AFRM eBulletin – 29 June 2018

Does Cardiac Rehabilitation Work?

Cardiac rehabilitation (CR) for patients with heart disease has traditionally been recommended on the basis of published studies citing improvements in cardiopulmonary fitness, psychological factors and quality of life and reductions in morbidity and mortality [1].

However, authors of a recent meta-analysis [2] asserted that many systematic reviews and meta-analyses which report the benefits of CR such as reduced mortality and hospital re-admissions are actually overestimating the benefits of CR. They, among others [3], reason that because such reviews include old studies (some as far back as 1975) which do not take into account more recent developments in the management of heart disease, they may not be correctly assessing the potential effect of contemporary exercise-based CR compared with current 'usual care'. The authors therefore only included studies since 2000 and found that CR did not impact on all-cause or cardiovascular mortality.

It should be noted that the meta-analysis did not evaluate the impact of CR on important outcomes such as cardiorespiratory fitness, lifestyle risk factor management, adherence to medication, diet, smoking cessation, psychosocial health and return to work. In addition, there was no information regarding patient adherence to exercise interventions. This is particularly important as evidence suggests that the actual dose of CR delivered can impact on outcome [4]. 

Despite these limitations, this study acts as a useful prompt to review similar recent meta-analyses. Two consistent messages emerging from recent published literature include:

1. Although moderately strong evidence exists regarding the positive effects of cardiac rehabilitation on exercise capacity in patients with coronary artery disease [5,6], heart transplants [7], and post-valve surgery [8], further good quality research and meta-analyses are required to evaluate the impact of cardiac rehabilitation on patient outcomes such as health-related quality of life, return to work and lifestyle change [9]. Systematic reviews and meta-analyses repeatedly comment on the poor quality of studies and the small sample sizes used [5;10;11], which limits their value.

2. Whatever the benefits conferred by CR, uptake by eligible patients continues to be poor globally, due to factors including physicians’ reluctance to refer some patients, geographic isolation, competing work or family responsibilities, and lack of resources and funding [4;12]. In particular, clinician endorsement is crucial in getting patients to go to cardiac rehabilitation. Once a cardiologist, cardiology unit or other treating doctor believes in and reinforces the value of cardiac rehabilitation, adherence and attendance rates improve.

Dr Frances Wise FAFRM

References:

