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A POSITION STATEMENT FROM THE AMERICAN ASSOCIATION OF CARDIOVASCULAR AND PULMONARY REHABILITATION
Larry F. Hamm, PhD, MAACVPR; Nanette K. Wenger, MD, MAACVPR; Ross Arena, PhD, PT, FAACVPR; Daniel E. Forman, MD; Carl J. Lavie, MD; Todd D. Miller, MD; Randal J. Thomas, MD, MS, FAACVPR
The Social Security Administration (SSA) oversees the disability determination process and the payment of disability benefits to Americans. According to recent SSA data, approximately 900 000 persons are receiving cardiovascular disability payments and about 145 000 adult claims for cardiovascular disability are processed by the SSA annually. An objective and comprehensive examination of functional capacity is an important part of the disability assessment process. This statement reviews various protocols for disability assessment of aerobic capacity, muscle function, and the physical requirements of job tasks. Cardiac rehabilitation programs are ideal settings for conducting comprehensive disability assessments of functional capacity in persons with cardiovascular disease. In addition, exercise training provided by cardiac rehabilitation programs can increase functional capacity in most patients.
K E Y
W O R D S
cardiac rehabilitation cardiovascular disability functional capacity assessment social security disability
Author Affiliations: Exercise Science Department, School of Public Health and Health Services, The George Washington University, Washington, District of Columbia (Dr Hamm); Division of Cardiology and Emory Heart and Vascular Center, Emory University School of Medicine, Atlanta, Georgia (Dr Wenger); Division of Physical Therapy, Department of Orthopaedics and Rehabilitation and Division of Cardiology, Department of Internal Medicine, University of New Mexico, Albuquerque (Dr Arena); Brigham and Womens Hospital, Division of Cardiovascular Medicine and Harvard Medical School, Boston, Massachusetts (Dr Forman); Department of Cardiovascular Diseases, Ochsner Medical Center, New Orleans, Louisiana, and the Department of Preventive Medicine, Pennington Biomedical Research Center, Baton Rouge, Louisiana (Dr Lavie); and Division of Cardiovascular Diseases (Dr Miller) and Cardiovascular Health Clinic, Division of Cardiovascular Diseases (Dr Thomas), Mayo Clinic, Rochester, Minnesota. This position statement was approved by the Board of Directors of the American Association of Cardiovascular and Pulmonary Rehabilitation on July 20, 2012. The authors declare no conflicts of interest. Correspondence: Larry F. Hamm, PhD, MAACVPR, Exercise Science Department, School of Public Health and Health Services, The George Washington University, 2033 K Street, NW, Suite 210, Washington, DC 20006 (lfhamm@gwu.edu). DOI: 10.1097/HCR.0b013e31827aad9e www.jcrpjournal.com
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Cardiovascular disease (CVD) in the United States affects an estimated 82 600 000 persons with more than half being older than 60 years. While CVD is most prevalent in the elderly, nearly 40% of adults aged 40 to 59 years have CVD.1 In 2008, 758 324 adults aged 18 to 64 years, whose primary impairment was CVD, were receiving disability benefits from the Social Security Administration (SSA).2(p54) With the increasing prevalence of obesity, physical inactivity, and type 2 diabetes mellitus in the adult US population, CVD and CVD disability claims will likely increase in the future. Thus, it is incumbent on the SSA and medical community to identify the most objective process for determining disability from CVD. The SSA defines disability as the inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.2(p43) The SSA further describes disability as individuals functioning at the lower end of the physical capacity spectrum but could pertain to individuals functioning at all levels along the physical capacity spectrum, including persons whose work may involve high levels of physical exertion. The Americans with Disabilities Act Amendments Act of 2008 defines disability as (1) a physical or mental impairment that substantially limits one or more major life activities; or (2) a record of such an impairment; or (3) regarded as having such an impairment. Major life activities include, but are not limited to, caring for oneself, performing manual tasks, walking, standing, lifting, bending, and working. A major life activity also includes the operation of a major bodily function, including but not limited to functions of the immune system, normal cell growth, digestive, bowel, bladder, neurological, brain, respiratory, circulatory, endocrine, and reproductive functions.3 Given these broad definitions of disability, it is important that individuals be assessed for disability using the most appropriate methodologies and that data from these assessments be interpreted in an objective manner. The purpose of this focused statement concerning cardiovascular (CV) disability is to: Review the process for determining disability according to the SSA rules and regulations and, in addition, according to the more general denition of disability, as used by the Americans with Disabilities Act Amendments Act of 2008; Discuss the recommended methods for functional aerobic assessment;
Discuss the recommended methods for functional assessment of muscular function; Review the scientic basis for assessing the physical requirements of contemporary job tasks and monitoring the CV responses to performing specic occupational tasks; and Discuss the potential role of cardiac rehabilitation (CR) in assisting individuals in their return to occupational activities.
