AACVPR

INTRODUCTION Professional organizations often develop from existing organizations, when a need is felt by a significant but minority number of members for services not being provided by the existing organization. In the early 1980s, a small but significant number of members of the American College of Sports Medicine (ACSM) felt a need for a separate organization, specifically dedicated to cardiac and pulmonary rehabilitation, and to address the specific needs of healthcare professionals in these two disciplines. These needs related to professional development, education, and networking. In addition, during this period, state associations were developing in cardiac and pulmonary rehabilitation, mandating the existence of a national "umbrella" association. Another obvious need was for an annual "national" meeting devoted solely to cardiac and pulmonary rehabilitation. Finally, also relevant to the eventual formation of the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) was the need for a professional journal, ultimately resulting in the publication of the Journal of Cardiac Rehabilitation in 1981.1 Through informal group discussions, followed by regional meetings and a national survey, the AACVPR was established in 1985. As we celebrate our 20th anniversary at this annual meeting in Milwaukee, we need to reflect on how we began, what has been accomplished in our first 20 years, and "where we go from here." THE PRE-AACVPR PERIOD…PRE-1985 Scientific Underpinnings: The "Classics" The early years of cardiac and pulmonary rehabilitation was a time of experimentation, research, and publication related to the practical application of the effects of exercise on the rehabilitation of the patient. These classic publications are the foundation of our profession and our association. However, the growth of cardiac and pulmonary rehabilitation prior to 1985, both in research and practical application, differed in terms of their acceptance by patients and the medical profession. Cardiac Rehabilitation As indicated, reports of the use of exercise with cardiac patients began with Heberden in 17722 and 1802,3 followed by Stokes in 1854.4 Both Heberden and Stokes recommended the use of exercise in the recovery process of cardiac patients. However, the beginning of modern-day concepts of cardiac rehabilitation can be traced to Levine and Lown in 1952,5 when they described the use of armchair exercise for cardiac patients. Levine and Lown's report was followed by Hellerstein and Goldstein in 1954,6 with their report on work classification units with cardiac patients. The significance of Hellerstein and Goldstein's report, and work classification units to modern-day cardiac rehabilitation, was the importance of a complete evaluation of the patient, to include cardiovascular fitness, emotional status, and the ability to return to the type of employment prior to the cardiac event. Collectively, starting in the late 1950s into the 1970s, there were numerous reports on the value of cardiac rehabilitation, and on the management of inpatient and outpatient programs.7-13 The period of the early to mid-1970s brought to cardiac rehabilitation recognition and acceptance by various professional associations. In 1972, the American Heart Association released Exercise Testing and Training of Apparently Healthy Individuals: A Handbook for Physicians.14 Although specific to the "healthy individual," the value of this handbook to cardiac rehabilitation was confirmation of many of the basic concepts of exercise testing and exercise prescription. In 1973, the American College of Sports Medicine released the Guidelines for Graded Exercise Testing and Prescription,15 which became the "Bible" for procedures and techniques in graded exercise testing and exercise prescription. Exercise Testing and Training of Individuals with Heart Disease or at Risk for its Development: A Handbook for Physicians16 was released by the American Heart Association in 1975. This handbook verified many of the modern-day practices of cardiac rehabilitation and was very important in the acceptance of the profession of cardiac rehabilitation by the medical profession. However, concerns about the risk of exercise for the recovering cardiac patient continued until Haskell's report in 1978, on "cardiovascular complications during exercise training of cardiac patients."17 Haskell gathered data from 30 programs with 13,570 participants, from the period of 1960 to 1977 and showed that there was very little risk to the participating cardiac patient. Risk for cardiac arrest was on the order of one event per 34,000 patient-hours, and risk for exercise-related death, 1 per 116,000 patient-hours. This was then verified by other reports in the literature.18-22 Pulmonary Rehabilitation The first reports of the therapeutic use of exercise in the rehabilitation of pulmonary patients were by Barach in 1948.23 Barach, considered by many to be the "Father of Physiologic Respiratory Therapy," experimented with various procedures including the use of an oxygen tent for patients suffering from congestive heart failure and pneumonia, and successful treatment of selected pulmonary disorders and pneumonia with antibiotics and aerosols of adrenalin.23 