Contents

1. Position Statement .............................................................................................................................. 3

2. Background ......................................................................................................................................... 4
2.1 Cardiovascular disease ................................................................................................................... 4
2.2 Cardiac rehabilitation ..................................................................................................................... 4
2.3 Evidence for cardiac rehabilitation ................................................................................................ 5
2.4 Exercise and cardiovascular disease .............................................................................................. 5
2.5 Current cardiac rehabilitation provision ........................................................................................ 6
2.6 Physiotherapy and cardiac rehabilitation ...................................................................................... 7
3. Physiotherapist involvement in cardiac rehabilitation in the United Kingdom ............................... 8
3.1 Standards........................................................................................................................................ 8
3.2 Hours .............................................................................................................................................. 8
3.3 Physiotherapy involvement in Phases of cardiac rehabilitation .................................................... 9
3.4 Grade of physiotherapy staff ......................................................................................................... 9
4. Physiotherapist specialist knowledge and skills .............................................................................. 11
4.1. Clinical skills ................................................................................................................................. 11
4.1.1 Acute ..................................................................................................................................... 12
4.1.2 Musculoskeletal..................................................................................................................... 12
4.1.3 Movement analysis ............................................................................................................... 13
4.1.4 Respiratory ............................................................................................................................ 14
4.1.5 Neurology .............................................................................................................................. 15
4.2 Communication and multi-disciplinary skills................................................................................ 15
4.3 Continuing professional development ......................................................................................... 16
5. Pathway for physiotherapists to achieve competence to prescribe exercise to cardiac
populations ............................................................................................................................................ 18
6. National Audit of Cardiac Rehabilitation ......................................................................................... 21
6.1 Demographics............................................................................................................................... 21
6.2 Physical activity levels (5 x 30 min sessions per week) ................................................................ 22
6.3 Physiotherapy input and risk categorisation................................................................................ 22
7. Summary ............................................................................................................................................ 24
8. Appendices......................................................................................................................................... 26
Appendix 1: Core Academic and Practical Skills taught at undergraduate level. .............................. 26
1

Appendix 2: CSP curriculum framework for qualifying programs ...................................................... 27

Appendix 3: Percentage of PT input and risk categorisation data ..................................................... 28
Appendix 4: References..................................................................................................................... 28
Acknowledgements ............................................................................................................................ 32
Document Contributors ..................................................................................................................... 32

1. Position Statement
Physiotherapists play a vital role within the multidisciplinary team (MDT) delivering
comprehensive cardiac rehabilitation (CR) to cardiac patients. The Association of Chartered
Physiotherapists in Cardiac Rehabilitation (ACPICR) is committed to supporting the advancing
role of the physiotherapist in this life saving intervention.
The aim of this document is to:

Report on the current involvement of physiotherapists within CR nationally

State the specialist skills, knowledge and experience of a CR physiotherapist

Provide a recommended pathway for physiotherapists to achieve competency to

prescribe exercise to cardiac populations

Support the role of the physiotherapist working in CR with data collected through the
National Audit of Cardiac Rehabilitation (NACR).

This document is aimed at:

Physiotherapists working within CR

CR managers

Commissioners.

2. Background
2.1 Cardiovascular disease
Cardiovascular disease (CVD) encompasses all diseases affecting the cardiovascular system:
heart, arteries and blood vessels. CVD is the leading cause of death and disability globally,
with more deaths annually than from any other cause (1). In the United Kingdom (UK) it
accounts for 191,000 deaths each year, approximately a third of all deaths (2).

Despite coronary heart disease (CHD) mortality rates declining over the past two decades, it
still remains the most common cause of death in the UK, accounting for a total of 88,000
deaths in 2008 (2). With an older population and the increasing levels of CHD that accompany
this, the healthcare and economic burden of CHD remains greater than ever and it is likely
this will only increase in the future (2).
2.2 Cardiac rehabilitation
Cardiac rehabilitation is defined as:
The co-ordinated sum of interventions required to ensure the best physical, psychological
and social conditions so that patients with chronic or post-acute cardiovascular disease may,
by their own efforts, preserve or resume optimal functioning in society and, through improved
health behaviours, slow or reverse progression of disease (3).

