Psychological, social, and medical factors affecting rehabilitation following coronary bypass surgery.

Coronary bypass surgery was developed in 1967 (Thurer, 1980) and is now performed on more than 350,000 individuals annually (Possanza, 1996). One of the many goals of coronary bypass surgery is the return of the patient to gainful employment (Allen, 1990). Though not a cure, the procedure is intended to alleviate symptoms of atherosclerotic heart disease and to improve quality of life.

Atherosclerotic heart disease is defined as an occlusion or blockage due to a buildup of plaque in the arteries which supply blood to the heart muscle. Symptoms of atherosclerotic heart disease include but are not limited to, angina pectoris (chest pain) or pain radiating down either arm, and possibly neck and or jaw pain (Falvo, 1991). Atherosclerotic heart disease can also be present with no symptoms at all (Falvo, 1991).

Coronary bypass surgery has considerable impact on the occupational status of individuals postoperatively (Rimm, Barboriak, Anderson, & Simon, 1976). Percentages of individuals returning to gainful employment following coronary bypass surgery are well below expected results despite the fact that 90% of individuals experiencing angina pectoris (chest pain) before coronary bypass surgery feel better physically after the operation (Russell, Abi-Mansour, & Wenger, 1986). However, many individuals choose not to work following coronary bypass surgery (Russel et al., 1986); they look back on their lives and decide to change their priorities, placing more value on human closeness and devaluing work (Thurer, Levine, & Thurer, 1980). Employment status prior to coronary bypass surgery is most predictive of the individual's work status after surgery. Individuals who were employed prior to surgery tend to return to work more often postoperatively (Allen, 1990; Caine, Harrison, Sharples, & Wallwork, 1991; Rogers et al., 1990; Russell et al., 1986).

Research by Russell et al. (1986) of individuals who had coronary bypass surgery at the University of Alabama in Birmingham found that over one fifth had a decrease in the number of work hours one year after surgery. P4rom the large number of individuals with heart disease only 11 to 20 percent participate in cardiac rehabilitation programs (Cardiac Rehabilitation Guideline Panel [CRGP], 1995).

The psychological, social and medical factors affecting length of recovery time and employment of individuals following coronary bypass surgery are discussed, as well as the importance for rehabilitation professionals understanding of the individual's functional capacities regarding employment following coronary bypass surgery. Finally, an accommodation which employers can make to enhance the re-employment of individuals following coronary bypass surgery is presented.

Psychological Factors

Cardiac rehabilitation exercise training can improve a patient's psychological status and functioning, though exercise training does little to reduce the levels of anxiety and depression commonly experienced by an individual recovering from coronary bypass surgery (CROP, 1995). To achieve maximum benefits from cardiac rehabilitation, psychological counseling must be included (Denollet, 1993a).

Psychological counseling included within the cardiac rehabilitation program serves two purposes, first to optimize psychosocial recovery, such as work and sexual relations, and second to prevent secondary coronary heart disease. Hagen (1991) noted that psychological adjustment problems experienced by individuals recovering from coronary bypass surgery affect the resumption of employment, psychosocial adaptation, and sexual functioning. The second purpose of psychological counseling involves providing behavioral change through identification of stressors which affect the individual (Bennett & Carroll, 1994) and management of risk factors through dietary, smoking, and physical activity change (Denollet, 1993b; McGee, 1994). Psychological counseling can facilitate change in all of the above risk factors.

Perceived control over recovery from coronary heart disease and its possible reoccurrence is important to individual adjustment (Fowers, 1994). Following coronary bypass surgery individuals are aware that heart disease is a chronic condition and life threatening. Coronary bypass surgery is not a cure for heart disease, and the individual is advised to attend to the known risk factors of diet, weight, smoking, stress, and physical activity. Even when these behavioral changes are made, buildup of plaque in the coronary arteries may reoccur. The uncertainty of when and if the blockage will reoccur presents a threatening situation and places great demands on the individual's emotional functioning (McAdams, 1990). Individuals experiencing emotional distress (depression or fatigue) also experience increased length of recovery time following coronary bypass surgery (Denollet, 1993b).

Greater success of cardiac rehabilitation depends upon an increased awareness of psychological aspects following coronary bypass surgery (Langosch, 1994). Langosch indicates the need for individuals to reduce levels of anxiety and depression while increasing their ability to handle stress and anger. An individual's fears of sexual dysfunction, dependency upon others to perform physical tasks, lack of money, and sudden death are often neglected by rehabilitation and medical professionals. Garner and Allen (1989) noted many individuals recovering from coronary bypass surgery receive little or no information about sexual activity from their attending physicians. Fears and lack of information experienced by individuals postoperatively can be addressed through psychological counseling.

A lack of attention to the psychological aspects of cardiac rehabilitation can affect employment opportunities (Thoreson & Ackerman, 1981). McGee (1994) indicates that a multidisciplinary approach to cardiac rehabilitation which includes psychological counseling will improve an individual's quality of life and increase the probability of persons returning to work.

