Social support and physical and psychological recovery one year after myocardial infarction or coronary artery bypass surgery.

The aim of this study was to evaluate the role of different support factors supposed to explain physical and psychological recovery after myocardial infarction (MI) or coronary artery bypass surgery (CABS). The subjects comprised 147 MI patients and 159 CABS patients. Support factors included formal services, semi-formal assistance, and informal social support. The outcome measures used for analysis were functional activities level (Duke Activity Status Index, DASI), physical working capacity, anxiety, and depression one year after MI or CABS. In general, support factors had a limited role in this study. The patient's functional and psychological status at three months was the main determinant to recovery at one year. The outcome factors measured at three months explained 36-56% of their variance at one year, and the support factors increased the explanatory power by 0-10%. The support model employed in this study revealed that some single factors may have a positive or negative role in the recovery after MI or CABS.

Dyslipidemia and hyperglycemia predict coronary heart disease events in middle-aged patients with NIDDM.

Patients with NIDDM are at increased risk for coronary heart disease (CHD). However, information on the predictive value of cardiovascular risk factors and the degree of hyperglycemia with respect to the risk for CHD in diabetic patients is still limited. Therefore, we carried out a prospective study on risk factors for CHD, including a large number of NIDDM patients. At baseline, risk factor levels of CHD were determined in 1,059 NIDDM patients (581 men and 478 women), aged from 45 to 64 years. These patients were followed up to 7 years with respect to CHD events. Altogether, 158 NIDDM patients (97 men [16.7%] and 61 women [12.8%]) died of CHD and 256 NIDDM patients (156 men [26.8%] and 100 women [20.9%]) had a serious CHD event (death from CHD or nonfatal myocardial infarction). A previous history of myocardial infarction, low HDL cholesterol level (<1.0 mmol/l), high non-HDL cholesterol (> or =5.2 mmol/l), high total triglyceride level (>2.3 mmol/l), and high fasting plasma glucose (>13.4 mmol/l) were associated with a twofold increase in the risk of CHD mortality or morbidity, independently of other cardiovascular risk factors. High calculated LDL cholesterol level (> or =4.1 mmol/l) was significantly associated with all CHD events. The simultaneous presence of high fasting glucose (>13.4 mmol/l) with low HDL cholesterol, low HDL-to-total cholesterol ratio, or high total triglycerides further increased the risk for CHD events up to threefold. Our 7-year follow-up study provides evidence that dyslipidemia and poor glycemic control predict CHD mortality and morbidity in patients with NIDDM.

Resource support and heart patient recovery.

This prospective study examines the effects of resources utilized by myocardial infarction (MI) and coronary artery bypass (BY) patients in the recovery process. The resource support model incorporates formal (institutionalized) and semi-formal (mutual aid) services along with informal assistance (social networks). Patient interview data were collected on 147 MI and 159 BY patients at hospitalization and at 3 months. Sociodemographic, illness and resource data were obtained, and hospital records were abstracted. Two outcomes were evaluated: activity limitations and work capacity. Bivariate and multivariate analyses were used to assess individual and resource effects. Multivariate analyses revealed that, for MI patients, a higher level of activity prior to hospitalization and a shorter hospital stay were significantly related to recovery. A smaller social network with greater frequency of contact enhanced recovery. For BY patients, recovery was significantly associated with higher social class higher level of activity prior to hospitalization and fewer health care visits. Outcome based on work capacity revealed that MI patients who were younger in age, male sex and who had fewer prescribed medications were more likely to recover. By patients had a similar pattern as that observed for MI patients in terms of age and sex. Co-morbidity had a negative effect on recovery. Those with less affective informal support were more likely to have recovered. The resource support model employed in this prospective study proved to have mixed results. However, the model may be a useful multifactorial framework for examining the effects on patient recovery over a longer duration.

The biopsychosocial disease consequence model in rehabilitation: model development in the Finnish 'work hardening' programme for chronic pain.