It is a complex intervention that requires the input of a MDT of qualified and competent
professionals to encompass and deliver the recommended seven core components: 1) Health
behaviour change and education; 2) Lifestyle risk factor management (including physical
activity and exercise); 3) Psychosocial health; 4) Medical risk factor management; 5) Cardioprotective therapies; 6) Long term management; 7) Audit and evaluation (4). CR not only
provides advice and support for patients to make healthier lifestyle choices but also supports
them to return to work and develop important self-management skills for long term
adherence (5).

CR has traditionally consisted of four Phases over various healthcare settings: I) The inpatient
stage or after a change in a cardiac condition; II) Early post discharge period; III) Structured
4

exercise training with continued educational and psychological support; IV) Long term
maintenance of physical activity and lifestyle change (6). The Department of Health
Commissioning Pack for Cardiac Rehabilitation (5) recommends a seven-stage pathway for CR
services, from identifying and referring eligible patients to discharge and transition to longterm management.
2.3 Evidence for cardiac rehabilitation
The efficacy of comprehensive exercise-based CR has been demonstrated in the literature
and is considered a fundamental intervention in CVD management and prevention (7, 8). It
has been shown to significantly reduce cardiac, cardiovascular and all-cause mortality (9 11).
CR has also been shown to improve patient quality of life, physical activity status and anxiety
and depression levels (12). Furthermore, CR supports early return to work and the
development of self-management skills (12). Recent evidence now suggests that exercisebased CR is also associated with a reduction in myocardial reinfarction (10) and a reduction in
early post discharge hospital readmission rates (13). Altogether it is one of the most costeffective treatments available second to only aspirin and beta blockers (14).
2.4 Exercise and cardiovascular disease
The benefit of keeping physically active has been advocated for thousands of years. The
ancient philosophers recommended exercise as a means of living long, healthy lives (15), and
in the 17th century Heberden recorded that one of his patients angina was cured through the
regular sawing of wood (16). Physical inactivity is linked to low levels of physical fitness and is
considered a major and independent risk factor in both the development and progression of
CHD (17-19). The more physically active an individual is, the greater their degree of fitness and
the lower their risk for developing CHD (17, 20). The importance of the relationship between
physical activity, physical fitness, cardiovascular health and survival has been well-established
from epidemiological research. Workers who were less physically active in their job suffered
more heart attacks compared to workers who were more active. Men who had a more
active lifestyle and participated in vigorous leisure-time exercise at least twice a week
reduced their risk of developing CHD by up to a third (21, 22). The importance of exercise in the
secondary prevention of CHD developed through these findings.
5

Structured exercise as a therapeutic intervention is central to comprehensive CR as it

enhances levels of physical activity, improves physical fitness and may also beneficially
modify other coronary risk factors such as blood pressure and helping with weight loss (23, 24).
In addition, it has been shown to help regain self-confidence (25, 26) and increase survival rates
(27, 28)

. Even small improvements in fitness appear to reduce mortality (29), but more vigorous

exercise regimes have a greater effect in populations with or without CVD (18, 30). In both
primary and secondary prevention of CVD, with every one metabolic equivalent increase in
aerobic fitness there is a reduction of 8 17% in mortality (31). It is recommended that
patients with CVD perform moderate intensity aerobic exercise for 20 30 minutes at least
two to three times a week (32).

Outcomes relating to cardiorespiratory fitness in the majority of CR programmes have been

shown to improve significantly in trained groups when compared to the controls (23, 33-36).
This improvement in fitness has been reported up to 20% more than that which can occur
spontaneously (37-40).

A systematic review and meta-analysis found that trials of CR which included an exercise
component showed a significant reduction in all-cause mortality (20%) and cardiac mortality
(26%) (9). These mortality effects of exercise therapy were found to be consistent across a
number of CHD groups, including post myocardial infarction, post revascularisation and
angina.
2.5 Current cardiac rehabilitation provision
Currently there are 307 CR centres across the UK, providing 348 Phase I III programmes (41).
Although the number of eligible people taking part in CR is slowly increasing there is still a
long way to go to ensure that every eligible patient has access to this intervention. In
particular, patients with heart failure (HF) make up only 1% of referrals and a quarter of all
programmes exclude patients with this diagnosis (41), this is despite guidance that CR is safe
and effective in this patient group (8, 42).

2.6 Physiotherapy and cardiac rehabilitation

Physiotherapists have played a key role in development and growth of CR in the UK since its
inception in the 1970s. Their professional training, clinical knowledge, experience and skills
qualify them to take the lead in the delivery of the physical activity and exercise component
of rehabilitation. The addition of a physiotherapist as a core member of the MDT has been
shown to increase physical activity levels in patients with CHD compared to usual care (43).