Lack of psychological counseling can explain a large percentage of the individuals who do not resume work following coronary bypass surgery (Danchin, David, Robert, & Bourassa, 1982). Early in the recovery process psychological counseling can clarify which fears of individuals recovering from coronary bypass surgery are realistic and which are irrational (van Elderen, 1994). The earlier the counseling begins in the recovery process, the more likely the individual will return to work (Wenger, 1989).

Social Factors

An important resource for individuals recovering from coronary bypass surgery is the social network of family, friends, neighbors, and coworkers (Russell et al., 1986). Kulik and Mahler (1993) indicate that higher levels of social support following coronary bypass surgery significantly helped the individual to have a better emotional status. Dracup, Moser, Marsden, Taylor, and Guzy (1991) found family support of the patient's participation in a cardiac rehabilitation program increased levels of psychosocial recovery.

The patient's family experiences significant change related to coronary bypass surgery. Seen as an interconnected system, a change in one family member causes the family system to adjust in some way. Issues of role strain, marital quality, and financial concerns place added physical and psychological stress upon the spouse (Artinian, 1991). Benson-Stanley and Frantz (1988) found a reversal of roles within the family following coronary bypass surgery with the patient's spouse (usually the wife) taking on the majority of household duties. Coping with heart disease was found easier for those couples that had a satisfactory relationship prior to the onset of illness (Waltz, 1986). Waltz also found families with a happy and fulfilling marriage experienced less adverse changes in the family situation following coronary bypass surgery. Finances cause major concern for spouses, with many feeling a high level of financial strain or economic inadequacy, especially when the principle wage earner undergoes coronary bypass surgery (Benson-Stanley & Frantz, 1988). Artinian (1991) found spouses experienced more stress than the patient undergoing surgery.

Following discharge from the hospital inclusion of significant others in the cardiac rehabilitation program could facilitate recovery for the patient and provide needed guidance and information. Significant others should be informed by rehabilitation counselors regarding psychological factors, and advised to report any long term depression or other adjustment concerns noted above to the physician.

Thurer (1980) noted some members of the social network may act in an overly protective manner which may hinder rehabilitation efforts. Social network members should be informed of needs individuals recovering from coronary bypass surgery have for accomplishing tasks, making decisions, and assuming control of their own lives (Amsterdam, Cadiux, Debusk, & Oberman 1994). Significant others may need guidance from the rehabilitation counselor regarding not placing individuals recovering from coronary bypass surgery in a role of helplessness by providing everything they need, allowing the patient to accomplish tasks on their own. Significant others may require guidance or more information from the rehabilitation counselor regarding medical factors which include noting and informing the physician of any behaviors or activities which are contrary to the physician's recommendations (non-compliance with; diet, exercise, quitting smoking, or medications).

Medical Factors

Two separate medical factors can influence the length of time for recovery and the return to employment. First, the medical approach utilized, and second, the bedside manner of the attending physician.

Medical Approaches

Several myocardial revascularisation procedures are available to relieve the symptoms of atherosclerotic heart disease. The procedures include but are not limited to coronary bypass surgery, percutaneous transluminal coronary angioplasty, and medical (drug) treatment. Each procedure has elements which are unique to that particular procedure and associated advantages and disadvantages. Recovery time from coronary bypass surgery is longer than any of the other procedures due to the invasive nature of the operation and the length of time required for the surgical incisions in the chest and on the leg to heal (Hampton et al., 1993). Extended recovery time means return to work is also delayed, however, less risk of angina and fewer complications are noted by Hampton et al. in the first two years.

Papadantonaki, Stotts, and Paul (1994) noted percutaneous transluminal coronary angioplasty is a less invasive procedure. Due to the less invasive nature of the procedure, early physical functioning in recovery is better than that experienced following coronary bypass surgery (Papadantonaki et al., 1994). However, as recovery time progresses this early advantage experienced through percutaneous transluminal coronary angioplasty is equaled by individuals receiving coronary bypass surgery (Rogers et al., 1990). Hospital stays for individuals receiving percutaneous transluminal coronary angioplasty were half as long when compared to individuals undergoing coronary bypass surgery (Hampton et al., 1993). Also, the return of angina and the need for medication or further revascularisation may occur for individuals having percutaneous transluminal coronary angioplasty (Hampton et al., 1993).

Medical (drug) treatment is recommended for low risk individuals. Over time the results of this form of treatment can equal results experienced with coronary bypass surgery and percutaneous transluminal coronary angioplasty. One disadvantage noted by Mark et al. (1994) was increased rates of mortality.