To compare the effectiveness of diverse rehabilitation programmes, comparable data about their effects on maintaining or improving the residual function of the rehabilitation patients should be gathered. Current rehabilitation theories and assessment procedures for functioning are not consistent enough for valid comparisons. The rehabilitation theory should be developed to produce coherence and generalizability to the rehabilitation process. The biopsychosocial disease consequence (BPSDC) model for functioning is presented for this purpose. The model describes the rehabilitation process of patients with chronic pain as a three-axial (biopsychosocial) and three-dimensional (disease consequences) assessment and intervention grid for functioning. It emphasizes the strict mutual relationship between the assessment procedures and intervention plans. Application of the BPSDC model in the Finnish AKSELI project studying the effects of two different programmes on patients with chronic low-back pain is described. Although the AKSELI studies indicated that in addition to the assessment procedures other factors also contributed to valid evaluation of outcomes, and it is hoped that the BPSDC model will encourage researchers to look for definitions of functioning, to assess functioning according to theoretical assumptions about the sub-areas of functioning, and to provide comparable outcome data for the evaluation of various programmes.

Reduction in sudden deaths and coronary mortality in myocardial infarction patients after rehabilitation. 15 year follow-up study.

The study was set up to evaluate the long-term effects on mortality of a comprehensive rehabilitation and secondary prevention programme lasting 3 years after acute myocardial infarction. The study group consisted of 375 consecutive, non-selected patients under 65 years of age randomly allocated to an intervention group (188 patients) or a control group (187 patients). After 15 years follow-up significantly lower incidence of sudden death (16.5% vs 28.9%, P = 0.006) and coronary mortality (47.9% vs 58.5%, P = 0.04) were seen in the intervention group compared with controls. Total mortality was 64.4% and 66.8%, respectively (ns). The incidence of cancer death was 16 in the intervention group and three in the controls. Cardiac failure, enlarged heart, New York Heart Association functional class II or more and membership in the control group were significantly associated with coronary mortality during the first 3 years, and after 3 years enlarged heart, diabetes and reinfarction were associated with late coronary death. Thus, comprehensive multifactorial intervention after acute myocardial infarction had favourable long-term effects on coronary mortality and sudden death but no effect on total mortality.

Does NIDDM increase the risk for coronary heart disease similarly in both low- and high-risk populations?

Finland has marked regional differences in the occurrence of coronary heart disease (CHD). Although the causes for these differences in CHD mortality and morbidity in the Finnish population are unknown, it offers an excellent opportunity to investigate the effects of non-insulin-dependent diabetes mellitus (NIDDM) on CHD risk in two populations differing significantly with respect to the occurrence of CHD. Therefore, we carried out a 7-year prospective population-based study including a large number of patients with NIDDM (East Finland: 253 men and 257 women; West Finland: 328 men, 221 women) and corresponding non-diabetic subjects (East Finland: 313 men, 336 women; West Finland: 325 men, 399 women). In both study populations the presence of NIDDM increased significantly the risk for CHD events (CHD mortality or all CHD events including CHD mortality or non-fatal myocardial infarction). Diabetic men had 3-4 fold higher and diabetic women 8-11-fold higher risk for CHD than corresponding non-diabetic subjects. Both non-diabetic and diabetic subjects had odds ratios (East vs West) for CHD events of about 2 indicating a similar East-West difference in the CHD risk. Regional difference was quite similar in men and women. These results imply that factors related to NIDDM, independently of conventional risk factors and the occurrence of atherothrombosis in the background population, must play a major role in the pathogenesis of atherosclerotic vascular disease in NIDDM diabetes.

Can treatment outcome of chronic low back pain be predicted? Psychological disease consequences clarifying the issue.

OBJECTIVE: To search for generalizable, psychological predictors of chronic pain treatment outcome. DESIGN: The prognostic power of the psychological predictors, classified into subareas of function, i.e., impairments, disabilities, and handicaps, was compared in predictive situations varying with the quality of patient samples, programs, and outcome measures. SETTING: Four rehabilitation centers in Finland providing "functioning activation" or more passive "spa resort" treatment programs for low back pain patients. PATIENTS: 173 low back pain patients for whom the inpatient rehabilitation program was funded by the Finnish Social Insurance Institution. OUTCOME MEASURES: The measures were panel assessment of global functioning (DSM III Axis V), self-report of handicap (Million), panel assessment of handicap (WHO index), panel assessment of adherence (four rating scales), and self-report of well-being (Faces scale). RESULTS: Multivariate, stepwise regression analyses suggested that the disability and handicap measures of functioning may be more effective predictors than impairment measures, which, however, add to the variance explained by the former. However, the predictive power of psychological impairments, disabilities, and handicaps varied with differences in patient group, outcome measure, and program. CONCLUSION: The "general predictors" of chronic pain treatment outcome may be difficult to find. Therefore, planning treatment for the individual patient may always have to be based on accurate multiaxial and multidimensional assessment of patient functioning.

