twice per day with 30 control patients.287 At 6, 12, and 24 weeks, there were no differences in exercise tolerance between intervention and control patients. One observational study of 50 patients with disabling CHD who were unsuitable for surgical intervention reported a significant increase in exercise duration after 8 weeks of exercise training, education, counseling, behavioral interventions, and stress management (p < .01).198 Without a comparison group, spontaneous improvement cannot be ruled out. Conclusions Limited data fail to demonstrate the efficacy of education or counseling as sole interventions, independent of exercise training or other elements of cardiac rehabilitation, in improving exercise tolerance. Education, counseling, and behavioral interventions may improve morale, self-esteem, and adherence to exercise. Symptoms RECOMMENDATION Cardiac rehabilitation education, counseling, and behavioral interventions are recommended, alone or as components of multifactorial cardiac rehabilitation, to reduce symptoms of angina. Scientific Evidence (Strength of Evidence = B) Four reports described changes in anginal symptoms as a result of cardiac rehabilitation education and counseling: two randomized controlled trials,149,274 one nonrandomized controlled trial,221 and one observational report.198 A randomized controlled trial in coronary patients described a statistically significant decrease in the frequency of anginal episodes in the stress management intervention group.149 A second randomized controlled trial of patients at least 6 months after myocardial infarction reported significantly (p < .05) less angina at the 3-year followup in patients who received Type-A counseling compared with control patients.274 A nonrandomized controlled study of patients after PTCA reported no significant difference between intervention and control groups in exercise-induced angina at the 18-month followup.221 One observational report described significant reduction in weekly anginal episodes and nitroglycerin use after 8 weeks of multifactorial rehabilitation.198 Conclusions Education, counseling, and behavioral interventions, either alone or as components of multifactorial cardiac rehabilitation, are associated with reduction in angina pectoris. Behavioral interventions are generally effective in reducing anginal pain. The benefit of exercise training in reducing angina is discussed in Chapter 2. Return to Work RECOMMENDATION Education, counseling, and behavioral interventions have not been shown to improve rates of return to work, which are contingent on many social and policy issues. In selected patients, formal cardiac rehabilitation vocational counseling may improve rates of return to work. Scientific Evidence (Strength of Evidence = C) Three randomized controlled trials addressed the effect of cardiac rehabilitation education, counseling, and behavioral interventions on return to work and showed no statistically significant difference in return to work between intervention (education, counseling, and social interventions plus exercise training) and control groups. 9,122,288 Conclusions Multifactorial cardiac rehabilitation, including education, counseling, and behavioral interventions, has not been shown to alter the rates of return to work. Education and counseling may improve a patient's potential for return to work. Many other factors that play a significant role in return to work, including willingness of the employer to reemploy the patient, the patient's level of job satisfaction, economic incentives, and perceived stress of the job, were not evaluated in the studies cited. Better understanding (via education) of capabilities and limitations regarding work may influence a patient's selfefficacy for returning to previous employment or for seeking job retraining. A randomized controlled trial in a health maintenance organization population (a nonrehabilitation setting) of the effect of occupational work evaluation on return to work in patients after myocardial infarction documented a 32percent reduction in duration of convalescence.56 Stress and Psychological Well-Being RECOMMENDATION Education, counseling, and psychosocial interventions-either alone or as components of multifactorial cardiac rehabilitation-result in improved psychological well-being. Education, counseling, and behavioral interventions are recommended to complement the psychosocial benefits of exercise training. Scientific Evidence (Strength of Evidence = A)_ Fourteen reports described the effects of education, counseling, and behavioral interventions as components of cardiac rehabilitation on psychological outcomes. Six were randomized controlled trials. 156,239,274,276,289,290 Six were nonrandomized controlled studies,277,287,291-294 and two were observational studies.295,296 Details of the randomized and nonrandomized controlled trials are shown in Tables 11 and 12. In all 6 randomized controlled trials, beneficial results in several psychological outcomes favored intervention patients over control patients. These outcomes included improvements in scores of overwork behavior and time urgency,276 Type-A behavior,274 distress,290 and quality-of-life and state anxiety measurements (at 8 weeks but not at 12 months).156 No differences between intervention and control groups were reported for depression, 156,276,289 anxiety and life dissatisfaction,276 or self-efficacy.239 Five of the six nonrandomized controlled trials reported statistically significant improvements in psychological outcomes,277,287,291,292,294 and one did not.293 Improvement in psychosocial outcomes favoring intervention patients over control patients occurred in hypochondriasis and emotional lability in relaxation and stress management groups;294 improved measures of state anxiety, somatization, interpersonal sensitivity, anxiety-depression, and Type-A behavior were also reported.291,292 No differences between groups were reported for measures of emotional reactivity, depressed mood, assertiveness, and job involvement;294 scores of obsessive compulsiveness and hostility;291,292 Sickness Impact Profile scores;287 and other measures of quality of life.293 One observational report of weekly group therapy for stress management that used relaxation techniques and management of anger reported improvement in mean global Type-A behavior scores as well as reductions in hostility, anger, depression, anxiety, obsessive-compulsive symptoms, interpersonal sensitivity, and somatization.295 Conclusions The studies cited provide evidence of psychological improvement following education, counseling, and/or psychosocial interventions. Training in behavior modification, stress management, and relaxation techniques is effective in lowering levels of self-reported emotional stress and in modifying Type-A behavior.274,291 In the largest randomized controlled trial-the Recurrent Coronary Prevention Project-Type-A behaviors were modified in men and women in a nonrehabilitation setting.274 Education, counseling, and psychosocial interventions in nonrehabilitation settings have been shown to improve time urgency and overwork behaviors,276 reduce stress,290,298 and improve measures of quality of life and anxiety.156 Specific aspects of the psychological interventions responsible for the beneficial psychological outcomes were not always provided. Interventions varied in duration and frequency and were delivered by personnel with varying expertise. Nonuniform outcome measures were used, making it difficult to compare results across studies. The better designed studies, which used more highly skilled or trained providers, demonstrated greater benefit. |