Although there were other significant investigators and reports leading to modern-day pulmonary rehabilitation, most prominent were Dr. William Miller and Dr. Thomas Petty. Both experimented with techniques and procedures currently in practice in programs across the country.24-30 As cardiac rehabilitation, pulmonary rehabilitation also benefited by the recognition from a national organization. In 1981, the American Thoracic Society released a statement supporting pulmonary rehabilitation as a necessary procedure for most pulmonary patients.31 Summary: The "Classics" In summary, these classic projects and reports not only contributed to the scientific basis of cardiac and pulmonary rehabilitation, but also led to the emergence of cardiopulmonary rehabilitation as a profession, with a necessary professional staff possessing specific skills and training. Without these early studies, the existence and eventual expansion of the number of cardiac and pulmonary rehabilitation programs in clinical, hospital, and university settings would not have occurred. This experimentation and research, and then practical application via patient programs, resulted in the need for a professional organization for cardiopulmonary rehabilitation practitioners. The Journal of Cardiac Rehabilitation One of the most important services of a professional organization is a scientific journal to meet the professional and scientific needs of the membership. The AACVPR was fortunate as the Journal of Cardiac Rehabilitation (JCR) was first established in March of 1981, 4 years before the actual formation of AACVPR.1 In 1979, proceedings of the 1978 Mount Sinai Medical Center (Milwaukee) conference, "Heart Disease and Rehabilitation: State of the Art," was published by Houghton Mifflin's Medical Division.32 Michael Pollock, PhD, organized the conference, and was approached by Houghton Mifflin Publishing Company to develop and publish a cardiac rehabilitation journal, with the co-editors to be himself and Victor Froelicher, MD. The first issue was to be released in January of 1981. However, in 1980, Houghton Mifflin sold their medical division, and the publishing of the journal was in jeopardy. With the concept of a journal of cardiac rehabilitation established, contact was made with Le Jacq Publishing of New York, NY. An agreement was reached, and the first issue of the Journal of Cardiac Rehabilitation was published in March 1981.1 Initially, the journal was bimonthly, but became monthly in January of 1983. In 1986, the Journal of Cardiac Rehabilitation was renamed the Journal of Cardiopulmonary Rehabilitation, and the subject matter and readership was thus expanded. The journal, now published by Lippincott, Williams and Wilkins, Philadelphia, PA, will celebrate its 25th year of publication in 2006. Succeeding Drs. Pollock and Froelicher, subsequent Editors-in-Chief include Barry Franklin, PhD, Kathy Berra, MSN, Gary Balady, MD, and Philip Ades, MD. 1980-1985: Organizing AACVPR Between 1980 and 1985, there was a growing need for a professional organization, as reflected by two significant processes. First, state associations were being formed, leading to the need for a national "umbrella" organization for providers of cardiac and pulmonary rehabilitation. From 1980 and 1985 the states of California, Illinois, Nebraska, and North Carolina organized state associations. Practitioners in the states of Delaware, New Jersey, and Pennsylvania also formed the Tri State Association during this period. Second, a group of ACSM members focusing on cardiac rehabilitation requested greater control within that organization. Requested were the following: An additional and separate annual meeting; An additional and separate publication; Guaranteed representation on the board of directors; A guarantee of a significant portion of the ACSM. As this group of ACSM members interested in a new association increased in number, 2 basic concepts were accepted. First, the new organization would be stronger if pulmonary rehabilitation was included, and second, ACSM would not be able to meet the needs of this new organization. Next in the organizational process was a survey of JCR subscribers regarding the need for an organization, followed by presentations and informational meetings throughout the country. Finally, in 1983 there was a meeting in New York City of the "steering committee," consisting of Ann Abbott, PhD, Kathy Berra, MSN, Barry Franklin, PhD, and Philip Wilson, EdD. Three of these individuals subsequently presided over the organization (Table 1, Figure 1). During this meeting, startup funding was offered by Le Jacq Publishing, the offer was accepted, and final organizational activities began toward AACVPR becoming a reality in 1985.Table 1: PRESIDENTSFigure 1: First Seven AACVPR presidents. Left to right: Phil Wilson, Kathy Berra, Barry Franklin, L. Kent Smith, Bill Bell, Linda Hall, and Pat Comoss.AACVPR…A REALITY 1985-1990: A New Organization Membership in AACVPR was first offered in 1985, and the first annual meeting was in 1986 at Las Colinas, Texas. The big question was, "Would anyone come?" Kathy Berra, the President Elect and program chair for the 1986 meeting commented in the November/December 2004 News and Views, "I am