Return to Work After a Coronary Event

Coronary heart disease (CHD) is the leading cause of death in the United States and around the world.1 On the basis of a recent survey, the American Heart Association estimated that CHD accounts for more than 20% of all deaths. Depending on gender and clinical outcome, individuals who survive the acute phase of a heart attack have a subsequent chance of cardiac events that is 1.5 to 15 times higher than that of the general population. In other words, CHD-related mortality increases to 40% when deaths within 1 year of a coronary attack are included.2 As far as the general workforce is concerned, it is worth noting that CHD is the leading cause of premature, permanent disability in the US labor force, accounting for 19% of the disability allowances by the social security administration.2 The current cost of coronary heart disease in the United States is estimated to be approximately $130 billion. This cost includes insurance, wage replacement, medication, and continued healthcare. Besides the enormous economic burden, CHD survivors and their families sustain considerable pain and suffering. Rehabilitating CHD patients to work is therefore highly desirable from both the economic and humanitarian perspective. A primary goal of cardiac rehabilitation is to facilitate resumption of daily activities, not only return to work. Return to work is a part of social readjustment after CHD. Functional, social, psychological, and vocational activities after CHD are important in the framework of cardiac rehabilitation. A multidisciplinary approach is therefore essential in cardiac rehabilitation.3 This review aims to highlight the impact of various factors such as age, gender, physical work capacity, education level, and type of occupation in addition to psychosocial factors that play a crucial role in determining the successful return to work of CHD survivors. For example, it may be noted that patients with a long history of unemployment are harder to reintegrate into the workforce and reactivate for work. Previous job stability also may be a predictive variable. Societal factors, independent of medical considerations, also are major determinants of work status. For example, local unemployment rates, less favorable working conditions, inflexible employer attitudes about adjusting work loads, employer return policies, and inadequate medical care benefits are cited as reasons for lower rates of return to work after an acute myocardial infarction (MI). It is important to note that current cardiac rehabilitation protocols are generally not very effective in returning individuals with CHD to work. A more successful intervention and suggestions for making such interventions more effective are presented in this article. BACKGROUND AND CURRENT STATUS Whether a patient will return to work after a serious cardiac illness is a complex question. Interviews of patients with coronary artery bypass grafts (CABG) have shown that the reasons for not resuming work are not based solely on cardiac findings. Only 30% to 40% of the individuals with a CABG questioned said that heart problems kept them from returning to work.4,5Table 1 lists the factors related to a CHD survivor's postoperative return to work.Table 1: FACTORS RELATED TO POSTOPERATIVE RETURN TO WORK AFTER CARDIAC EVENT6The rate of return to work after an acute MI is decreased for women who have worked previously, older workers, blue-collar workers with physically strenuous jobs, and individuals with psychiatric problems, Psychological factors play a prominent role in determining whether a CHD patient will indeed return to work. In this sense, the impact of an acute MI is as much psychological as it is physical. For example, in response to the stress of the CHD illness, some patients become emotionally distressed, and productivity is thereby, influenced. The factors influencing return to work are presented in Table 2.Table 2: PREDICTORS OF PROBLEMS IN RETURN TO WORK AFTER A MYOCARDIAL INFARCTION7EFFECT OF EDUCATION LEVEL ON RETURN TO WORK A higher level of education favors successful return to work. Of patients returning to work after bypass surgery, three times as many had finished high school as postoperatively retired patients.8Table 3 summarizes the effect of education on return to work.Table 3: RETURN TO WORK AND EDUCATIONAL LEVEL9EFFECT OF OCCUPATION TYPE ON RETURN TO WORK The type of occupation plays an important role in determining successful return to work. In most cases, it is related directly to education level because 65% of patients not working postoperatively have been blue-collar workers, whereas the remaining 35% have been white-collar workers.10 The relation was reversed for working CHD patients, with 30% of these patients working at blue-collar jobs and the remainder working at white-collar jobs. EFFECT OF GENDER ON RETURNTO WORK Problems with return to work after an acute MI among women merit special attention. Increased morbidity among women after an acute MI has been suggested as a reason for their lower rates to return to work. Although one study showed no relation between initial MI severity and return to work among women, in general, 6-month self-reports of physical limitations have shown that these are correlated with lower working rates at 2 years.7 A higher rate of psychiatric