The lexicon of ‘Cardiac Rehabilitation': is it time for an evolutionary new term?

Cardiac rehabilitation (CR) contributes significantly toward the care of cardiovascular disease (CVD) patients, and is recognized by various health care organizations in their practice guidelines and position statements [1–3]. Even so, it is commonly perceived as less important compared with pharmacological or interventional therapy in mainstream cardiology, as is evident from its less-than-vigorous promotion in contrast to drug therapies such as antiplatelets, statins or β-blockers. The physicians’ belief in the benefits and effectiveness of CR directly influences their support and recommendations. Patients who are not fully aware of its nature and benefits are less likely to join and are less adherent. Diminished perceptions of the importance of CR may be partly responsible for its persistent under-utilization [4, 5]. Recently, some have questioned whether the term ‘CR’ may be an impediment [6, 7]. Is the name still as relevant today as it was decades ago when it was first created? Does the nomenclature ‘CR’ affect the way in which the program is perceived and promoted? Although the actual origin of the term ‘CR’ is unclear, the historical background and evolution are well documented. In 1912, Herrick first provided the original clinical description of an acute myocardial infarction [8]. Subsequent concerns about physical exertion and the risk of complications led to the adoption of prolonged bed rest for post-myocardial infarction patients [9]. It was not until 1952, when Levine and Lown expounded on the harmful effects of prolonged recumbency that this practice was gradually changed [10]. The first CR programs appeared around the 1960s when Turell and Hellerstein advocated a comprehensive rehabilitation of patients recovering from acute cardiac events [11]. The focus then was on the successful integration of patients back into society, improving recovery times, decreasing hospitalization stays, and improving function. Since then CR has undergone a profound transformation, with modern programs embracing secondary prevention activities; smoking cessation, education, behavioral and lifestyle modification, and psychosocial evaluation and counseling. The gradual inclusion of these components, is reflected in the different definitions given to CR over time [1–3]. Today's modern CR purports to reduce the progression of atherosclerotic disease and the recurrence of vascular events, by incorporating risk factor reduction and lifestyle modification into traditional exercise-centric CR, thereby reducing morbidity and mortality [1–3]. Modern programs are increasingly flexible, with newer programs allowing customization of content to accommodate individual needs and preferences. The primary goal of CR has evolved beyond just early mobilization through physical rehabilitation, to encompass physical and psychological well-being, risk factor reduction, and health maintenance. Health care providers often do not emphasize this important detail to potential beneficiaries. For patient motivation and uptake to improve, it is critical that clear explanation and explicit recommendations be given. The word ‘rehabilitation’ derives from the Latin word ‘rehabilitare’ meaning to ‘make fit again'. The earliest use of the word between the sixteenth and nineteenth centuries described the ‘reinstatement of someone who had fallen out of favour to previous position or privilege or the reestablishment of one's reputation or the restoration to a higher moral state'. Some of the recent definitions of the term ‘rehabilitation’ by the Oxford Dictionary of English are (i) prepare someone who has been ill or in prison to resume normal life by training and therapy and (ii) restore the reputation of someone who has earlier been out of favour. The word implies that intervention is required to restore a loss of function or status, much as one would associate with a person with physical or mental disability after a traumatic accident or disease. Even less positive connotations derive from the 1940s when it was also commonly used to refer to reformation of criminals and addicts from their undesirable behaviors. Words can convey powerful images, and thus, it is important that they are clear and concise. Poorly chosen words can curtail enthusiasm, impact self-esteem, and lower expectations, while well-chosen words can motivate, offer hope and impact both thinking and results. Although the term ‘rehabilitation’ may still be relevant to certain subgroups of cardiac patients, particularly those with severe disease or significant disability, or those returning to more physically demanding jobs, for the majority of today's cardiac patients this is no longer the case. Improved acute medical care and advances in surgical and interventional techniques promote faster recovery and decrease complication rates, resulting in dramatically reduced hospital stays [12–14]. The physical and psychological impact of cardiac disease has lessened, and this may have lead to patients trivializing their condition, or dismissing the need for further ongoing treatments such as CR [14]. The term ‘CR’ describes only a single aspect of its multifaceted nature, and may cause patients to reject CR programs entirely if they do not perceive ‘rehabilitation’ as necessary. Already various institutions are offering traditional CR programs utilizing a different title, ‘cardiac wellness’ or ‘healthy heart’ programs. These programs emphasize aspects of CVD prevention, healthy lifestyle, and chronic disease management in addition to rehabilitation. Several editorial articles have also suggested doing away with the current terminology or aligning it more with secondary prevention or chronic disease management [6, 7], arguing that this might enhance its status among policy makers and other health care workers, and in so doing hopefully improve resources both in terms of funding and staffing. Although the necessity to integrate prevention into rehabilitative activities has been widely recognized by many individuals and large professional organizations, modifying the traditional title of ‘CR’ is not without demerits or obstacles. CR has matured and progressed over the decades, and has achieved improved recognition and status among the medical fraternity. Both national and international CR associations and journals have been formed over the years and CR as an entity is firmly entrenched into current guidelines. Different geo-political and cultural circumstances also present different difficulties and challenges. Four years ago in Europe, specialists from many different European countries created the European Association for Cardiovascular Prevention and Rehabilitation within the framework of the European Society of Cardiology. The name of the Association has been a particular issue not only for those involved in this work but also for the mother society. The favorite term for the European Society of Cardiology has been ‘preventive cardiology'. However, this term has been opposed by most of those actually working in the field of CR. The main and often the only reason for this opposition has been the fact that in most European countries CR is paid for by the government and/or health insurance companies whereas prevention is usually not remunerated. This is because of the fact that public health institutes and administrations still see CR in its traditional way with rehabilitative aspects at the center of its activities. Thus, the question remains. Should the term ‘CR’ be jettisoned or modified for the modern era? Whether we develop a new terminology altogether or subsume the term as part of a larger entity such as ‘comprehensive cardiovascular care’ or ‘preventive cardiology', one thing remains clear: CR or its incarnation should be an integral part of the management of CVD patients. If the lexicon term ‘CR’ makes it more difficult to provide this care, then there is an obligation to make this assessment, and if necessary, proceed with the needed changes. Clear and concise explanation of its nature and benefits to all potential recipients is paramount to ensuring its effective uptake and utilization. Changing the minds and views within the medical society and of all potential beneficiaries of CR is not the only task for the future of those working in this field. Addressing these views to politicians, health administrators and insurance companies is a mandatory component of this process for it to become successful.

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