Physician Interaction With Patients

Physicians must be sensitive to the perspective of the individual regarding his or her illness, impact upon social functioning, and the effects of treatment on the life of the patient (Goswami, 1992). Physicians may adopt an overly protective role toward and certify patients as "disabled" when, in reality, physical capabilities exceed physical demands of the jobs available to them (Barnes, Ray, Obennan, & Kouchoukos, 1977; Oberman & Kouchoukos, 1979). Hall, Roter, and Katz (1988) found that during medical visits physicians who express positive verbal communication such as reassurance, support, and encouragement to their patients had better results with those individuals adhering to treatment recommendations.

An important factor to consider is how physician's advice concerning return to work is perceived by individuals recovering from coronary bypass surgery. Clancy, Wey, and Guinn (1984) found the perception of physicians' instructions not to return to work negatively affected how many individuals recovering from coronary bypass surgery actually returned to work. Patients have reported failure to return to work due to lack of reassurance from medical professionals that they could safely do so (Allen, 1990; Wenger, 1989). Allen also noted a small percentage of individuals who reported the physician had told them not to return to work when they felt fine.

Functional Capacities

An accurate understanding an individual's functional capacity helps the rehabilitation professional in the decision making process regarding employment possibilities. Research by Eskelinen, Kohvakka, Merisalo, Hurri, and Wagar (1991) revealed the tendency of individuals to rate their health levels (including functional capacity) higher than the actual levels found with medical examinations. A high rating of health levels by the individual recovering from coronary bypass surgery places them at risk of exceeding safe levels of physical activity. An accurate evaluation of the relationship between the individual's ability and the specific work environment is important, thereby enabling the rehabilitation professional to safely match the individual to the physical and psychosocial demands of any employment opportunities considered. Hiatt, Regensteiner, Hagarten, Wolfel, and Bass (1990) developed a functional capacity measure which accurately assesses an individual's physical capacity as compared to the demands of a specific employment position.

Type of employment also plays an important role in the decision of where, or if, the individual will return to work (Anderson, Barboriak, Hoffmann, & Mullen, 1980). Shrey and Mital (1994) noted the more physically demanding the job, the longer it will take the individual to return to pre-surgery levels of employment, and the more sedentary the job the quicker the return to work.

Rehabilitation professionals can provide prospective employers and supervisors with information regarding functional capacity which, in turn, facilitates a more rapid return to work (Bennett & Carroll, 1994). The more rapid the return of the individual to some form of employment, the more likely the individual will adjust both physically and psychologically (Shrey & Mital, 1994).

An Accommodation For Employment

A reasonable accommodation recommended for individuals experiencing difficulty entering employment after coronary bypass surgery is transitional work. This approach helps increase the strength and stamina of the individual with minimum risk of re-injury, risk to the individual or other workers (Shrey & Mital, 1994). Transitional work can place the individual in a safe employment situation which promotes reduced concerns about physical functioning. Shrey and Mital (1994) identify four requirements for effective transitional work programs: "1) objective worker evaluations, 2) a classification of the physical job demands, 3) medical surveillance and follow-up, and 4) graduated progression to an acceptable permanent placement option." (p. 44)

Traditional cardiac rehabilitation programs usually do not include transitional work programs; however, when combined the two programs yield higher return to work outcomes than traditional cardiac rehabilitation programs alone (Shrey & Mital, 1994). When cardiac patients return to work they perceive themselves as valued employees. The employer benefits from transitional work by keeping a previously employed individual who has experience with the employer and the job requirements. Employers are also often supportive of methods which facilitate continuing employment of individuals with the same job prior to the acquisition of their disability (Greenwood, Johnson, & Schriner, 1988).

Conclusion

Most cardiac rehabilitation programs center around the individual's physical conditioning. It has been noted that there are more dimensions to the recovery process which need to be addressed by rehabilitation professionals. One of these dimensions is the individual's need for psychological counseling. Psychological problems of anxiety, depression, sexual functioning, and the fear of sudden death need to be addressed for the individual to move forward in the rehabilitation process.

Another dimension is the individual's need for a social network comprised of family, friends, neighbors, co-workers, and employers to assist the individual with the difficult task of recovery. Overly protective members of the social network unknowingly hold back the recovery process. Education of the social network members is necessary to enhance the rehabilitative process. Social network members must be made aware of the importance of accomplishing tasks, making decisions, and assuming control of their lives for patients recovering from coronary bypass surgery (Amsterdam et al., 1994). Attention to the specific needs of significant others must be addressed by rehabilitation professionals to further enhance the recovery process.

Improvement of physicians' attitudes regarding employment of coronary bypass patients must occur. Positive feedback about employment possibilities could help increase percentages of individuals returning to work following coronary bypass surgery. Functional capacities of individuals recovering from coronary bypass surgery need to be determined to increase the possibility of employment. Employers not knowing the full abilities and capabilities of rehabilitated individuals may continue to exempt them from employment. The use of transitional work programs, in particular, may assist in returning coronary bypass surgery patients to employment.

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Daniel L. McMurray, MS, CRC, Rehabilitation Institute, Southern Illinois University at Carbondale, Carbondale, IL 62901.