The human body is a wondrous combination of muscle and bone, flesh and blood. Yet for all the magnificent physical accomplishments it is capable of, the body's function revolves around one fundamental organ-the heart. With a healthy heart, it can excel. With a weak heart, it falters. Heart disease remains one of the primary causes of death and physical deterioration in this country, for both men and women. So of all the great services that physical therapy professionals provide, perhaps none is more important than cardiac rehabilitation.

Paul D. Gaspar, PT, DPT, CCS, understands this well. A cardiac-certified specialist, he is also president/founder of Gaspar Physical Therapy, with five clinics in the San Diego area.

"My personal population is about half cardiovascular and pulmonary patients because I specialize in that," he told ADVANCE. "For the clinics as a whole, cardiovascular and pulmonary physical therapy represent about 5 percent of our patient visits. We offer the treatment at two of our offices, Carlsbad and Encinitas."

Initial Interest

A physical therapist for 17 years, Dr. Gaspar established his practice in 1994. "We would get a lot of walk-in patients who asked if I could treat them for their cardiovascular conditions, whether it was after a heart attack, bypass, stent or pacemaker insertion. I would say, 'Yes, I can help you but I need to make sure your cardiologist is OK with it.'"

Dr. Gaspar then arranged a meeting with many of the top cardiologists and pulmonologists in the area. They helped organize a program with him that they would feel comfortable sending patients to. "And it has thrived ever since," he related. "We've really been the only people providing this service in our community during the past 15 years."

Patient Population

Among the cardiac rehab population today at Gaspar Physical Therapy, about 85 percent are over 65. This group breaks down comparably between those in their late 60s, 70s and 80s, with only a handful of people in their 90s.

"But there is certainly a decent number of cardiac rehab patients in their 40s and 50s as well," Dr. Gaspar said. "We've had several patients in that age group come here following heart attacks or interventions such as angioplasties or stents. So obviously they have a very strong genetic predisposition to atherosclerotic heart disease."

The overall cardiac rehab population at Gaspar Physical Therapy is about equally divided between men and women, he continued.

"You may be aware of the Red Dress campaign to educate women, as well as the families and spouses of women, that heart disease is just as prevalent in women and they actually have higher mortality rates after heart-related events. Often the symptoms go unrecognized because heart disease has traditionally been seen as a male situation."

One significant difference between men and women, however, is the age at which heart disease develops.

"I would say atherosclerotic heart disease tends to occur on average about 10 years later in women," noted Dr. Gaspar. "So our female patients usually are a little older than our male patients but there are just as many of them. When it comes to patients we see after valve replacement, the valves in the heart tend to wear out at a fairly similar age between men and women, from what we've seen with our referrals. It's the same with patients who have had a pacemaker put in. That's more of an age-related development than a male or female situation."

Middle-Age Matters

Dr. Gaspar sees the most notable prevalence of male patients versus female in the 40- and 50-year old age group. This is an important population to recognize because so often cardiac therapy is perceived to involve older patients.

"When people have atherosclerotic heart disease in their 40s or 50s, we try to aggressively educate them about risk factors," said Dr. Gaspar. "Then hopefully they can slow down or even reverse the predisposition for having those risk factors and further acceleration of their heart disease."

If left unchecked, as the decades pass that 40- or 50-year-old is going to develop worse blockages in the same areas or additional blockages in other areas, he continued.

"So although we're aggressive with everybody, it's even more of a focus with that population. And it's sometimes easier to get them to change behaviors than an 80-year-old who had a bypass surgery and now has an all-new blood supply wrapping around the areas that were previously blocked."

Aggressive Education

What form does this aggressive education take?

"The risk factors we can help control are related to their cholesterol profile and diabetes management, if they have diabetes," explained Dr. Gaspar. "Obviously since those factors are highly linked to diet, we have more direct control over them because we exercise people intensively. The amount of exercise they are getting carries over to body composition and our efforts to control their waistline."