struck by how right we were! We knew that the professions of cardiac rehabilitation and pulmonary rehabilitation were multidisciplinary and multidimensional. We also knew that no organization existed that embraced this concept fully. We began, and remain to this day, an organization of dedicated healthcare professionals with a wide range of specialties. Each of us adds to the whole, each of us brings unique expertise, each of us shares the same goals: to return the patient to optimal emotional and physical health."33 "How many people would come?" Over 500 cardiopulmonary rehabilitation professionals attended that first annual meeting in Texas. A highlight of the conference was the awarding of the first AACVPR Award of Excellence, to Herman Hellerstein, MD. Table 2 lists the recipients of this award over the first 20 years of our association.Table 2: AWARD OF EXCELLENCE RECIPIENTSBerra goes on to indicate that the early challenges were many: "building membership, developing a sound financial base, creating administrative offices, and making ourselves known to the healthcare world as the experts in cardiac rehabilitation and pulmonary rehabilitation."33 The period of 1985-1990 was also a time of growth and maturity of the association. Highlights included expanding our name from "cardiac" to "cardiovascular and pulmonary," and JCR renamed from the Journal of Cardiac Rehabilitation to the Journal of Cardiopulmonary Rehabilitation. In addition, Tom Miller and Associates of Middleton, WI were hired to manage the association. The first issue of News and Views was released in 1987.34 The beginning of work on our first Clinical Practice Guidelines, Barry Franklin appointed JCR Editor-in-Chief, and tremendous growth of the state affiliates, also highlighted the 1985-1990 period. 1991-1995: Maturation The period of 1991-1995 was a period of development of a significant body of publications by AACVPR. This was also a time of reflection, discussion, and decisions on the mission and purpose of the organization. Evidence of publication productivity included the release of the 1st edition of the Guidelines for Cardiac Rehabilitation Programs in 1991,35 and the 1st edition of Guidelines for Pulmonary Rehabilitation Programs in 1993.36 In 1994, "Core Competencies for Cardiac Rehabilitation" was released as a position statement in JCR.37 Also during this period, JCR was named the journal of the Canadian Association of Cardiac Rehabilitation. The year of 1995 was truly a banner year for publications by AACVPR. The year began with JCR approved for listing in Index Medicus and Medline by the National Library of Medicine, "Clinical Competency Guidelines for Pulmonary Rehabilitation Guidelines"38 and "Outcome Measurement in Cardiac and Pulmonary Rehabilitation"39 were published in JCR, and the 2nd edition of Guidelines for Cardiac Rehabilitation Programs was released. In addition, in 1995 the federal funded "guidelines project" was completed with the release of Clinical Practice Guideline #17, Cardiac Rehabilitation.40 These "guidelines" were also released by the federal government in "quick reference format," entitled Cardiac Rehabilitation as Secondary Prevention.41 This document introduced the concept of cardiac rehabilitation also as a secondary prevention program, with the emphasis that comprehensive cardiac rehabilitation involves cardiac risk factor management alongside exercise therapy. These publishing accomplishments are an example of a responsible professional organization meeting both the needs of its membership, and educating others of the substance of the profession. Reflection, discussion, and decisions on the mission and purpose of AACVPR continued during the period 1991-1995, including extensive debate on changing the name of the organization to include the concept of prevention. Philosophically, many felt the current name did not reflect the true mission of the association. After much reflection and debate, it was agreed the name would remain the American Association of Cardiovascular and Pulmonary Rehabilitation, but with the "tag line" phrase "Promoting Health and Preventing Disease." Also during this period an effort began to develop a program certification process, and debate on the formation of a World Council of Cardiopulmonary Rehabilitation was begun. 1996-2000: A Comprehensive Professional Organization Highlights of this period began in 1996 with the hiring of legislative analyst Phillip Porte of GRQ Associates, Washington, DC, to provide expert legislative representation in Washington for AACVPR and its members. Also in 1996, our annual meeting was endorsed and supported by the American Heart Association. The program certification process was established with 168 cardiac and 101 pulmonary programs being certified. Financial grants were provided to several state affiliates for projects related to outcomes research, and the Heart and Lung Foundation was initiated to raise capital funds for AACVPR projects. Publication of educational materials was again a major accomplishment during the period of 1996-2000 with the release of the 2nd edition of Guidelines for Pulmonary Rehabilitation Programs, and the 3rd edition of the "cardiac rehabilitation program guidelines," with the