Encouraging Flow: A State Of Calm and Deep Focus May Improve Exercise Compliance in Cardiac Rehabilitation

Abstract

Cardiovascular disease (CVD) accounts for more deaths worldwide than any other illness. Over 80% of CVD can be prevented by lifestyle changes. Improving compliance with exercise requirements and reaching 30 minutes of brisk physical activity (PA) on most days remains a challenge. Only a minority of eligible CVD patients complete cardiac rehabilitation (CR) and fewer sustain PA long term. Changing work environments, urbanization, and virtual engagement foster a sedentary lifestyle in students and healthy adults. Disabilities and comorbidities limit PA in older CVD patients. The Flow phenomenon was described in the 1970s as an intrinsically enjoyable state, typically achieved by highly trained people encountering significant challenge like competitive tennis or writing new music. Siddha Tamil medicine has recognized the importance of this 2,000 years ago, recommending ways to experience flow and engage enthusiastically. We hypothesize that flow can be learned and targeted during CR. Older cardiac patients despite comorbidities can experience some level of flow state during CR. This significantly improves long term PA adherence while also sustainably improving other aspects of lifestyle, including diet, smoking cessation, stress reduction, and medication compliance. Clinicians can estimate flow at baseline, following PA sessions and during clinic visits to encourage a deeper mind-body connection. Once PA becomes enjoyable, compliance and cardiac outcomes may improve in CVD.

Flow Phenomenon in Cardiac Rehabilitation and Implications for Sustainable Lifestyle Changes

Cardiovascular diseases (CVD) are the leading cause of mortality accounting for 17.9 million or 31% of all deaths globally in 2016 according to the WHO.¹ Importantly, 80–90% of CVD can be prevented by lifestyle improvements such as addressing tobacco use, unhealthy diet, obesity and physical inactivity.² Sedentary lifestyles increase CVD mortality by 90% and may account for 250,000 deaths in the U.S. alone.^3,4 Variety of factors like increasing urbanization, changing workplace culture, and busy schedules leave little time for physical activity (PA). Over 85% of CVD patients do not reach exercise requirements due to comorbidities, fear or lack of interest.⁵ Improving PA through exercise and sports can improve and sustain healthy lifestyle in CVD patients.

Background

The flow phenomenon is an intrinsically enjoyable, exceptionally positive state of mind and is the psychological process underlying peak performance. Mihaly Csikszentmihalyi described flow in 1975 as the experiential state that occurs as one approaches optimal engagement with a task.⁶ When in flow, a person becomes totally involved in an activity, free from self-consciousness. While it can be reached with any activity, most of the literature focuses on athletic performance and artistic creativity. The nine dimensions of flow are challenge-skill balance, the merging of actions with awareness, having clear task goals, unambiguous feedback, full concentration on the task at hand, a sense of control, a loss of self-consciousness, a perception of the transformation of time and an autotelic (or intrinsically rewarding) experience. During Heartful Living, our eight-week physician-led cardiac wellness program, we educate and encourage exercise related flow experiences.⁷ This is central to self-inquiry, or asking ‘who am I?’ in the Siddha mindfulness tradition using various mind-body and positive psychology tools to elevate consciousness.⁸ Deeper self-awareness is the central tenet of this program that targets sustainable lifestyle changes at any age, despite significant comorbidities. Every day of the two-month course, cardiac patients explore different challenging yet safe PA with potential to experience flow.⁶

Hypothesis

We hypothesize flow phenomenon can be employed during CR in CVD patients and would improve long-term compliance with exercise and enhance confidence. Flow was first described in 1970s as an intrinsically enjoyable state in well trained people performing complex tasks like playing tennis or writing new music, but occurs with daily activities as well.⁹ The high level of challenge may allow this flow or ‘self-less’ engagement to maximize performance, often beyond expectations. Siddha medicine has recognized the importance of this and systematically taught techniques to achieve ‘uvagai’ (meaning extreme happiness or bliss). Ancient Tamil literature dating back 5,000 years recommends specific mind-body techniques including yoga, dance, and martial arts to experience flow and live better.^{8, 10} In 1996 Jackson reported a 36-item Flow State Scale to measure all these dimensions and quantify flow during sports events in athletes which has been adapted for mental activities in older adults.¹¹ We hypothesize that flow during PA can be quantified in CVD patients. We start with siddha mindfulness methods that deepen mind-body connection. Thus, our CVD patients are able to intuitively improve exercise capacity and continue to gain confidence in a positive feedback loop. To our knowledge, we are the only program prospectively targeting flow in CR.

We believe cardiac patients can learn to experience flow state during CR despite comorbidities and older age. Being intrinsically enjoyable, this can potentially improve and sustain PA. Beyond being a ‘prescription,’ PA can potentially transform into an enjoyable lifetime pursuit. We describe two CVD cases in cardiac rehabilitation (CR) to illustrate how targeting flow during PA has transformed their lives.