The lead in the delivery of the exercise component of CR is however by no means exclusive to
the physiotherapist, as an interdisciplinary approach may also include or solely be led by an
exercise specialist (exercise physiologist/ sports scientist / exercise instructor). It is therefore
imperative to recognise and understand the individual professional competencies that each
exercise professional possesses and contributes to the CR team.

3. Physiotherapist involvement in cardiac rehabilitation in the United

Kingdom
3.1 Standards
The British Association for Cardiovascular Prevention and Rehabilitation (BACPR) Standards
and Core Components document outlines what patients, healthcare professionals and
commissioners should expect from a high quality CR programme. It recommends an
integrated MDT of qualified practitioners with the appropriate skills and competencies to
provide the service and include a physiotherapist within this (4). The Scottish Intercollegiate
Guidelines Network guidelines also include physiotherapist involvement (6).

National audit data shows a significant reduction in the professions available in the delivery
of CR (41), the exception being exercise specialists, where there has been a significant
increase. From 2007 2010 the number of centres reporting access to a physiotherapist
dropped from 75% to 62%, with only 162 centres out of 262 reporting input in the year 200910 (41).
3.2 Hours
The recommended physiotherapy input per 500 patients is 2.0 whole time equivalent (WTE)
of a band 6/7 physiotherapist (6). Data shows that although a number of CR programmes
report having a physiotherapist within their MDT or access to one, the hours dedicated to CR
were most likely to be provided on a part-time basis only (44). The ACPICR membership data
(2009 10) supports this with members reporting to work a mean of 17 hours per week in
CR. This is nearly identical to data published in 2004 (45) which reported 71.3% of
physiotherapists devoted less than 18 hours per week to CR. ACPICR membership data is not
able to relate these reported hours to the number of patients. However, data from the NACR
reported only 11% of programmes met the physiotherapy staffing levels recommended per
quota of patients (46).
The Coronary Prevention Group England (47) conducted a survey of Phase III CR. All but two
programmes surveyed (26/28) in England employed a physiotherapist as one of its core team
8

members, although 43% of co-ordinators reported lack of physiotherapy time to be their

greatest deficiency in service delivery.
3.3 Physiotherapy involvement in Phases of cardiac rehabilitation
A UK-wide survey (45) reported that the majority of physiotherapists (83%) working in CR were
involved in Phase III rehabilitation. ACPICR membership data supports this, with 82% of
members reporting involvement in Phase III (Table 1), significantly more than any other
phase, however many physiotherapists frequently work in more than one phase of
rehabilitation.

Table 1: Percentage of physiotherapy involvement in CR Phases I IV (ACPICR data 2011)

Phase
I

II

III

IV

28%

21%

82%

11%

3.4 Grade of physiotherapy staff

ACPICR membership data shows that the majority of physiotherapy members are working at
a senior level (Table 2). Of 115 members who provided details of their grade, 96% are
working at an Agenda for Change (AfC) banding of 6 and above.

Table 2: Percentage of CR physiotherapists working within AfC bands 5 8 (ACPICR data

2011)
Band
5

4%

31%

55%

10%

Key Points

Physiotherapists are considered part of the comprehensive team involved in the

delivery of CR.

Physiotherapists are involved in all phases / pathways of the CR process, however

predominantly in the delivery of Phase III rehabilitation.

Many CR programmes fall below the number of physiotherapist hours that national
standards recommend.

The majority of physiotherapists are working within CR at the recommended AfC

band.

Recent national data shows a significant decline the reported access CR programmes
have to a physiotherapist.

10

4. Physiotherapist specialist knowledge and skills

Physiotherapy uses physical approaches to promote, maintain and restore physical,
psychological and social well-being, taking account of variations in health status.
Physiotherapy is science-based, committed to extending, applying, evaluating and reviewing
the evidence that underpins and informs its practice and delivery. The exercise of clinical
judgement and informed interpretation is at its core" (48).

To become a Chartered Physiotherapist, a comprehensive science honours degree training

programme must be undertaken to demonstrate core academic knowledge and achievement
in underpinning professional knowledge and skills (Appendices 1 & 2).