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shift in the step where the majority of allowances occur from step 3 to step 5. In 1990, approximately 60% of allowances occurred at step 3 compared with only 26% in 2008.2 Step 3 allowances are determined by SSA state agencies called Disability Determination Services, where most teams are composed of 2 people, a lay disability examiner and a physician. Allowances at steps 4 and 5 are more laborious, expensive, and timeconsuming and commonly are resolved before an administrative law judge.
Figure 1. Five-step disability determination process.2(p8) Reprinted with permission by the National Academies of Science. Courtesy of the National Academies Press, Washington, District of Columbia.
CV Disability Statistics
Approximately 900 000 individuals receive CV disability payments.2(pp54-55) The number of adult CV claims submitted varies modestly from year to year and has averaged 145 000 claims annually for the past 20 years.2(p55) Although the allowance rate using the 5-step process has remained constant at about 40%, there has been a T a b l e 1 Adult Cardiovascular Listingsa
4.02 4.04 4.05 4.06 4.09 4.10 4.11 4.12
a
CV Listings
Each of the individual CV Listings (as proposed by the 2010 IOM Committee) shares the requirement for a CV anatomical abnormality plus a functional limitation (with a few exceptions). The anatomical abnormality is specific to each Listing, whereas the functional impairment is a common pathway for the majority of the Listings and reflects an inability to perform activity requiring 5 metabolic equivalents (METs) of energy expenditure. The requirement for a functional limitation relates to the highly variable impact on physical capacity of patients with the same anatomical disease. If the results of an ET are not available in the applicant medical record, functional capacity can be determined from the applicants limitations of activities of daily living described in the
CR and Cardiovascular Disability / 3
Chronic heart failure Ischemic heart disease Recurrent arrhythmias Congenital heart disease Heart transplant Aneurysm of aorta or major branches Chronic venous insufficiency Peripheral arterial disease
Adapted from Institute of Medicine.2(p10) Reprinted with permission by the National Academies of Science. Courtesy of the National Academies Press, Washington, District of Columbia.
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Advantages
Inexpensive No clinical expertise required to administer Inexpensive but not commonly used in general CVD Ability to monitor ECG, HR, BP, SpO2 Less expensive than CPX Ability to monitor ECG, HR, BP, SpO2 Widely available in clinical facilities Aerobic capacity is accurately measured Ability to monitor ECG, HR, BP, SpO2 Level of effort can be documented
Disadvantages
No documented response to exercise Estimated aerobic capacity is subject to error Variability in the administration of the test Estimated aerobic capacity is subject to error Aerobic capacity estimated from exercise workload is subject to error Unable to objectively quantify level of effort Potential for an untoward event Most expensive option Less availability in clinical facilities Requires specialized equipment and specially trained staff Potential for an untoward event
CPX
Abbreviations: BP, blood pressure; CPX, cardiopulmonary exercise test; CVD, cardiovascular disease; ECG, electrocardiogram; ET, exercise test; HR, heart rate; 6MWT, 6-minute walk test; SpO2, peripheral oxygen saturation.
medical record or by the requirement for 3 hospitalizations during the preceding year to treat the condition.2 This latter criterion reflects both the difficulty of stabilizing the medical condition and the challenge for the applicant to maintain a job in the face of frequent absences to receive hospital medical treatment.