Intensive physical and psychosocial training program for patients with chronic low back pain. A controlled clinical trial.

STUDY DESIGN: The authors conducted a controlled clinical trial with 1-year follow-up to define the effectiveness of an intensive physical and psychosocial training program on patients with low back pain. SUMMARY OF BACKGROUND DATA: The intervention group included 152 patients (mean age 40.5 yr, Million index 45.1/100), and the reference group included 141 patients (mean age 40.4 yr, Million-index 44.5/100). METHODS: The progressive intervention program consisted of intensive physical training and psychosocial activation. The outcomes were physical and psychosocial measures, the pain and disability index (Million), sick leaves, and occupational handicap. RESULTS: The intervention was more efficient with respect to physical measures and pain and disability index. There were only mild or no differences in changes between the study groups in psychologic variables, sick leaves, or retirement. CONCLUSIONS: The intervention program could improve physical disability, but to improve occupational handicap, activities of the whole society (social legislation, labor market policy) are needed.

Cardiac rehabilitation and return to work after coronary artery bypass surgery.

The work situation of 66 male patients who underwent elective coronary artery bypass surgery (CABS) and who had been randomly allocated to receive cardiac rehabilitation (group R) was compared with the work situation of 59 similar patients allocated to receive only standard care (group H). The follow-up time was one year. The proportions of subjects working in groups R and H were 26% and 20% (p = ns) before the CABS, 45% and 34% (p = ns) 6 months and 56% and 38% (p = ns) 12 months after the CABS, respectively. The increase in proportion of subjects who worked was significant in both groups at both 6 and 12 months after the CABS (p < 0.05 for all changes). The increases were not significantly different between the whole groups, but in patients younger than 55 years of age, return to work was more frequent in group R than in group H (at 12 months 60% vs. 35%, p for the difference in change = 0.02). Stepwise logistic regression analysis of the factors influencing return to work showed that a patient's judgement of his own working capacity as good 6 months after CABS (odds ratio (OR) 8.5, confidence interval (CI) 2.3-32.0), functional class I 6 months after the CABS (OR 6.7, CI 1.8-24.5), his desire to work (OR 6.4, CI 1.6-26.0) and absence from work of less than 3 months before the CABS (OR 4.9, CI 1.2-20.2) were significant positive predictors of return to work 1 year after the CABS.

Mental health and functioning: a case analysis of rehabilitation patients.

The relationship between mental health and functioning has been inconsistently described. Here, the role of mental health in determining functioning was studied from a large multi-axial (biopsychosocial) and multi-dimensional (impairments, disabilities and handicaps) point of view. Case-analysis of rehabilitation patients indicated that inconsistent findings may be due to an incorrect linearity assumption. Results indicated that: (1) good mental health may aid the patient to benefit from rehabilitation. However, (2) it does not guarantee good future functioning, because the impact of mental health on functioning varies in interaction with other functional aspects. On the other hand, (3) poor mental health does not necessarily impede good future functioning, whereas (4) poor mental health, associated with other aspects of poor functioning, quite reliably predicts poor functioning after rehabilitation. It was concluded that single psychological factors cannot predict functioning. To improve prediction, broader models of functional assessment in rehabilitation should be used.

Exercise habits and physical performance during comprehensive rehabilitation after coronary artery bypass surgery.

The effects of training as part of a comprehensive rehabilitation programme on exercise capacity and habits was studied in 171 male coronary artery bypass surgery patients randomized into a rehabilitation (R) (n = 93) and a reference, hospital-based treatment (H), group (n = 78). The rehabilitation programme started with a 2-day informative course before surgery and continued with a 3-week exercise-based course 2 months after surgery followed by a 2-day refresher 8 months post-operatively. The percentages of subjects having regular exercise were 22% and 10% pre-operatively, 42% and 38% 6 months and 46% and 38% 12 months after surgery in the R and H groups, respectively. The changes in the proportions observed in R and H groups were not significantly different. Total work during a bicycle exercise test increased from 38.9 +/- 24.3 kJ pre-operatively to 64.0 +/- 31.4 kJ 6 months (P less than 0.001) and to 70.0 +/- 35.7 kJ 12 months (P less than 0.001) post-operatively in group R and from 40.8 +/- 25.6 kJ to 57.3 +/- 26.6 kJ (P less than 0.001) and to 60.4 +/- 30.8 kJ (P less than 0.001) in group H, respectively. The increase from the pre-operative value was greater in group R than in group H both 6 (P = 0.03) and 12 months (P = 0.02) after surgery. Respective changes occurred in maximal work load, but the increase was significantly greater in group R than in group H only 12 months post-operatively.(ABSTRACT TRUNCATED AT 250 WORDS)

Quality of life during rehabilitation after coronary artery bypass surgery.