Physiotherapists are autonomous practitioners, who work independently to assess, diagnose

and identify patient needs. This requires the physiotherapist to have in-depth knowledge of
disease presentation (clinical signs and symptoms), anatomy and physiology, pathology and
knowledge of the evidence based treatment options in the specialist area in which they work.
A physiotherapists autonomous, problem solving approach allows flexible patient
management as opposed to a rigid, protocol driven one.
Guidelines recommend that the CR physiotherapist should be at a Band 6 / 7 level (6),
implying that working in this area requires specialist knowledge and experience.
4.1. Clinical skills
Physiotherapists undertake a minimum of 1,000 hours of clinical experience at
undergraduate level, enabling them to develop a range of assessment and therapeutic skills
and consolidate their theoretical knowledge through practical application. After graduation,
many physiotherapists consolidate their knowledge and skills by rotating through core clinical
areas including musculoskeletal, neurology, respiratory, orthopaedics and elderly care. This
varied experience is essential in the holistic assessment of cardiac patients, as many present
with non-cardiac co-pathologies such as arthritis (17%), back pain (10%), stroke (6%) and
chronic obstructive pulmonary disease [COPD] (5%) (49), which need to be considered
individually and in combination, to allow safe and effective exercise.
11

The key knowledge and skills considered to be unique to the role of the CR physiotherapist
within the MDT detailed in the following sections (4.1.1 4.3) were collated from ACPICR
members and from the results of a telephone survey investigating the perceived skills and
attributes of the CR physiotherapist from the perspective of nurses and other exercise
professional staff members of the CR team.
4.1.1 Acute
Experience gained working in an acute environment, assessing and treating medical and
surgical patients, not only gives the physiotherapist knowledge of a variety of conditions and
procedures but also an appreciation of the clinical signs and symptoms displayed by an
unwell patient. Many physiotherapists working in CR will have had experience of assessing
and treating cardiothoracic, cardiology and vascular patients in the hospital environment.

The ability to recognise important clinical signs is paramount in the assessment of exercise
appropriateness and clinically reasoning whether further investigations or referrals are
required. Working in an acute setting provides the physiotherapist with knowledge and
exposure to a wide variety of diagnostic techniques such as electrocardiograms, chest x-rays,
computed tomography and magnetic resonance scans, angiography, lung function tests and
echocardiograms. They will be familiar with reading reports, understanding medical
terminology and interpreting this appropriately to adjust their assessment and exercise
prescription whilst demonstrating the ability to clinically reason their actions. Having this
background knowledge is advantageous for gaining an accurate patient history, building a
clear picture of the patient journey and giving insight to ask appropriate questions when gaps
may be evident. Knowledge of common medications such as those used for respiratory or
musculoskeletal conditions is also beneficial, as recognition can raise awareness of any
significant past medical history and its severity.
4.1.2 Musculoskeletal
A physiotherapist is able to adapt exercise prescription for a wide range of musculoskeletal
co-pathologies, which enables patients who may have otherwise been deemed unsuitable to
participate in the exercise programme. In addition, they are able to identify patients for
whom exercise is contraindicated (Box 1). Examples of when physiotherapy assessment skills
12

were considered advantageous included patients presenting with a frozen shoulder after
coronary artery bypass graft, back and neck pain, knee replacement and muscular problems.
The physiotherapist is able to use their knowledge and experience to reassure patients,
answer questions and provide appropriate advice. Results from the telephone survey found
83% felt the physiotherapists musculoskeletal knowledge was an important and unique facet
of their role within the team. They reported their knowledge assisted in patient assessment,
exercise appropriateness, exercise prescription and advice.
4.1.3 Movement analysis
Patients frequently present to CR with mobility and balance issues. A physiotherapist is
trained in movement analysis and has the ability to identify musculoskeletal and balance
issues from observing gait pattern. This skill is beneficial in the initial assessment when
choosing an appropriate functional capacity test and may identify previously unknown
problems, such as a neurological deficit. The physiotherapist is able to prescribe individually
appropriate exercise, which may incorporate balance re-education or issue a mobility aid if
required, which in turn may lead to a reduction in energy expenditure.

13

Box 1: Clinical example of patient presenting with back pain.