percent-predicted value, which can be derived from established regression equations.9 Ventilatory expired gas analysis also allows for the determination of exercise intensities that can be sustained for prolonged periods of time through the detection of ventilatory threshold, which is of particular value in individuals whose occupational requirements involve sustained periods of aerobic activity. Finally, peak respiratory exchange ratio (RER) defined as the ratio of carbon dioxide production and oxygen uptake provides an accurate determination of subject effort. Attainment of a peak RER 1.10 is widely recognized as a valid and reliable indicator of excellent patient exercise effort.1 When exercise is terminated at a peak RER 1.00, in the absence of an abnormal exercise response (hemodynamic, electrocardio. gram [ECG], pulse oximetry, etc), the peak Vo2 obtained may not be a valid representation of the individuals true aerobic capacity.6 During a CPX, abnormalities detected in blood pressure (hypertension or hypotension), ECG (ST-segment changes, arrhythmias), and/or pulse oximetry (desaturation) should be documented. Rating of perceived exertion as well as angina and dyspnea should be quantified using established scales.7,10,11 Coupling abnormal response(s) with the exercise intensity at onset of the abnormality is valuable in providing recommendations for activity/occupational modifications. Specifically, activities corresponding to workloads that surpass a threshold at which ischemic ECG changes, oxygen desaturation, onset of arrhythmias, or angina/ dyspnea occur should be avoided.
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estimated from the workload achieved on the given modality employed (ie, ergometer or treadmill) and is commonly expressed in METs, where 1 MET equates to 3.5 mLkg1min1. A peak MET level of 5 has been proposed as a key threshold for disability assessment.2(pp14-15,18) This equa-tes to an estimated oxygen cost of 17.5 mLkg1min1, which is higher than the 15.0 mLkg1min1 threshold proposed when oxygen uptake is directly measured. This discrepancy is due to the fact that estimated . aerobic capacity can significantly overestimate true Vo2.
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endurance, and power are 3 aspects of function used to denote specific properties of muscle-related function.25 The shift from sitting in a chair to standing, for example, relies on strength, the maximum force produced by a muscle or group of muscles, generated by muscles in the lower limbs to facilitate the lift. Endurance is the separate but related capability to sustain repeated muscular contractions over time. One may rely on strength to lift groceries, but it requires endurance to carry them into a car. Endurance tends to be greater if the functional task entails a relatively smaller percentage of ones maximal strength. Power relates to the speed with which force can be implemented. Power characterizes critical timing of force generation, such that falling may be averted if force in a potentially stabilizing leg is sufficiently swift. Power has been correlated with mobility, independent of maximum strength. The combination of muscle strength, endurance, and power are often critical for disabled individuals. It is also important to recognize the interconnection between muscle function and aerobic capacity. Adults lacking sufficient strength components predictably have diminished mobility. Impaired strength can result directly from an underlying disease (eg, degenerative disease) and be compounded by the effects of decreased physical activity (PA) and subsequent deconditioning that result from the disease limitations. Despite the strong rationale to focus on strength, endurance, and power as elemental parts of disability evaluations, these assessments are not straightforward and are often omitted. No single test definitively evaluates composite muscle health. Assessments often vary with the muscle group being tested, the type and speed of contraction, the type of equipment, and the joint range of motion (ROM). Even patient size is relevant. Angles and acceleration of movement vary with the proportions between patient and equipment and potentially influence results. Muscle testing requires steps to achieve proper posture, consistent speed of movements, full ROM, and suitable warm-up.
adjustable, and recent guidelines on handgrip assessments reflect efforts to standardize techniques and increase reliability of assessments.27 Dynamic strength assessments are more complex, as they require measurement of force over the ROM, entailing concentric and eccentric contractions over time.26,27 Specialized isokinetic devices provide a technological mechanism to regulate speed and resistance to ensure stable resistance across the ROM. Although isokinetic assessment has a solid theoretical basis, it is seldom used in the clinical setting. Traditionally, the 1-repetition maximum (1-RM) is the standard of dynamic assessment, that is, the maximum resistance that can be moved 1 time through the full ROM. Given that strength fluctuates across a ROM, the 1-RM reflects the weakest strength across the ROM. It is usually determined by adding weights (using free weights or an exercise machine) until an individual can no longer achieve a full ROM. 1-RM evaluations reflect inherent variability in regard to increments of resistance added until the 1-RM is determined: amount of time between tries; differences in warm-up, posture, spotting, speed of movement; the steps to ensure that full ROM is completed; and the fundamental motivation of the person being assessed. However, the 1-RM is often not used in clinical practice. Instead, clusters of RM, such as a 4-RM or even 6-RM, can be used and are particularly good for evaluating persons with disability or muscle weakness.