  1. McMahon SR, Ades PA, Thompson PD. The role of cardiac rehabilitation in patients with heart disease. Trends Cardiovasc Med. 2017 Aug;27(6):420-425.
  2. Powell R, McGregor G, Ennis S, Kimani PK, Underwood M. Is exercise-based cardiac rehabilitation effective? A systematic review and meta-analysis to re-examine the evidence. BMJ Open. 2018; Mar 14;8(3):e019656.
  3. Sumner J, Harrison A, Doherty P. The effectiveness of modern cardiac rehabilitation: A systematic review of recent observational studies in non-attenders versus attenders. PLoS ONE 2017; 12(5): e0177658. 
  4. Santiago de Araújo Pio C, Marzolini S, Pakosh M, Grace SL. Effect of Cardiac Rehabilitation Dose on Mortality and Morbidity: A Systematic Review and Meta-regression Analysis. Mayo Clin Proc. 2017 Nov;92(11):1644-1659. doi: 10.1016/j.mayocp.2017.07.019.
  5. Dibben GO, Dalal HM, Taylor RS, Doherty P, Tang LH, Hillsdon M. Cardiac rehabilitation and physical activity: systematic review and meta-analysis. Heart 2018; Apr 13. pii: heartjnl-2017-312832. doi: 10.1136/heartjnl-2017-312832.
  6. Yang X, Li Y, Ren X, Xiong X, Wu L, Li J, Wang J, Gao Y, Shang H, Xing Y. Effects of exercise-based cardiac rehabilitation in patients after percutaneous coronary intervention: A meta-analysis of randomized controlled trials. Sci Rep. 2017; Mar 17;7:44789. doi: 10.1038/srep44789.
  7. Anderson L, Nguyen TT, Dall CH, Burgess L, Bridges C, Taylor RS. Exercise-based cardiac rehabilitation in heart transplant recipients. Cochrane Database Syst Rev. 2017 Apr 4;4:CD012264. doi: 10.1002/14651858.CD012264.pub2.
  8. Sibilitz KL, Berg SK, Tang LH, Risom SS, Gluud C, Lindschou J, Kober L, Hassager C, Taylor RS, Zwisler AD. Exercise-based cardiac rehabilitation for adults after heart valve surgery. Cochrane Database Syst Rev. 2016; Mar 21;3:CD010876. doi: 10.1002/14651858.CD010876.pub2.
  9. Taylor R, Dalal H. Editorial: Impact of Cardiac Rehabilitation on Cardiac Mortality. Eur Heart J Qual Care Clin Outcomes. 2018; Apr 24. doi: 10.1093/ehjqcco/qcy017.
  10. Long L, Anderson L, Dewhirst AM, He J, Bridges C, Gandhi M, Taylor RS. Exercise-based cardiac rehabilitation for adults with stable angina. Cochrane Database Syst Rev. 2018 Feb 2;2:CD012786. doi: 10.1002/14651858.CD012786.pub2. Review. PubMed PMID: 29394453.
  11. Risom SS, Zwisler AD, Johansen PP, Sibilitz KL, Lindschou J, Gluud C, Taylor RS, Svendsen JH, Berg SK. Exercise-based cardiac rehabilitation for adults with atrial fibrillation. Cochrane Database Syst Rev. 2017; Feb 9;2:CD011197. doi:10.1002/14651858.CD011197.pub2.
  12. Dalal HM, Doherty P, Taylor RS. Cardiac rehabilitation. BMJ. 2015 Sep 29;351:h5000. doi: 10.1136/bmj.h5000.

A message from your President

RMSANZ Rehabilitation Snapshots 2018 and AFRM Annual Members Meeting

I recently had the pleasure of attending the Rehabilitation Medicine Society of Australia and New Zealand (RMSANZ) Rehabilitation Snapshots meeting in Melbourne. I congratulate the RMSANZ, Michael Chou and the organising committee on an excellent weekend program which provided presentations and updates on a range of important topics including brain injury, prosthetics and upper limb management after stroke (to name only a few). The weather was good weather for high quality, indoor professional development experiences – well perhaps not Melbourne’s best weather but I like a bit of cold and less so, the wet. Congratulations again to the team at RMSANZ. We are in the process of working out the best method of ensuring good regular communication between the AFRM and the RMSANZ so that the two organisations can work together as much as possible. 
 
The AFRM Annual Members Meeting (AMM) was also held during the program and if you did not have a chance to see the meeting papers I encourage you to have a quick look at the briefing papers. The reports from the President, Chairs of the Policy & Advocacy and Education Committee’s and the Trainee Report provide an excellent summary of the Faculty’s activities over the past 12 months and there has been quite a lot going on. It’s difficult to pick out highlights but I would mention the ongoing work around increasing awareness and promotion of our specialty (see my last President’s Post for more information) and review of both the Adult and Paediatric Rehabilitation Medicine Scope of Practice documents. 
 
As of May, this year there were 221 AFRM trainees including nine Paediatric Rehabilitation Medicine trainees and 177 Fellows who are accredited supervisors.  During the AMM we welcomed 22 new Fellows who had been awarded Fellowship of the AFRM since September 2017. On behalf of all in the Faculty, a warm welcome to you all and best of luck as you embark on your careers as Rehabilitation Medicine Physicians.
 
Professor Tim Geraghty 
President, AFRM

Applications open for 2018 AFRM Module 1 Assessment from 30 July

We are pleased to advise applications will be open for the next AFRM Module 1 Assessment from 30 July 2018 for all eligible trainees (who have met the training program requirements) for the Tuesday, 9 October 2018 examinations.