The effect of a three-phase comprehensive rehabilitation programme on the quality of life during the first postoperative year after coronary artery bypass surgery was studied in 205 male patients randomly allocated into a rehabilitation (R) and a hospital-based treatment (H) group. The rehabilitation programme included physical exercise, relaxation training, psychological group sessions, dietary advice and discussions about postoperative treatment of coronary disease. There was no difference between R and H groups in the frequency of postoperative complaints, number of hospital admissions and satisfaction of sexual life. An almost significantly greater number of subjects in R group than in H group perceived their health as good 12 months after surgery. The Beck Depression Index score decreased significantly in R group but not in H group during follow-up. A greater increase in hobby activities was observed in R group than in H group. More subjects in R group than in H group considered rehabilitation important for recovery, whereas more patients in H group considered support by the spouse and family, the subjective mental strength and a secure income as important.

Coronary heart disease risk factors before and after bypass surgery: results of a controlled trial on multifactorial rehabilitation.

The effect of a three-phase multifactorial institution-based rehabilitation programme on coronary heart disease (CHD) risk factors was studied in an open randomised trial comprising 228 patients undergoing coronary artery bypass surgery allocated into a rehabilitation (R) group (n = 119) and a hospital (H = control) group (n = 109). Follow-up examinations were performed at 6 and 12 months. Serum total cholesterol and triglyceride levels decreased significantly in both groups during follow-up. These decreases were not significantly different between the R and H groups. Serum high density lipoprotein (HDL) cholesterol level increased significantly at 6 and 12 months in the R group, but not in the H group. The differences in the changes between the groups were not significant. The ratio of serum HDL cholesterol to total cholesterol increased significantly in the R group from the preoperative value of 0.154 to 0.179 (P less than 0.001) at 6 months and to 0.180 (P less than 0.001) at 12 months. In the H group these values were 0.152, 0.166 (P less than 0.001) and 0.168 (P less than 0.001), respectively. The significance of the differences in the changes between the groups were P = 0.01 at 6 months and 0.06 at 12 months. These differences were more obvious in patients aged 55 years or under. There was a significant decrease (P = 0.005) in the proportion of smokers in the R group and a significant increase in the proportion of patients taking regular exercise in both groups as assessed by questionnaire.(ABSTRACT TRUNCATED AT 250 WORDS)

High fasting plasma insulin is an indicator of coronary heart disease in non-insulin-dependent diabetic patients and nondiabetic subjects.

The association between fasting plasma insulin level and coronary heart disease (CHD) was studied in 909 non-insulin-dependent diabetic (NIDDM) patients, aged 45-64 years, and in 1,373 nondiabetic control subjects. Both diabetic and nondiabetic subjects with various manifestations of CHD had higher plasma insulin levels than did subjects free of CHD. By plasma insulin quintiles formed according to values in nondiabetic subjects, the age-adjusted prevalence of CHD defined by symptoms and/or electrocardiographic changes in diabetic men was 48.2% in quintiles I + II (lowest), 54.8% in quintiles III + IV, and 65.7% in quintile V (highest) (p = 0.006). The respective prevalences in diabetic women were 53.5%, 59.1%, and 73.3% (p = 0.004); in nondiabetic men, 28.1%, 33.7%, and 43.3%, respectively (p = 0.016); and in nondiabetic women, 28.1%, 34.9%, and 44.3%, respectively (p = 0.007). An essentially similar association was observed between plasma insulin level and definite or possible myocardial infarction (MI). In diabetic subjects, a positive association between plasma insulin level and CHD manifestations was also found when insulin strata were formed using quintile cutoff points determined separately from diabetic subjects. The association between plasma insulin level and the prevalence of CHD or MI disappeared or was weaker, especially in men, when adjustment was made for body mass index, hypertension, and triglyceride or high density lipoprotein (HDL) cholesterol level. The association between high plasma insulin level and CHD was significant in diabetic subjects with a body mass index greater than 27 kg/m2 but not in those diabetics with a body mass index less than or equal to 27 kg/m2. A significant clustering of hypertension, high triglyceride values, and low HDL cholesterol levels was observed in diabetic subjects in the highest insulin quintiles. The results suggest that hyperinsulinemia is an indicator of CHD in both NIDDM patients and nondiabetic subjects. Hyperinsulinemia may be directly atherogenic, but it is more probable that hyperinsulinemia reflects insulin resistance, which may be a factor enhancing atherogenesis by causing adverse changes in many CHD risk factors.