A patient presented to an initial CR assessment following a percutaneous coronary

intervention (PCI) complaining of recent onset low back pain. After questioning the patient
and asking pertinent questions including checking for neurological symptoms, the
physiotherapist clinically reasoned mechanical back pain to be the likely diagnosis. They
decided that the patient was suitable for CR but liaised with the musculoskeletal
physiotherapist, who the patient was already seeing, to ensure that they understood the
cardiac issues and treatment continued, to complement and allow inclusion to the CR
exercise component.
The patient presented to their first exercise session a few weeks later and the
physiotherapist reviewed them and enquired to their back pain. They reported having
hydrotherapy sessions as part of their musculoskeletal physiotherapy treatment and also
regular massages. Their pain was not improving and they were now reliant on painkillers and
a TENS machine, their level of function had also significantly reduced. The physiotherapist
was concerned as their symptoms had worsened when an improvement with time and
treatment would have been expected. Other red flags were present - the back pain was
unrelenting and they had lost a significant amount of weight in a short time period without
trying. On questioning the patient, no neurological signs or symptoms were apparent.
The physiotherapist explained to the patient that they were not suitable to participate in the
exercise component of the programme at present and they required further investigation
into the cause of the back pain. The CR nurse called the GP that day to relay the concerns
and for the patient to be reviewed urgently. When a follow up telephone call was made, the
patient reported that an x-ray identified spinal fractures and subsequent investigations
diagnosed him to have myeloma. Although the diagnosis was not known at the time of
review, it was clear that the patient had sinister signs and symptoms and exercise was
contraindicated. Exercising with spinal fractures could lead to spinal cord compression a
medical emergency.

4.1.4 Respiratory
A physiotherapist possesses knowledge of a variety of respiratory conditions including COPD
and asthma and clinical skills in breathing techniques, auscultation and oxygen therapy.
Their respiratory knowledge and skills were recognised by 29% in the telephone survey, with
reports that the physiotherapist provided advice on breathing and relaxation techniques for
breathlessness and relaxation techniques. The physiotherapists knowledge of respiratory
14

pathologies such as COPD and pneumonia was also acknowledged and their ability to use a
stethoscope to auscultate the lungs fields, allowing a more in-depth assessment of suitability
for exercising and providing advice and support to patients (Box 2).

Box 2: Clinical example of a patient presenting with a respiratory problem.

A patient presented to the CR programme having had a primary PCI. She had a past history
of bronchiectasis and due to coughing and breathlessness had avoided exercising. Many
years ago she had enjoyed walking and attended a local gym. During the assessment she
expressed reluctance to attend the exercise programme due to the embarrassment of
coughing. A functional capacity test (FCT) was carried out and the patient began coughing, it
was decided to refer her to an outpatient respiratory physiotherapist to learn chest clearance
techniques and breathing control. The patient then agreed to try the programme because
she had found her respiratory symptoms had been more controlled. She repeated the FCT
and was not limited by coughing. She completed the 6-week exercise programme and
improved both in confidence and fitness. She was referred onto the local gym to continue
her rehabilitation.

4.1.5 Neurology
Stroke is included under the CVD umbrella and has the same risk factors as CHD, so it is not
uncommon to have a patient presenting to CR with a past history of having suffered a
transient ischaemic attack or stroke with residual physical symptoms. It is advantageous that
physiotherapists will have awareness and knowledge of the various physical manifestations
of stroke and possess the skills to adapt the exercise accordingly (Box 3).
4.2 Communication and multi-disciplinary skills
Physiotherapists are trained to place strong emphasis on a multidisciplinary approach to
patient management and are experienced in working as part of a team to achieve patient
orientated goals. A physiotherapist frequently will have worked in both an acute hospital
environment and the community setting treating patients in their home or local community
centre. This provides an understanding of the NHS health care system, the interaction
between primary and secondary care and the importance of prompt referrals to appropriate
agencies for on-going care, support and rehabilitation. This experience provides the
15

physiotherapist with an enhanced insight into the patient journey and an appreciation of the
variation and complexity of the patient pathway, from diagnosis to intervention, on-going
management and the professionals involved. This all contributes to an understanding and
empathetic approach to each individual patient.

Box 3: A clinical example of a patient presenting with a history of stroke.

A patient presented to CR post PCI with a past medical history of a having suffered a stroke.
The residual symptoms were a mild left sided weakness and reduced balance, which required
the patient to mobilise with a walking stick. The patient reported she rarely left the house
and her confidence was low. Home based cardiac rehabilitation was not a service offered
within the area so the patient was encouraged to attend the hospital based physiotherapist led exercise classes. Initially the exercises were adjusted to ensure safe participation but
after the patient had attended a number of sessions her balance showed clear signs of
improvement and the patient was able to perform the exercises unaided and without
adjustment.