Applications will be open from 30 July 2018 and will close on 13 August 2018 at 5pm (AEST) and any applications received after this closing time cannot be accepted.  For all eligible candidates, this is the last time the Module 1 Written Assessment will be held as a second sit within the AFRM training program.  Going forward the Module 1 Written assessment will be held once a year, normally within the first six months of the year.

A reminder you will need to have satisfactorily completed all requirements for the January to June 2018 training period by the relevant deadlines in order to be eligible​. The Training Handbook provides more information. 

If you have any further questions please email examinations@racp.edu.au

Applications for AFRM research, study and travel grants close soon

Apply now for ​​the following grants and scholarships:

Add the RACP Foundation to your favourites or email foundation@racp.edu.au for further information.

View RACP Congress 2018 ​​resources

Videos of selected shared sessions and all presentations from RACP Congress 2018 are now online.

Browse through a range of thought-provoking material to stimulate, challenge and inspire you and your work.

The RACP has permission to share all material with you and if a presentation or video is not available it is because permission has not yet been received.

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Funding grants for women's leadership development

Women & Leadership Australia (WLA) is administering a national initiative to support the development of female leaders across Australia’s health care sector. 

The initiative is providing women working in the sector with grants to enable participation in a range of leadership development programs. 

The leadership development programs are part-time and delivered nationally via WLA’s blended learning model. Scholarship funding is strictly limited and will be awarded based on a set of selection criteria being met.

Expressions of Interest 
Find out more and register your interest by completing the Expression of Interest form before 7 September 2018: www.wla.edu.au/health

Expand your end-of-life care knowledge

To help you improve your skills in end-of-life care, the RACP is offering free access to an online course on the topic.

The course begins on Wednesday, 18 July.

For more information visit the event webpage.

Trainee events

The Royal Australasian College of Physicians publishes notices of events and courses as a service to members. Such publication does not constitute endorsement or mandating of any such events or courses. 

Go to the events list at any time to see what events are coming up.

AFRM ​training resources

Bi-National Training Program (BNTP) 

The AFRM conducts the BNTP on the last Wednesday of every month from February to November. These training sessions are broadcast across Australia and New Zealand. The BNTP sessions use Zoom conferencing to provide trainees with Rehabilitation Medicine knowledge and information. These sessions are not intended to prepare trainees for the AFRM Fellowship Examinations. 

View session dates

Important note: If you join the session late, the videoconference room will indicate that it is locked and will not allow you to connect. Please ensure that you turn your webcam off before you join the session. Due to the nature of the recordings if you connect to the videoconference with your webcam on you will appear on the screen. 

To join the videoconference on the day, follow this link to the Zoom Software.

Please note this is the URL embedded in the above link: https://racp.zoom.us/j/3899131497 

The meeting ID: 389 913 1497 

Email the RACP events team at events@racp.edu.au or call +61 2 8247 6240 to arrange equipment testing. Ensure you do this as soon as possible to avoid any last-minute disruptions.

NSW Saturday Lecture Series

Go to the events list at any time to see what events are coming up.

AFRM contact details 

Member enquiries
Phone: (AUS) 1300 69 7227
Phone: (NZ) 0508 69 7227
Email: memberservices@racp.edu.au 

AFRM Faculty enquiries (including Council and committees):
Anastasia Barabash, Executive Officer, AFRM
Phone: +61 2 8076 6315
Email: afrm@racp.edu.au

AFRM Education and Training enquiries:
Name: ​Lanica Roventa, Education Officer
Phone: +61 2 8076 6350
Email: rehab@racp.edu.au  

AFRM Examination enquiries:
Name: ​Vanessa Hall, Examination Coordinator 
Phone: +61 2 9256 5422
Email: examinations@racp.edu.au  

AFRM training site accreditation enquiries:
Name: Sonia Tao, Education Officer
Phone: +61 8247 6233
Email: accreditation@racp.edu.au 
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