ReCent Medical News
June 2023
Heart rate variability
The objective diagnostic for subjective conditions in disability income insurance
The emergence of wearable technology provides the catalyst to enable monitoring of heart rate variability (HRV) in a quick, easy and efficient manner. The use of this data feed can be an important means to assist the claimants’ medical practitioner in ensuring the right functional capacity assessment is made. Whilst the clinical diagnosis provides a basis for the medical management of a claimant’s condition, in the claims assessment world, the key driver is evaluating and understanding functional capacity for work. The diagnosis itself is not the sole determinant in evaluating functional capacity for work.
The management of any disability income insurance claim should, at its core, be focused on what the claimant can do from a functional capacity perspective, rather than what they cannot. The claim assessment pathway for any subjective condition is always paved with uncertainty when evaluating the veracity of the claimed functional incapacity. The search for an objective functional assessment tool on which to assess this aspect continues to be a problematic proposition.
With wearable technology, have we found an objective measure that could assist claim assessors in understanding functional capacity better, and whether a claimant has reached a point in their recovery cycle that allows a graduated return to work to be considered and implemented? Can it provide the data feed enabling claimants to better self-manage their functional capacity fluctuations associated with their diagnosed condition?
Source: Viggiano, Michelle, June 3, 2019 – AIM Human Performance 9
What is HRV?
HRV is commonly used for optimising athletic performance, but it also has applications in the claims assessment and rehabilitation world.
The use of HRV has proven to be a powerful tool in indicating the “fitness” of your autonomic nervous system, and therefore the ability of your body to recover. It is an objective indicator of how your body is coping with life stressors and general wellbeing.1
Low HRV score is associated with numerous health conditions such as chronic fatigue, chronic pain, depression, fibromyalgia and irritable bowel syndrome.2, 3, 4, 5 High HRV score generally indicates your nervous system is responsive, it’s elastic, it’s awake and ready to respond to the environment appropriately.6, 7
It will also indicate a poor balance between the action and rest systems, and suggest that the nervous system is leaning more towards one than the other.8 This would indicate decreasing capacity and is a sign of stress tolerance and associated resilience decreasing. Therefore, it will be an indicator for the claimant to take some rest breaks, practise mindfulness, breathe and self-manage.
Considering these factors, HRV is an objective indicator that could be utilised by an Exercise Physiologist in a rehabilitation/work conditioning program. It will give insight into whether the exercise program is helping or hindering, provide direction on exercise prescription and highlight whether other lifestyle and medical factors affecting recovery need to be addressed. It will then allow the treating practitioners to understand, with greater certainty, how the management of the subjective-based condition is progressing with objective real-time data.
This information will also allow the assessor/rehabilitation consultant to work closely with the claimant and their medical practitioner to ensure the appropriate rehabilitation support and work readiness program is being delivered, thereby returning the claimant to good health, and reducing cost of claims for the insurer.
Interview
with Brad Domek, Director Specialised Health
To enable further comprehension of its potential application in the claims management world, we have teamed up with a pioneer in the usage of HRV in Australia and New Zealand – Specialised Health.
Below, we discuss the subject in more detail with the company's Director Brad Domek.
What are the benefits of using HRV tracking?
"At Specialised Health we’ve developed two distinct programs which utilise HRV tracking at its core. “Headstrong” is a rehabilitation program using HRV to optimise exercise prescription for those with a mental health condition and “Bounce” is a 12 week fatigue management program aimed at building functionality in those suffering from chronic fatigue or cancer-related fatigue. Within these programs, clients are asked to rate themselves, before and after the program, in various aspects of their life; for example their satisfaction with their current level of social interaction, their perceived ability to manage their stress, the quality of their sleep etc.
Two areas stood out in particular being the patient’s perceptions of their ability to self-manage their condition without external assistance and their ability to identify “booming and busting” trends. In these metrics patients recorded a 33% and 34% increase respectively after only 12 weeks of intervention despite often wrestling with their condition for more than 2-3 years! These results represent to us a much more empowered and independent patient who is no longer seeking a silver bullet for their condition but one who is taking charge of their situation and trying to move forward and this is just one of the many benefits of using HRV tracking."
How did HRV become a part of your established exercise physiology (EP) programs?