name changed to Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs. Also during this period, the outcomes committee released the Outcomes Tools Research Guide.42 In 1997 there was a joint release by the American College of Chest Physicians and AACVPR of the "pulmonary rehabilitation guidelines," in Chest and JCR.43,44 Kathy Berra, MSN, became the Editor-in-Chief of JCR in 1996, and Gary Balady, MD, assumed this position in 2001. The period of 1996 to 2000 also brought the electronic age to AACVPR, with an AACVPR Web site established in 1996, and the News and Views newsletter distributed electronically in 2000. In 1998, "How to Inform Payers and Influence Payment for Cardiac and Pulmonary Programs"45 was entered on the AACVPR Web site as a member benefit. Also significant in 2000 was a change in the AACVPR management company to Smith Bucklin and Associates of Chicago, Illinois. 2001-2005: A New Century of AACVPR This period started with the 2001 annual meeting being cancelled due to the tragedy of 9/11. The 1st Peripheral Artery Disease Symposium, jointly sponsored with the American College of Cardiology, was rescheduled and held in Atlanta in March 2002. As in the previous period of 1996-2000, publication accomplishments were significant in 2001-2005. The outcomes committee released an updated Outcomes Tool Research Guide, available on the AACVPR Web site, and the Web site "reimbursement manual" was updated. The 3rd edition of Guidelines for Pulmonary Rehabilitation Programs and the 4th edition of Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs were both released in 2004. Activity of JCR included Philip Ades, MD, becoming Editor-in-Chief in 2004, and Continuing Education Credits first being offered in the 2004 JCR January/February issue. Finally, during the period of 2001-2005, the first Heart and Lung Games were held in Demerest, Georgia, and the Heart and Lung Foundation received a donation of $100,000 to forward the goals of AACVPR. Program recertification was first offered, communication to AACVPR members transitioned from paper to electronic, and the board was reorganized with a downsizing from 23 to 12 persons. CONCLUSIONS Where do we go from here? In the early 1980s, the founders of the AACVPR were concerned with establishing a viable and productive national organization, which would meet the professional needs of persons involved as staff in cardiac and pulmonary rehabilitation programs. With membership offered for the first time in 1985, we were under way. Although memberships were available in AACVPR in 1985, and our first annual meeting was in 1986, organizational needs continued to be the emphasis into the early 1990s. However, the period from 1991 to 1995 was also a time of reflection and refocusing on the purpose of AACVPR. This was when we truly became an organization serving both our members, and the profession of cardiopulmonary rehabilitation. Great accomplishments in publications, the completion and release of the federal government funded Cardiac Rehabilitation Clinical Practice Guidelines,40,41 and increased member professional enhancement occurred from 1991 to 1995. The period closed with a redefinition of the purpose and mission of AACVPR. Maturation as a professional organization occurred during the period of 1996-2000. While certification of programs was a major accomplishment during this period, another was the continuing development and publication of materials specific to both professional staff development, and the administrative aspects of operation of cardiac and pulmonary rehabilitation programs. By year 2000, AACVPR had over 3,000 members with almost 2,000 attending the annual scientific meeting. Finally, the new century is upon us. We have continued with our publication efforts, and our maturity as a professional organization. However, as we close this period, we as an organization, and each of us as members of the organization, must again reflect on "where are we now… and where are we going?" What changes in our focus and detailed perception of the future are necessary for AACVPR in the years to come? As individual members of the organization, what can we do to advance accomplishments of AACVPR? As summarized in Table 3, there have been many major accomplishments by AACVPR in our first 20 years. Is there a significance of this 20-year history to us in 2005, and beyond? The history of our organization 5, 10, 20 years from now will be decided by our actions now, and in the very new future. The history of all organizations is in the future, but past history can also give us a partial view of that future. We should all reflect on the words of Hippocrates in 400 b.c.Table 3: MAJOR EVENTS IN THE OF will not must also and possessing work to it is the of exercise to use but of and to it is as it to the of various exercise both and to which of to and which to and not only but also to exercise but of to the of the patient to of the to of the to changes of the to the of the in which the patient and to the of the we need to the therapeutic use of which when with and risk factor treatment can meet the mission of and from cardiovascular and pulmonary education, rehabilitation, research, and

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