Treating the whole person

Cardiac rehabilitation is a multi-disciplinary approach, which recognises that a cardiac event affects a person physically and psychologically. Because negative psychological states can hinder a person’s physical recovery – particularly stress – it’s important that psychological wellbeing is addressed.

Identifying normal reactions to a cardiac event

These include:

• shock
• fear
• loss
• anger
• sleep problems
• relationship issues
• intensification of earlier issues.

These usually ease as physical recovery is made. Some people experience positive feelings after a cardiac event – such as joy, relief or gratitude – and it is important to hold on to those feelings.

Understanding stress and how to manage it

Along with genetic and lifestyle factors, stress is a major contributor to cardiac disease. It is, however, possible to manage it more effectively and to reduce the risk it poses to your health.

What causes stress?

Anything can cause stress. Stress occurs when the demands placed upon us – by self or others – exceed our perceived capacity to cope with those demands.

Common areas where stress can be experienced include:

• health
• finances
• relationships
• work.

We are all different and respond in different ways to the same events. What is interesting and challenging to one person may be a source of stress for another. One person may thrive under pressure and perform best when they have a tight deadline but someone else may struggle and become stressed when demands escalate.

How stress affects us

Too much stress causes us to feel threatened, and because the body is unable to distinguish between physical and psychological threats, it responds to psychological stress the same way it would to a physical threat.

This involves the nervous system releasing stress hormones, including adrenaline and cortisol, into the blood stream. It prepares the body for emergency action and is often called the fight or flight response. The heart rate increases, muscles tense up, digestion slows down, breathing becomes more rapid, senses become more acute and sweating starts. It is the body’s way of protecting you by helping you stay focused, energetic and alert.

The sympathetic nervous system activates the fight or flight response and the parasympathetic nervous system activates the relaxation response, also known as rest and digest.

In emergency situations, stress can save lives and in day-to-day living it helps people rise to the challenges they face. However, problems develop when the body is unable to switch off this stress response.

Early signs of stress

Not all stress is bad for you. In small and infrequent doses it can increase
focus, energy and drive. But persistent stress can adversely affect you
mentally, emotionally, behaviourally and physically.

Symptoms include:

• poor concentration
• impaired memory
• irritability
• tension
• tearfulness
• headaches
• frequent infections
• sleep problems and so on.

Long-term effects

A prolonged state of fight or flight can contribute to major health
problems, such as:

• high blood pressure
• high cholesterol
• cardiac and respiratory disease
• diabetes
• stomach ulcers
• reduced immune function.

Prolonged stress

Muscles: Tension leads to aches and pains and even muscle spasm.

Heart: Racing heartbeat and high blood pressure can lead to strokes or heart attacks.

Blood: The work of the heart is made harder by the thickening of blood.

Lungs: Super-oxygenated blood can lead to black-outs and upset heart rhythms.

Liver: The body’s own fats and proteins are broken down and released to provide further energy.

Cholesterol: High cholesterol in the blood can cause hardening of the arteries.

Skin: Without proper blood supply, diseases may develop.

Digestion: Shutdown can lead to problems, particularly if you eat on the run. Acidity can lead to ulcers.

Managing stress

The first step in dealing with your stress is to recognise its cause. Having
done this, ask yourself the following questions:

• Can I eliminate it?
• Can I reduce it?
• Can I offset its effects?

If we cannot eliminate stress from our lives, we can often reduce it by:

• being realistic about what has happened to us and our expectations of
  recovery
• pacing ourselves
• introducing balance
• eating healthier
• exercising
• improved sleep
• learning to say no, ask for help, delegate, be more assertive
• challenging our thinking habits.

Thinking differently – responding rather than reacting

It is the interpretation of a situation – whether to do with health, finances, relationships or work – which causes stress, rather than the situation itself.

The interpretation involves thoughts which produce emotions that directly impact the body. Our interpretations are likely to have been conditioned and influenced by familial and social conditioning and possibly by traumatic events.

The conditioning is effective because it has been embedded in our subconscious. The more aware we become of our habitual, auto-pilot thinking patterns embedded in the sub-conscious, the more aware we become that through our conscious mind we can learn to respond rather than react when faced with the challenging situations in our lives. This involves becoming mindful of what we are thinking or doing in the present moment rather than worrying about the past and the future.

Offsetting the effects of stress

If we cannot eliminate or reduce stress, we can offset the effects of stress through deep relaxation.

Different levels of relaxation:

• Superficial (surface) relaxation, achieved through enjoying a hobby, reading or watching television, for example.
• Deep relaxation, achieved through actively suspending the effects of life’s challenges on your mind and body.

The benefits of deep relaxation

Relaxation is sometimes described as the single most important key to health and wellbeing. It is the antidote to stress, which is known to contribute to the development of disease. There are many benefits to being able to relax. These include:

• improved blood flow to the heart and slowed rate of beating
• lower cholesterol levels
• reduced blood pressure
• improved immunity
• helping to keep blood sugar levels stable
• increased blood flow to the muscles, reducing muscle tension
• pain reduction
• increased energy
• improved concentration
• reduction of negative emotional states such as anger and frustration
• greater ability to handle problems
• more efficiency in daily activities.