Muscle Endurance
Endurance is assessed by measuring the number of contractions performed using a specific percentage of a 1-RM. Assessments can be made using timing of static contractions until fatigue, or measuring the number of active contractions until fatigue. Endurance assessments are not routinely incorporated into clinical evaluations but provide important perspective on general health and functional capacity.26-28 Among disabled adults, endurance assessments provide functional perspectives, which are useful in quantifying the clinical impact of limitations from disease or injury, and providing important benchmarks with which strength training and adjunctive care can be guided and monitored.
Muscle Strength
Strength can be measured statically, with no overt muscle movement, or dynamically, wherein the muscle changes in length.26,27 Static or isometric exercise assessment is achieved by devices that measure force generated in the upper and lower extremities. Cable tensiometers and handgrip dynamometers are popular devices, because of their relative convenience and safety. However, because each assessment characterizes only a specific muscle group and angle, there are some limitations in their capacity to assess overall muscular strength. Most dynamometers are now size-
Muscle Power
Power evaluations are even less commonly performed despite a growing body of literature highlighting their clinical relevance. Assessment of power requires expensive specialized equipment that measures 1-RM as well as percentages of 1-RM that are able to capture the associated timing dynamics. In
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general, peak power is lowest in relation to both very low and very high 1-RMs and greatest in relation to the movements at 60% to 85% of the 1-RMs. While this may seem too theoretical to recommend as part of standard assessment, the impact of power on mobility is unequivocal.29
conditions, as well as during psychological stress during working conditions. The use of additional clinical expertise (eg, occupational therapist, physical therapist) may be helpful when conducting job task analysis. In addition, cardiac rehabilitation clinical staff may require additional training to assess job tasks.
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physiological response to exercise is normal and the peak aerobic capacity achieved exceeds physical demands for a given occupation. However, in occupations with extreme physical demands, a clinical ET may be insufficient to determine clearance to return to work. In such cases, a comprehensive functional assessment in the clinical setting in addition to a real or simulated work site assessment is recommended. While ET constitutes the standard by which cardiac abnormality is customarily assessed, it does not account for potential instability that can be induced by mental strain.42 Adults who show no signs of cardiac instability during routine exercise assessments may develop ischemia, arrhythmia, and other manifestations of cardiac instability in a stressful employment environment. This is an additional reason to conduct a disability assessment in the workplace. Telemetry or ambulatory ECG monitoring during workplace assessment may reveal significant consequences that are otherwise not apparent. Additional research is needed to resolve issues related to work site assessment and establish its value.
Technologies, Inc, Hanover, Maryland), that can expand the range of the simulated testing. Simulated job task testing does not account for psychological or environmental stress that may be encountered by the patient on the job. Occupational therapists can provide valuable additional expertise for this type of testing. Continuous ECG monitoring and intermittent blood pressure determinations can provide documentation of myocardial ischemia, cardiac dysrhythmias, and hypotensive or hypertensive episodes that may be elicited by the job task simulation. The equipment necessary for this monitoring is readily available in outpatient CR facilities. Occupational therapists can provide additional expertise for simulated job task assessments.
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Several key steps can help maximize the role of CR programs in the assessment, treatment, and reversal of CV disability: Train CR staff about key components of CV disability assessment and treatment strategies that reduce CV disability. Include activities in CR that simulate work conditions, specic to job-related responsibilities, in patient assessment and treatment plans.58 Measure impact and outcomes of cardiac disability assessment and treatment program services, relative to patient physical work capacity, psychological health, and return to work. Provide education and communications to local providers regarding the need for and availability of cardiac disability assessment and treatment services provided through the local CR program.
health and the resultant inability to work. Social Security Administration should support research on the disability-related effects of health insurance reform to improve program planning and future updates of the Listings. It would appear to be cost-effective to conduct research to validate the Listings, both at SSA and externally, with a full and balanced program of research addressing policy implications, programmatic issues, correlation of CV impairments and impairment severity with functional limitations related to work capacity, and the underlying prevalence of trends in CV impairments in the population.
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