problems among women after an acute MI than among men also may account for this finding. For instance, women have more depressive symptoms after an acute MI than men, a finding that is consonant with the prevalence of depression in the general population. Women, particularly married women, often may be more discouraged from returning to work. Moreover, women may have a different attachment to their work than men. In this sense, leaving the labor force may be easier for women than men, and may be an adaptive response to an acute MI.7 EFFECT OF AGE ON RETURN TO WORK An acute MI is very likely responsible for hastening the midlife task of reevaluating the meaning of work. This could account for the changes in work patterns among this age group after an acute MI. For patients who experience an acute MI in midlife (age 40-60 years), the life-threatening aspects of the disease mirror the central psychological tasks of midlife.7 In many experiments, the experience of an acute MI has been found to hasten retirement decisions. Older patients who experience an acute MI, particularly those older than 60 years, are less likely to return to work than younger patients.7 EFFECT OF PSYCHOLOGICAL FACTORS ON RETURN TO WORK The most important and decisive factors associated with return to work after a cardiac event are psychological in nature, such as a negative influence of postoperative depressive mood.11 Patients with depression return to work significantly more often at 6 months if their defense mechanisms are adequate, if their life adjustment is satisfactory, and if they had realistic and concrete plans for the future.12,13 The patient's desire to work again after a cardiac event is another important psychological predictor.14 It is worth noting that 97% of patients who did not want to work again actually did not resume work. On the other hand, each of those who were working had the desire to do so. The availability of disability benefits is another factor that cannot be ignored. If a patient receives as much money from retirement or disability payments as he or she earned by doing the job, this fact favors a decision not to resume work. The attitude of the patient toward his work and the amount of work he or she has done over a lifetime is another factor. If patients feel they have already worked enough during their lifetime, there is a very high chance that they may not want to return to work. Many patients are afraid they will not be able to work as efficiently as before the cardiac surgery. They fear financial restrictions, loss of prestige, and the like. The high mental rigidity observed in many coronary patients acts as an impediment against adequate adjustment to vocational changes and limitations. The studies conducted by Boll et al12 showed that the preoperatively expressed desire to work again after surgery in addition to an optimistic attitude with concrete plans for the future correlated most closely with the study criterion. It is interesting to observe that these correlations were better than those of various clinical predictors. Vocational rehabilitation is favored by a dominant personality structure and higher activation, as well as by more optimism and plans for the future, including the desire to work after surgery.12,13 The main determinants for a patient not returning to work after CABG are of socioeconomic origin. The most important among these is the patient's preoperative work status. The longer the patient has been unemployed, the less likely it is that he or she will return to work. Age also is an important factor in determining return to work after surgery. The unemployment rate of patients younger than 55 years is substantially lower than among older patients. The authors conclude that several variables characterizing emotional state and the specific situation of a patient favor or impede successful return to work. Table 4 presents the psychological variables observed preoperatively, immediately after the operation and just before discharge.12 It can be observed that these factors correlate significantly with vocational outcomes. It is interesting to note that psychological factors directly affecting postoperative return to work of patients with cardiac surgery have remained unchanged over time.Table 4: SIGNIFICANT CORRELATIONS BETWEEN RETURN TO WORK AND PRE- AND POSTOPERATIVE PSYCHOLOGICAL VARIABLES*12EFFECTIVE OCCUPATIONAL WORK EVALUATION PROGRAMS: SHORTCOMINGS OF CURRENT PRACTICES Although the need for work simulation in the occupational therapy of cardiac patients has been recognized, it is generally thought that a standard clinical assessment is sufficient to simulate the physical and psychological stress of work.15 The studies on which this conclusion is based involved simulated upper extremity static work and dynamic leg exercises. The majority of jobs, in either the production or the service industry, involve a combination of activities such as physical movement, postural changes, load handling, and force exertions over a prolonged period. Studies involving work simulation need to simulate actual working conditions and real jobs. For example, there is no semblance between treadmill exercise and industrial jobs. Even from a physiologic standpoint, the majority of industrial jobs do not require the kind of physical capacity that treadmill