There are a variety of activities which can help you achieve a deep relaxation response. These include:

• massage
• aromatherapy
• meditation
• yoga
• Tai Chi.

The best way to start relaxation practice is to schedule a set time either once or twice daily, even just for ten minutes, maybe first thing in the morning before other tasks get in the way. Find a quiet, warm place where you won’t be disturbed.

Deep relaxation is a skill that needs to be learned and it takes practice and patience to truly harness its stress-relieving power. Try out different methods to find which suits you.

Relaxation exercises

Here are five examples of relaxation exercises.

Caution

After trying the relaxation exercises in the next section, get up slowly as your blood pressure and pulse rate may have lowered and you might feel a bit dizzy if you move too quickly.

Deep breathing

Deep breathing is the cornerstone of many other relaxation practices and all you really need is a few minutes and a place to stretch out. It is a simple, yet powerful, relaxation technique that is easy to learn, can be practiced almost anywhere and provides a quick way to get your stress levels in check. The key to deep breathing is to breathe deeply from the abdomen, getting as much fresh air as possible in your lungs. When you take deep breaths from the abdomen, rather than shallow breaths from your upper chest, you inhale more oxygen. The more oxygen you get, the less tense, short of breath and anxious you feel.

• Make yourself comfortable in a chair or lying down, and loosen your clothing, if necessary.
• Focus on your breathing – feel its rhythm, depth and speed.
• Put one hand on the upper part of your chest and the other just below your ribs on your abdomen.
• Slowly inhale. Feel your abdomen rising under your hand.
• Exhale for a little longer than the inhalation. Feel your abdomen fall under your hand.
• Pause for a few moments, and then repeat the process.

Some people find counting also helps with deep breathing. First breathe in deeply to a count of three. Hold the breath for a further four counts and then breathe it out to a count of five. If the three-four-five ratio is uncomfortable for you, you can adapt this to any ratio that feels right for you but try to make the exhalation longer than the inhalation. You’ll know that you’re following the technique correctly if the hand on your abdomen moves up and down but the hand on your chest remains still.

Body scan

It is possible to start this exercise from the feet and work up or from the head and work downwards.

• Take a few minutes to relax, breathing in and out, in slow deep breaths. When you are relaxed and ready to start, shift your attention to your left foot, then to your left calf and thigh, noticing any feelings and sensations.
• Repeat with the right foot, calf and thigh.
  Gradually shift your attention, again noticing any feelings or sensations, to your hips and buttocks and let it travel up your back to your shoulders and neck, then to the back of your head, to your face and jaw and down into your chest.
• Move your attention along your left arm to your hand and fingers and then repeat with your right arm. Shift your attention back into the chest and then down to the abdomen.

Progressive muscle relaxation

Progressive muscle relaxation gives you awareness of what tension and relaxation feel like in different parts of the body.

It is possible to start this exercise from the feet and work up or from the
head and work downwards.

• Take a few minutes to relax, breathing in and out in slow deep breaths.
• When you are relaxed and ready to start, shift your attention to your left foot. Take a moment to focus on the way it feels.
• Slowly tense the muscles in your left foot, squeezing as tightly as you can. Hold for a few seconds.
• Relax your left foot. Focus on the tension flowing away and the way your foot feels as it becomes limp and loose.
• When you’re ready, shift your attention to your left calf and thigh. Follow the same sequence of muscle tension and release.
• Repeat with the right foot, calf and thigh.
• Move slowly up through your body – hips and buttocks, back, neck and shoulders, head, face and jaw, arms and hands, and chest – tensing and relaxing your muscles.

Visualisation

In this technique, the goal is to visualise yourself in a peaceful setting.

• Think of a scene – real or imaginary – that makes you feel safe, warm and peaceful. The place may be on a sunny beach with the gentle sea breezes, swinging in a hammock in the shade of the woods or even in your own garden.
• Imagine you are there. See and feel your surroundings – the breeze, the
  temperature, picture the colours, hear the sounds and smell any scents.
  Relax and enjoy it.

Toe tensing

A simple exercise where tensing and relaxing your toes releases tension from the rest of your body.

• Lie on your back and close your eyes.
• Sense your toes.
• Now pull all your toes back towards your face. Hold for a few seconds.
• Relax your toes and count to 10 slowly.
• Repeat the above cycle 10 times.

Helpful tips

• Challenge your musts, ought to’s and shoulds.
• Learn to say no.
• Respond rather than react – don’t jump to conclusions.
• Acknowledge and express your emotions.
• Deep relaxation.

Helpful links

Guided meditations can be found on CDs, apps and online.

Some helpful links include:

• Cardiac Rehabilitation Service - listen relaxation exercises
• Forumhealthcentre.nhs.uk