With all risk factors, education about physical activity must be emphasized, he continued.

"We need to determine how much is enough while of course staying within safe precautions. Patients also need to have some counseling on nutrition and diet. That's significant for controlling lipid profile, diabetes and obesity. So as a physical therapist, I feel very comfortable giving recommendations like the American Heart Association guidelines."

Post-Surgery

When Dr. Gaspar first sees a patient for cardiac rehab often depends on the type of surgery that person underwent.

"With angioplasty and stents, it could be a week or two later," he related. "With a heart attack or bypass, usually between three and six weeks. It depends on age too. Sometimes older patients go home and just doing very minimal daily activities is enough exercise for them at the start. But patients who exercised in the past or have a relatively high level of fitness or function are going to start earlier with the therapy process."

These patients typically have higher goals and are able to tolerate more assertive therapy.

"One of the important aspects about starting earlier is to not let patients, particularly women, get into a situation where they're afraid to return to normal activities," said Dr. Gaspar. "Fear avoidance is extremely prevalent among females following a heart-related event."

In fact, a significant number of women actually suffer from clinical depression after a heart attack or bypass surgery, he added.

"So we want to get them right in and realize this isn't the end of their life. They can do everything they used to and often after finishing with us do more than they ever had in the past. We build their confidence, make sure we're improving their quality of life and level of function, as well as keep them safe. We lean on them pretty hard because we like results."

Clinic Visits

Interestingly, Dr. Gaspar does not advocate a set number of visits per week to get those results. "We don't do the typical three times a week for three months that is often arbitrarily prescribed across the board for cardiac rehab patients," he related. "The main focus is teaching them what they need to learn and them following through with the recommendations we and the cardiologist have."

Although frequency may start at two or three visits per week, the staff at Gaspar Physical Therapy weans that number down as patients prove they are able to execute home programs and adhere to health and wellness guidelines. "Particularly their diet, and the frequency and intensity with which they exercise. If we get a really assertive patient that I'm positive will follow through on his own, I might see that person every other week or just once a month. So we really decide on a case-by-case basis, along with the patient and doctor."

On the other hand, if it is apparent that a patient hasn't followed through with the recommended diet and exercise plan, Dr. Gaspar will increase visit frequency.

Exercise Aspects

What type of exercise is most important?

"Definitely aerobic involving repeated movements of larger muscle groups," he explained. "Anything that will get patients into the target heart rate zone we've recommended for an extended period of time."

How that exercise is performed can depend on a patient's co-morbidities. "Some patients have orthopedic problems like a bad back, knee or hip. Maybe they can do the exercise bike but not the treadmill, or vice versa. Walking is obviously most functional, but in terms of improving exercise capacity, I don't have a specific favorite. If patients can't do the treadmill, we put them on the bike or an upper-body ergometer or they can swim."

Dr. Gaspar also supports another type of exercise that can sometimes be neglected in cardiac rehab. "Everybody talks about aerobic exercise when it comes to the heart, but in terms of managing risk factors, strength training is very important as well. Particularly in improving metabolism and blood-sugar control for those patients with diabetes or metabolic syndrome. For older people too, which is a large percentage of our population, strength improves overall level of function and risk for falls. So there are many good reasons to include strength as well as balance training."

No matter what the exercise regimen, Dr. Gaspar strongly recommends the expertise of physical therapists.

"I think PTs are uniquely educated to treat these patients because there are often multiple issues at the same time," he concluded. "Half our patients have orthopedic problems that need to be treated concurrently with their cardiac concerns. A lot of them also have balance issues. I don't think there's any better health professional to deal with balance issues than a PT. There's certainly nobody better to deal with spine, hip or knee issues. So when you have all those problems at the same time, including cardiac, I don't know how you could see anybody except a PT and get better results."

Brian W. Ferrie is managing editor of ADVANCE and can be reached at bferrie@advanceweb.com