4.3 Continuing professional development

Physiotherapists have a responsibility to ensure they maintain their continued professional
development (CPD), a practice which begins at an undergraduate level with students
developing a CPD portfolio. Continued Health Professional Council (HPC) registration to
practice as a physiotherapist is renewed biennially and is dependent upon providing evidence
of CPD. Physiotherapists also undertake an annual knowledge and skills review whereby they
must provide evidence of continued evaluation of recent evidence and on-going training to
ensure that they remain competent and up to date in their practice.

16

Key Points

An experienced physiotherapist (band 6 and above) possesses clinical knowledge and

skills in the areas of acute medicine, musculoskeletal, movement analysis, respiratory
and neurology.

It is this knowledge and skill alongside their exercise qualifications that make them
unique in their contribution to the CR team, allowing them to lead the exercise and
activity components for all phases.

Cardiac patients frequently present with co-morbidities such as arthritis and back
pain. Physiotherapists possess the knowledge and skill to safely and effectively
include these patients in the exercise component when they may otherwise be
deemed unsuitable and conversely, identify patients for whom exercise is
contraindicated.

Other professionals within the CR team strongly recognised the physiotherapists

musculoskeletal knowledge and skill as an important and unique facet in their role in
the team. To a lesser extent their respiratory knowledge and skills were recognised.

Physiotherapists place strong emphasis on CPD. They also possess a high level of
communication and interaction within the MDT.

17

5. Pathway for physiotherapists to achieve competence to prescribe

exercise to cardiac populations
Through their training, physiotherapists gain many of the necessary skills and attributes to
plan and lead exercise for patients with cardiac disease. Knowledge of cardiac
pathophysiology, intervention and management, as well as exercise prescription and
programming, coupled with exposure to cardiac patients at various stages of the health care
journey provide a sound foundation from which additional specific and specialised skills can
be added to achieve competence in leading safe and effective exercise to the cardiac
population.

The following postgraduate route is recommended by the ACPICR in order to achieve minimal
competence in this specialised area of healthcare:

1.

Familiarisation and adherence to evidence based guidelines:

National Service Framework for Coronary Heart Disease, Chapter 7, Standard 12.
Cardiac Rehabilitation (2000) (50). Tackling Cardiac Disease in Wales: The Cardiac
Disease National Service Framework for Wales, Standard 6 (51)

Sign Guideline No 57. Cardiac rehabilitation (2002) (6)

The BACPR Standards and Core Components for Cardiovascular Disease Prevention
and Rehabilitation 2012 (4)

ACPICR Standards for Physical Activity and Exercise in the Cardiac Population (2009)
(32)

BACPR EPG Core Competences for the Physical Activity and Exercise Component of
Cardiovascular Rehabilitation Services (2012) (52)

2.

Department of Health Commissioning Guide on Cardiac rehabilitation (2010)(5)

NICE Commissioning Guide on Cardiac Rehabilitation Guideline (2011) (53).

Experience of working in cardiology/cardiac surgery and cardiac rehabilitation.

Exposure to the patient journey through cardiology services enables the therapist to
consolidate their knowledge of the cardiac disease process, diagnosis, investigations and

18

treatments. The structure of physiotherapy services is such that Band 5 physiotherapists gain
approximately four months of supervised experience within each rotation.

3.

Evidence of CPD through additional postgraduate training and attendance at courses.

The ACPICR recommend attendance at the following courses is an essential requirement:

BACPR Physical Activity and Exercise in the Management of Cardiovascular Disease

(Part 1)

BACPR/ACPICR Advanced Application of Physical Activity and Exercise in the

Management of Cardiovascular Disease (Part 2).

In addition, attendance at other relevant courses and study days to enhance knowledge and
inform practice:

BACPR - EPG conferences and study days

BACPR Monitoring Intensity in Clinical Populations course

BACPR / ACPICR Heart Failure and Exercise Study Day

BACPR How to ensure your cardiac rehabilitation programme meets BACPR standards.