A prospective study of patients with sciatica. A comparison between conservatively treated patients and patients who have undergone operation, Part I: Patient characteristics and differences between groups.

Based on a prospective study on 342 sciatica patients examined with rhizography, the aim was to determine which factors others than the rhizography finding and the grade and duration of symptoms were related to the selection of patients to undergo operation. Compared with surgically treated patients, conservatively treated patients who did not undergo operation and who had pathologic rhizography findings had pessimistic attitudes to possible surgery, often expressed a desire to retire, and considered their work as physically stressful. The women in this group were older and had lower pain indices than women who underwent operation. Conservatively treated patients with negative rhizography had more severe occupational handicaps, minor expectations of possible surgery, physically more strenuous jobs requiring difficult physical positions, and lower indices for pain and ADL than did the operated patients. The social and ergonomic background problems are emphasized in sciatica patients conservatively treated after rhizography.

A prospective study of patients with sciatica. A comparison between conservatively treated patients and patients who have undergone operation, Part II: Results after one year follow-up.

The prospective study included 122 sciatica patients who had not undergone operation (NOPs) and 220 sciatica patients who had undergone operation (OPs); all had been examined by rhizography. The follow-up study was done on 110 (90%) of the NOPs and 212 (96%) of the OPs. The NOPs were divided into two groups: 30 patients with pathologic rhizography (PR) and 80 patients with negative rhizography (NR). Pain-, ADL-, and occupation-handicap indices showed that after the 1 year follow-up the OP group had the best result and the NR group the lowest result. The PR group had nearly as good a result as the OP group. Thus, sciatica patients are candidates for conservative therapy, even though they have pathologic findings in rhizography, if the symptoms are mild. To improve therapeutic outcome, more accurate diagnostic tools are needed to develop specific therapy especially for those sciatica patients with negative rhizography.

Clinical, social, and psychological factors and outcome in a 5-year follow-up study of 276 patients hospitalized because of suspected lumbar disc herniation.

The study consisted of 276 patients who were hospitalized between 1980 and 1982 because of suspected lumbar disc herniation. No randomization of treatment was used. On the basis of clinical indications 179 patients were operated on and 97 had further conservative treatment. Results of physical, social, and psychological examinations performed after 1 year were related to the 5-year outcome defined by occupation handicap of the WHO system. For operated patients, subjective working incapacity, sensory deficit of leg, tightness of hamstrings, age, and pain in lumbar extension predicted a poor outcome. Predictive factors for non-operated patients were increased occurrence of occupational hazards and co-morbidity.

Prognostic value of an exercise test one year after myocardial infarction.

An exercise test was performed in 306 patients who had had acute myocardial infarction one year previously. The five year cumulative coronary heart disease mortality was 40.0%, when the test had to be discontinued because of ventricular arrhythmias but only 13.0% if discontinued because of fatigue (P less than 0.05). If the maximum work load was less than 80 W the mortality was 30.7% compared with 16.6% in patients who exercised at least 80 W (P less than 0.01). If maximum systolic blood pressure was less than or equal to 150 mmHg mortality was 40.3% compared with 8.5% in patients with greater than 200 mgHg (P less than 0.001). The mortality was 38.2% in patients having single monoform ventricular ectopic beats at a rate of three or more per minute or multiform, paired or early cycle ventricular ectopic beats or ventricular tachycardias: this compared with 14.1% (P less than 0.001) in patients having no or only single monoform ventricular ectopic beats at a rate of less than three per minute. ST-segment depression in univariate testing had no prognostic value. When both exercise test and clinical variables were used in survival analysis (Cox's regression) the most important variable was heart volume and after that ventricular arrhythmias. In multivariate regression analysis ST segment depression also had additional prognostic value. Thus ventricular arrhythmias turned out to be the most important prognostic factor measured during exercise test.