Case 1: Exercising Beyond Maximal Treadmill Capacity

In spring 2018, a 50-year-old sedentary chemical engineer presented to the local emergency room with 30 minutes of chest discomfort. He went into ventricular fibrillation cardiac arrest requiring CPR and two shocks at 200 joules. Anterior ST elevation improved with thrombolysis and subsequent cardiac catheterization revealed 95% mid LAD and 60% proximal right coronary artery disease. PCI was performed with drug eluting stent to the LAD. Mild left ventricular (LV) dysfunction with anteroseptal hypokinesia and reduced ejection fraction (EF) of 40% was noted by the echocardiogram. Perindopril 5mg, Bisoprolol 2.5mg and atorvastatin 40mg were started along with dual antiplatelet agents. He completed CR as well as our cardiac wellness program and three months later, his LV EF improved to 50–55% range. Patient improved his diet, reduced work stress, and practiced yoga two times a week. His exercise tolerance improved steadily over three months with his confidence returning to exercise maximally in the modified 0–10 Borg rating of perceived exertion (RPE) scale. He reached his goal of treadmill running at a constant speed of 3.7mph three times a week without angina. Most sessions would forcibly terminate due to exhaustion at 30–40 minutes on reaching RPE 10 with heart rate about 125 bpm. However, few times a month he experienced a peculiar ‘breakthrough’ phenomenon while still on the treadmill. His heart rate would stabilize at about 133 bpm, and importantly, RPE would drop to 2 and he reported feeling ‘relaxed’ and ‘weightless’ while still running at 3.7mph (Figure 1). He would comfortably run an additional 15–20 minutes, electing to stop while still feeling energetic on these occasions. We believe that entering a flow state accounts for the dramatic decline in RPE. The BEFIT score (see Discussion) of the first patient was 22 on occasions when he ‘broke through’ beyond 40 minutes on the treadmill. Warm-up angina and ‘second wind’ phenomena may have some overlap, but typically occur after a break and do not involve losing track of time, weightlessness, or altered awareness

Figure 1.

Graphic description of a typical exercise session. Treadmill running at a constant speed of 3.7mph typically for 30–40 minutes forcibly terminating with Borg RPE reaching 10. Some sessions would continue additional 15 minutes when patient enters flow state with RPE dropping to 2 and heart rate stabilizing at about 133bpm.

Case 2: Professor Takes to Competitive Running After STEMI

In the summer of 2018, a 68-year-old professor at University of Missouri-Columbia developed acute chest pain that woke him up from sleep. He was not on cardiac medications. Cardiac risk factors were sedentary lifestyle and family history of a brother with heart disease at 60 years. Inferior ST elevation infarction was diagnosed at the ER requiring revascularization with drug eluting stent to the right coronary artery. Echocardiogram showed inferior hypokinesia, EF 45%. He was initiated on guideline mediated medical therapy and completed three months CR and our cardiac wellness program. At follow-up LV function improved with LV EF 60%. At baseline, prior to 2018, he could only walk two to three blocks. Progressive increase in exercise capacity with CR has led him to begin competitive running for the first time at the age of 69 years. By April 2019, he completed a 5 km run in 45 minutes. PA has become an integral part of his life because he has discovered how it helps improve physical and mental wellbeing. The BEFIT score of 14 at baseline increased to 18 over months corresponding with more athletic engagement. He is now resistance and endurance training year-round at a fitness academy along with student athletes to improve his performance for more challenging athletic events in his ‘70s.

Discussion

Both patients participated in Heartful Living along with traditional CR. Based on flow experience during competitive tennis, the authors have developed a simplified five-item scale to quantify flow, which is yet to be validated. After completion of the PA, our BEFIT scale grades the flow experience from 1 to 5 (1=strongly disagree, 2=disagree, 3=neutral, 4=agree, and 5= strongly agree). The BEFIT items are 1) I performed Beyond my expectations; 2) Things happened Effortlessly and I felt weightless; 3) PA was a Fun and rewarding experience, I look forward to repeating; 4) The sense of self “I” was lost, yet there was intuitive awareness; and 5) Time just stopped, long periods feeling like a blur or a moment. Based on preliminary data, a score ≥ 18 indicates flow experience, with higher scores increasing the likelihood of enjoying and embracing long term PA (Figure 2).

Figure 2.

BEFIT flow scale (0 to 25) and typical scores following physical activity and general characteristics and exercise perception in adults. Participants are encouraged to score based on how they felt after completion of a recent ‘fun’ exercise or ‘good’ sporting experience.

Current guidelines do not restrict athletic participation three months after coronary revascularization, if LV function is preserved without evidence for ischemia or arrhythmia.¹² Case reports document the safety of gradually increasing to maximal tolerated exercise and reaching beyond 100% of age predicted maximal heart rate even in older cardiac patients.¹³ Positive psychological effects of flow include long-term adherence with physical activity, stress reduction, compliance with diet, medications, and risk factor control and better outlook towards life.^{14, 15} The BEFIT flow scale needs validated in CR and other populations. Working with psychologists, we plan to prospectively evaluate if increasing BEFIT scores correlates with improved PA compliance. Ideally, we would like to compare BEFIT scores, PA adherence, and CV outcomes for traditional CR alone versus CR combined with Heartful Living mind-body education.

Conclusions

The flow experience can play an important role in holistic health and cardiac rehabilitation. Despite the numerous challenges faced by older cardiac patients with comorbidities, aiming for flow is likely to improve and sustain physical activity. Starting with intuitive mindfulness methods, we encourage our CVD patients and their families to explore sports or physical exercises that induce flow. Further study will clarify if targeting flow after a cardiac event may help patients increase exercise capacity, deepen self-awareness and intuitively pursue a more active lifestyle.