exercises enhance. The shortcomings of existing cardiac rehabilitation programs is further demonstrated by the fact that rehabilitation programs, which enhance the aerobic capacity of cardiac patients (treadmill or bicycle exercise-based programs), have failed to reduce periods of work disruption after myocardial infarction. Most patients with a positive outlook toward their postoperative life and those who believed that their illness would last for a short time are generally able to resume work within 6 weeks.16 However, it also has been observed that exposure to rehabilitation programs tends to improve patients' exercise tolerance, thereby shortening the time to resumption of work. Most rehabilitated patients with a positive future outlook manage to return to their previous jobs within 10 weeks.17 Despite the fact that most CABG patients can return to their premorbid functional status (aerobic capacity), the results of CABG surgery with respect to vocational rehabilitation have been disappointing. Whereas many studies analyzing correlative factors report return to work figures in the 70% to 90% range (average, 75%) within the first year after surgery,15,18–20 other studies report that these figures have not been sustained in the past several years. Table 5 compares the decisive factors that play a crucial role in the patient's return to work after surgery for MI and CABG.Table 5: COMPARISON OF THE DETERMINANTS FOR NOT RETURNING TO WORK AFTER MI AND CABG3It appears, then, that many individuals do not return to work or lead more productive lives after surgery, although they report marked improvements in terms of symptoms and functional capacity. Indeed, some of the aforementioned studies noted that although 90% of the patient population may have had symptomatic improvement and relief of angina, only 50% return to work. Stanton et al21 found no overall improvement in return to work or in hours worked after surgery. It is obvious that although surgical and medical/pharmacologic interventions have been effective in relieving symptoms of angina pectoris (chest pain) and in increasing tolerance for exercise,22 the efficacy of these methods alone in returning cardiac patients to their premorbid position in society, a presumed goal of cardiac rehabilitation, has been less than optimal. Physical work demands are important in the assessment of the CHD patient's return to work capacities. It has been shown that significantly heavy physical labor delays return to work, but does not affect the ultimate return to work outcome at 1 year. Wiklund et al23 found that 83% of workers previously engaged in lighter sedentary work resumed employment, whereas only 67% of those engaged in physically heavy work returned to work. These findings suggest that a cardiac rehabilitation program based on job-related elements should be pursued rather than aerobic exercise-based rehabilitation programs that have no semblance to real work situations, physically or cognitively. The preceding discussion presents no evidence that existing cardiac rehabilitation programs achieve a reduction in lost time from work, a major objective of rehabilitation. Given the enormous economic and social burdens that CHD imposes upon society and the patient, the time to resumption of work must be reduced. The fact that contemporary cardiac rehabilitation programs have not been shown to reduce periods of work disruption further is a motivation to research other approaches. Most cardiac rehabilitation programs have only elements of phases 1 and 2, and are supervised only by clinical professionals (cardiologists, exercise physiologists, and nurses). However, when early return to work is the major goal of the cardiac rehabilitation program, a multidisciplinary team approach is needed. SUGGESTED INTERVENTIONS Conventional cardiac rehabilitation training programs focus on the use of aerobic exercise to restore the functional capacity of CHD survivors. If a cardiac rehabilitation training program's primary goal is to return the CHD survivor to work, it is reasonable to base phase 2 of the cardiac rehabilitation training program on actual job-related activities. Mital et al24 designed and field tested a job-simulated phase 2 cardiac rehabilitation program. The sample population was stratified according to the patient's gender and the nature of the work he or she performed at the time of MI and work disruption. The sample population was stratified further according to the nature of work. To contain the size of the study, only two broad categories were used: (1) physical work, including the performance of medium to very heavy jobs, and (2) sedentary light work, including office, secretarial, and managerial work. Thus, within each gender, half the patients had a history of performing sedentary light work, whereas the other half had a history of performing medium to very heavy work. The overall stratification of the sample population thus allowed a study of the effect that a job-simulated cardiac rehabilitation training program had on both men and women performing two very different categories of work. The details of this population are depicted in Table 6.Table 6: MEAN, STANDARD DEVIATION, AND RANGE OF POPULATION DESCRIPTORS24The training activities included flexibility exercises, dexterity exercises, and strength-oriented upper- and