectiveness upon patient outcomes
• undergo process evaluation to identify inadequacies, to assure program quality and
to improve program delivery
• be evaluated following professional advice regarding appropriate evaluation methods
Cost, Cost Saving and Cost Effectiveness
There is marked variation in the cost of programs throughout the world. Costs depend
largely on the program duration, frequency of attendance and the intensity of
rehabilitation exercise. Low cost programs are feasible provided that high intensity
exercise is avoided, thereby obviating the need for technology in risk stratification and monitoring. The major cost is then related to the salaries of program staff. With a well attended program, approaching optimal size for exercise and education groups and for both group and individual counselling and support, it appears that the aims of the program may be generally achieved with twice weekly (possibly once weekly) sessions of group work lasting two hours per session over a period of six weeks. This type of twice weekly program can be reasonably conducted at a mean cost of approximately $40 per session per patient and a total cost of $480 per patient completing the program. The cost of a once weekly program would probably approach $300 per patient.
There is now evidence that significant cost saving may be achieved through cardiac
rehabilitation and secondary prevention programs. These savings are largely from
reduced subsequent hospital admissions and reduced costs of medical care. There are
additional savings that arise through pension, retirement and sickness benefits, provided that work resumption and remaining in work is achieved. These cost savings may be very large in an ageing population prone to development of preventable heart failure.
While cost benefit and effectiveness studies are so far not widely reported, it is
apparent that cardiac rehabilitation programs have benefits and effectiveness similar
to other successful interventions in the treatment of cardiac and vascular disease.
Recommendations
Cardiac rehabilitation and secondary prevention programs should:
• Avoid high intensity exercise to assure low cost
• Assure educational and behavioural contents are sufficient for secondary prevention, thereby reducing future medical and hospital costs
• Encourage continuation in gainful employment, thereby reducing pension,
retirement and social security costs
• Be directed to assure the above and, further, to improve other patient outcomes,
including longer life expectancy and improved quality of life such that the gains
are apparent relative to the cost.
Although the primary focus of these Best Practice Guidelines has been upon producing recommendations for outpatient programs conducted during convalescence, much of the literature cited in support of recommendations was based upon longterm maintenance programs. It should be emphasised that behaviour change is a process which requires considerable time. Thus, participation in ongoing community based programs is recommended to encourage maintenance of behaviour change and modification of risk factors.
segunda-feira, 17 de maio de 2010
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