19

- Degree / Diploma Physiotherapy

- HPC registration
- CSP membership

Rotational Experience
(Cardiorespiratory, Neurology, Musculoskeletal)

Exposure to supervised CR experience

- ACPICR membership
- Part 1 & Part 2 courses

Meet essential competencies in BACPR

positional statement 2012(54)

Lead CR exercise delivery

On-going CPD
- EPG conference / BACPR conference
- Peer review activities
- MSc / Modules in CR
- Additional BACPR/ACPICR study days

Figure 1: ACPICR recommended pathway to lead exercise in early CR

20

6. National Audit of Cardiac Rehabilitation

The National Audit of Cardiac Rehabilitation (NACR) allows CR centres to input patient
progress data into a national database and staffing levels are taken from an annual national
survey. The NACR can provide an insight into the impact a physiotherapist has on CR
outcomes, by comparing centres who have access to physiotherapists skills and those who
do not. Data from the year 2007 2008 was analysed.
During this year, 222 centres submitted data to NACR, of which 133 (55.9%) reported having
access to a physiotherapist*. In 85% of these centres (113/133) physiotherapists were
graded at either an AfC band 6 or 7 and only 23 CR programmes (10.4%) met the staffing
levels of 2.0 WTE per 500 (or 1 WTE for 250) Phase III CR patients. The total number of
patients in this audit who started a phase III programme was 46,362, with 30,085 (65%) of
these receiving CR in a centre which had dedicated physiotherapy hours.
6.1 Demographics
There was little difference in the age and gender of patients from those centres with access
to a physiotherapist and those without. Those centres with access to a physiotherapist
tended to be on average slightly larger-sized centres that have enrolled patients with slightly
more co-morbidities (Table 3).
Table 3: Demographics of centres with and without physiotherapy (PT) input.
PT input

No PT input

Number of centres

133

89

Average number
patients per centre

340

293

Gender (Male %)

71

69

Average Age (Years) M

65.1

65.7

70.2

71.2

Co-morbidities (Mean)

1.66

1.55

(*) Centres that did not respond to the survey or did not complete the staffing levels section in the survey are
classified as having no access to a physiotherapist

21

6.2 Physical activity levels (5 x 30 min sessions per week)

Data showed that independent of whether there was physiotherapy input or not, physical
activity levels had greatly increased from the start of Phase III to the end, with an average of
34% of patients reported exercising five times a week for periods of 30 minutes or more at
the beginning increasing to 53% at the end (table 4). When comparing centres with and
without physiotherapy input there was a difference in the change in physical activity levels.
Centres receiving physiotherapy input to their programme had a significantly greater
(p<.002) improvement in activity levels (61.8%) compared to centres with no physiotherapy
input (48.7%).

Table 4: Percentage of patients reporting exercising 5 times a week for periods of 30 minutes
duration or more at the beginning and end of phase III, in centres with and without
physiotherapy (PT) input.
No of
patients

Start of
phase III

End of
phase III

% Increase

PT input

7,088

33.5

54.2

61.8

No PT input

5,250

35.1

52.2

48.7

6.3 Physiotherapy input and risk categorisation

The percentage of physiotherapy input in relation to the recommended staffing guidance (2.0
WTE per 500 patients) and the risk categorisation of patients were analysed. Physiotherapy
input was divided in to: No physiotherapy; < 25%; 25 49%; 50 74%; 75 99%; 100% of
recommended staffing levels. Results showed that there was a difference between the
levels of physiotherapy staffing and the risk category of patients exercising. Centres with
more dedicated physiotherapy time (75 100 and 100% recommended) accepted a
significantly higher (p = .01) number of patients who were categorised as high risk
compared to centres with less than the recommended amount of physiotherapy input
(Appendix 3).

22

Key Points

Just over half of centres (55.9%) who had submitted data, reported having access to a
physiotherapist. Centres with physiotherapy input appear to be larger, treating an
average of 340 patients compared to 293 with no physiotherapy input.

Centres with physiotherapy input had a greater average number of co-morbidities (1.66)
reported than those with no physiotherapy input (1.55).

Centres receiving physiotherapy input to their programme had a significantly greater

(p<.002) improvement in physical activity levels (61.8%) from the beginning to the end of
phase III CR compared to centres with no physiotherapy input (48.7%).

Centres that met or exceeded the recommended staffing level of 2.0 WTE per 500
patients (or 1 WTE for 250 patients) accepted a significantly higher (p=.01) number of
patients categorised as high risk.