"In 2016, one of our Exercise Physiologists at Specialised Health was providing strength and conditioning services to a professional soccer club where the high performance team was experimenting with various methodologies which were all aimed at improving player recovery post-training. One such methodology focused on the measurement of players' HRV due to strong documented evidence for HRV use to aid training in the endurance sports of ironman, triathlon and rowing. At the same time, we were working quite extensively with clinical cohorts of patients who were suffering from fatigue symptomology i.e. chronic fatigue syndrome, post-viral fatigue, cancer-related fatigue, and more. We discussed that there was likely a strong potential use-case for HRV given the similarities in the outcomes we were seeking, albeit with clients who were at different ends of the functional spectrum.
Fast forward to 2022 and HRV has become a powerful metric that we incorporate into many client programs enabling us as practitioners to highly tailor our patient’s rehabilitation journey. As a result, their ability to build strength, fitness and overall functionality is far improved. Our use of HRV has also extended beyond the initial cohort of fatigue sufferers to help those with mental health conditions, cancer recovery and auto-immune conditions, however, we believe many more applications will continue to be uncovered."
What does an exercise physiology program using HRV look like in practice?
"Patients measuring their HRV as part of a rehabilitative protocol will perform a measurement using a chest strap linked to their smartphone every morning. By doing so we are able to obtain insights into the state of their autonomic nervous system and how it is responding to the various stressors encountered in the recent past.
After an initial period, usually 3 – 4 weeks, of observing each patient’s daily activities (stressors) and the associated recovery period, a specific and targeted level of additional stress is then added to the patient’s day, in the form of a structured activity or exercise program."
How does the use of HRV in your exercise physiology program provide better outcomes in improving overall functional capacity than a stand-alone EP program?
"When working with a highly-trained individual, perhaps a sportsperson or athlete, you can be forgiven for deferring to their perceptions of whether they tolerated a load or not and using these perceptions to inform your decision-making process around whether additional load should be added to their training regime or not. This population would be assumed to be highly in tune with their body, they have a strong history of training and usually vast experience with encountering different training loads and monitoring how their body felt as a result. As such their subjective reports of tolerance or intolerance to the load would likely be deemed to be a reliable source of information to go by.
However, this often isn’t the case and it’s actually the lack of reliability in these subjective reports that leads to overtraining and injury in the athletic population.
If we took these same assumptions into the clinical space, i.e. placing complete trust in the subjective reports of an ill, often untrained and often deconditioned individual about whether they tolerated a load or not, the likelihood of their subjective report, and the subsequent program prescription being accurate, is far lower.
HRV offers an additional, objective, data point that is able to be considered when a clinician is determining the right amount of additional stress which should be added to a training load. Getting this loading right is usually the key to a patient being able to build greater tolerance and therefore greater functionality."
In-practice HRV outcomes
Two real life examples Brad was able to share:
Example 1
This General Practitioner gained vital insights into how she could optimise her pacing, her exercise and relaxation in her battle with chronic fatigue syndrome.
“Learning how to pace using HRV has been invaluable and learning how to listen to your body and give yourself permission to rest and meditate has been very useful.”
Find the entire case study on Specialised Health's website.
Example 2
The following is an example of one of our EPs building resilience to fatigue with a patient suffering from a mental health condition, PTSD. Read the full example on Specialised Health's website.
Next steps
Hannover Life Re of Australasia has now embarked on an observational pilot which will run over the next 6 – 9 months on disability income protection claimants suffering from a mental health condition. The goal of the pilot is to understand further whether the incorporation of HRV in an EP program can provide improved functional capacity outcomes for claimants sooner rather than later.
Another key deliverable will be to potentially identify a certain claim profile where the use of EP + HRV delivers improved functional capacity and sustainable return to work outcomes. The pilot program has been named Headstrong for future referencing.
The ultimate goal of any functional upgrading program is to return claimants back to good health, and in turn, return to work sooner rather than later but with a sustainable intent. Because the mental health space is so subjective, we propose using HRV and other biofeedback to help provide some objectivity regarding the evaluation of functional capacity.
“Supposing is good, but finding out is better”
Mark Twain
Outlook
Part 2 of this article will deliver the outcomes of the observational pilot and provide some conclusions regarding the use of HRV within an EP program but also importantly its application within a compensatory environment.
References
To view the references, please click here.
Authors
June Khaw
Rehabilitation Consultant
Hannover Life Re of Australasia
Mark Wise
Technical Claims Team Manager
Hannover Life Re of Australasia
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