whole-body exercises. During each training session, the CHD patient began with flexibility exercises, followed by progressive time exercises (PTE), and then flexibility exercises again. The flexibility exercises preceding PTE served as warm-up exercises, and those after PTE served as cool-down exercises. The training protocol is shown in Table 7. Each patient performed the same type of exercise in the same sequence.Table 7: PROTOCOL USED IN THE JOB-SIMULATED PHASE II CR TRAINING PROGRAM24Flexibility exercises accounted for the motions of the spine, lower extremities, upper extremities, and neck. Flexibility activities of the spine and lower extremities were performed in alternate sessions. During other sessions, the upper extremity flexibility activities were performed. Spinal flexibility and lower extremity activities included spinal flexion and extension, spinal rotation, sit and reach, alternate standing and squatting with straight back-bent knees, and ankle flexion-extension. Upper extremity and neck flexibility activities encompassed the following components: shoulder flexion-extension, shoulder abduction-adduction, wrist flexion-extension, lateral deviation of the wrist, forearm pronation-supination, neck flexion-extension, and neck rotation. In the first six sessions of training, each flexibility exercise was performed six times: four times before PTE and twice after PTE. Each individual also was instructed to count from 1 to 8 in the final position of each flexibility exercise repetition. In the second and third the of each flexibility exercise was by three times in the warm-up and in the cool-down and the count was by Thus, in the third of training, the of each flexibility exercise was and the count also was The PTE was to improve and During each of the CHD patient as many as at a to 50% of as the load a group could a working During each training session, the individuals the PTE as many times as they could the exercise no longer because of overall local or of cardiac symptoms In the of physical capacity, it should be noted that training often to be in of from improvement to as much as one daily activities load individuals to 50% of their physical are an important part of a overall capacity, and should be an part of cardiac rehabilitation Each CHD patient performed two of overall exercises and upper exercises. Each exercise was conducted in alternate training sessions. The overall exercises involved an industrial task a combination of and The authors have noted that individuals are to if the cardiac rehabilitation program includes elements such as Each patient performed four different of dexterity and and shoulder of the and the are in the following The is to in the of for jobs that require and dexterity and The of and with as in The is to the following 1: to as many as into the of the within a time to as many as into the of the within a time both to as many into the within a time and into the both The time is 60 The is based on the of have shown that the is related to job performance in a of industrial such as light and the The dexterity the use of to a in each A high for work involving the use of 2: dexterity The dexterity in The of and two with The is to all the from one and them on of the other with the of the This type of is important in many different jobs, in industrial training, and in many of 3: dexterity in the field study were stratified by the nature of the task or performed at the time of MI. Table 8 the results of and improvements in aerobic capacity and heart when were by the nature of work.Table EFFECT OF CR TRAINING ON AND FOR AND in Table improvements in aerobic capacity were only for the heavy work The improvements in each cardiac rehabilitation program, were not different from each other For heart of the and changes were The changes in each cardiac rehabilitation program also were not different from each other for either work The CHD patients who in this field study had an overall improvement in their physical and functional The training program also in a return to work rate for the job-simulated training program, as with for the cardiac rehabilitation training program. The physiologic of the CHD patients in the study also was with that in a phase 2 cardiac rehabilitation training program. It was that a training program, such as the job-simulated training program in this field study, is far to cardiac rehabilitation phase 2 training programs that aerobic Besides physical functional and physiologic of CHD a job-simulated phase 2 cardiac rehabilitation training program returned more of them to the same job they before the Given the of cardiac rehabilitation training programs in returning CHD patients to work, a approach to cardiac rehabilitation to have such a program is it would be to the results in other It would be particularly interesting to the outcome of such a program in an industrial If the results are it would be the approach to cardiac rehabilitation. A of results also would be in that this approach to cardiac rehabilitation has merit and should be a of standard cardiac rehabilitation It should be noted that field study can be and time The of cardiac rehabilitation programs, as by the return to work for CHD patients, is a motivation for other that for The job-simulated phase 2 cardiac rehabilitation training program is such an