23

7. Summary
National standards include a physiotherapist as a key member of the MDT required to deliver
comprehensive CR. It is evident that the physiotherapist is considered an integral and valued
member of the CR team, bringing unique and essential knowledge and skills which this
document has outlined. It is imperative that both the physiotherapists knowledge and skills are
appreciated when comparing them to those possessed by other exercise specialists. Although
they share some common ground they are essentially different in what they individually offer to
the CR MDT.
The NACR data supports the inclusion of a physiotherapist within the CR team. Data showed
that centres meeting the recommended physiotherapy staffing levels accepted a significantly
higher proportion of patients that were categorised as high risk compared to centres with
reduced and no physiotherapy input. It is well documented that high risk patients continue to
have poor uptake in CR and are still routinely excluded from participating, in spite of evidence
that CR significantly reduces HF-specific hospital admissions and is therefore considered a cost
effective intervention (8, 42). These results suggest that having a physiotherapist at the
recommended staffing level could be instrumental in facilitating the inclusion of high risk
patients within CR and consequently cost savings may be made.
It is well recognised that higher risk patients are likely to have existing co-morbidities. This may
also contribute to increased rates of hospital admission, re-admission and subsequent mortality
(55)

. Physiotherapists ability to manage these co-existing medical conditions may help to explain

why the NACR data showed there to be a higher number of high risk patients in the centres
which had access to more physiotherapy hours.
NACR data also showed that centres receiving physiotherapy input to Phase III programmes
had a significantly greater improvement in physical activity levels compared to centres with
no physiotherapy input. This suggests that physiotherapists may be making more effective
changes in activity behaviour and increasing fitness levels, which is associated with
substantial health gains, improved quality of life and reduction in mortality.
Physiotherapists should be considered an essential member in all CR MDTs, as their skills and
attributes make them key in helping services meet the challenge of improving the availability
24

and uptake of services for all eligible patient groups, especially high risk patients whose
inclusion into CR has remained low and static. Physiotherapists also possess the knowledge
and skills required to rehabilitate patients with other forms of CVD, including peripheral
arterial disease and stroke. The benefit and worth of the physiotherapist in their
contribution to CR must be recognised and not underestimated.

25

8. Appendices
Appendix 1: Core Academic and Practical Skills taught at undergraduate level.

Anatomy
Physiology
Exercise physiology
Movement analysis
Motor learning
Physical activity and health
Exercise prescription and programming
Health psychology
Health promotion
Social aspects of health and illness
Health care policy
Principles of assessment
Physiotherapy techniques
o Manual therapy
o Exercise and movement
o Electrophysical modalities
o Heath education and potential

26

Appendix 2: CSP curriculum framework for qualifying programs

Below is the CSP (2002) recommended framework for students training to become a qualified
physiotherapist to acquire the necessary professional knowledge and skills to apply to
therapeutic patient care.

Underpinning professional knowledge

Underpinning professional skills

Biological sciences
Physical sciences
Behavioral sciences
Clinical sciences
Health care policy, organisation and
delivery
Legal framework of practice

Assessment
Clinical reasoning
Research, critical evaluation and
appraisal
Intervention planning
Intervention management
Self- and caseload management
Communication
Teamwork and inter-professional
practice

The application of professional Knowledge and skills

Professional practice areas
- Patient groups
- Therapeutic approaches
- Human ability and potential
Professional practice environments
- Organisational issues
- Healthcare developments

Professional attributes, identity and relationships

Appreciation of ethical, moral and legal issues

Understanding of scope of practice and professional
self-regulation
Active engagement with reflective practice and
commitment to CPD
Active engagement with patient partnership
Active engagement with evidence-based practice
Ability and aptitude for inter-professional working

27

Appendix 3: Percentage of PT input and risk categorisation data

Risk
% of physio input to recommended
SIGN guidelines (2 WTE per 500)

Low Risk

Medium

High Risk

Count

Row N %

Count

Row N %

Count

Row N %

No physio

5431

55.2%

2357

23.9%

2059

20.9%

<25%

2472

52.1%

1131

23.9%

1139

24.0%

25% -49%

2954

61.4%

1023

21.3%

832

17.3%

50% - 74%

1300

51.7%

625

24.9%

590

23.5%

75% - 99%

789

43.6%

419

23.1%

603

33.3% *

100% +

994

41.7%

592

24.8%

799

33.5% *

* Chi-square test (p <0.001)

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31

Acknowledgements
We would like to thank Veronica Morton for her help in analysing the NACR data.

Document Contributors
Michelle Wright, BSc (Hons), MCSP. Barts Health NHS Trust
Samantha Breen, MPhil, MCSP. Manchester Heart Centre
Dr Sally Turner, PhD, MSc, MCSP. Hampshire Hospitals NHS Foundation Trust
Margaret Upton, Grad Dip, MCSP. Hywel Dda Health Board
Jenni Jones, MSc, MCSP. BACPR President. Department of Cardiovascular Medicine NHLI
Imperial College London

32