It's not on a city tour, and there isn't a department store inside, but many Bermudians pass through Jaye Hefner's place of business every year.

Dr. Hefner is medical consultant, and director of the cardiac rehabilitation programme at Spaulding Rehabilitation Hospital in Boston, Massachusetts, a hospital that sees an average of three Bermudians per month.

Many of the Bermuda patients have brain and spinal cord injuries obtained in cycle accidents, but a fair number have also had heart attacks and strokes.

Dr. Hefner was recently in Bermuda to talk with health care professionals about cardiac rehabilitation after a Myocardial Infarction (MI), the technical term for a heart attack.

"It is the most common thing we see," she said. "A person from Bermuda would have a heart attack and would be transferred the United States, to Massachusetts General Hospital, let's say, and maybe have an intervention or not. Then they would come to Spaulding on our cardiac rehabilitation programme, and stay for a certain length of time, usually about three to four weeks."

The Spaulding cardio rehabilitation programme is an inpatient programme, with four components of cardiac rehabilitation.

"The first part is exercise training, which is fitness," Dr. Hefner said. "That is getting a person more active. It has to be supervised, so it is a very specific prescription that is written for them to start exercising again. There is also vocational and psychological training."

She said the psychological aspects are important, because 70 percent of people are depressed after having a heart attack.

"Most people are afraid to exercise," she said. "They are told that if you have a heart attack you have to take it easy.

"Physicians often don't do a good job of counselling a person in regards to how they can exercise. The most common thing that comes up is the patient asks 'when can I start having sex again?'

"The doctor says they don't know. In soap operas people are having sex right there in the hospital. We tell them to wait until after they are released, at least," Dr. Hefner laughed.

The vocational part of the rehabilitation is also important, because many people don't go back to work after having a heart attack, even though they are capable of it.

"If you have someone who is in their 60s and they were gainfully employed, there is a 50 percent chance they won't go back to work," said Dr. Hefner.

"It is not because they can't but because they are not counselled how to do so. They get depressed. They wind up having a disability."

Thirty to 40 percent of patients that Dr. Hefner sees are under 60 years old, which she admitted was a high figure.

"So the other part of cardiac rehabilitation is risk reduction, and medical treatment," she said. "That is modifying someone's risk factor for another stroke, heart attack or vascular event. That is where you deal with things like smoking cessation, blood pressure modification, any type of ongoing medical therapy, drugs."

Unfortunately, she said many patients don't give up smoking, even after having a heart attack or stroke.

"The risk factors that you can't modify are your gender, your age and your family history, and some lipid disorders," she said.

"We know that some people are just going to have some risk factors because that is who they are. Essential hypertension is like that also. But many more risk factors are modifiable. Things we can change are smoking, diet, a sedentary lifestyle, obesity, weight-related disorders and diabetes."

She said although there are people who develop certain diseases like heart disease or diabetes because of a genetic pre-disposition, the vast majority is lifestyle induced. She urged people to make themselves cognisant of their own risk factors.

"Many people don't come in for screening tests," she said. "They don't actually know what their blood pressure is or what their goals for their blood pressure should be. They don't really know that much about healthy eating and weight loss."

She said most exercise guidelines say that people need at least 30 minutes of aerobic exercise such as running or walking four days a week. People also need, to a lesser extent, some strength training.

"In rehab medicine, we basically deal with three types of exercise and strength training which help you do activities in daily living," she said.

"We do lifting weights or resistance training. We work on range of motion. That is going to help you take your groceries out of your car and get them into your house. Then there are sport-specific types of exercise and those are for athletes, and how you can prevent injuries or treat them.

"The last type of exercise is either fitness or endurance. That is increasing your aerobic capacity."

Dr. Hefner was in Bermuda along with other staff members from Spaulding including Lois Siegelman, facilitator of services and Director of Admissions at Spaulding Rehabilitation Centre, Dianne Lamb.

"We are working on enhancing the relationship between the two facilities and making sure there is a continuum of care as people go back and forth between Boston and Bermuda," said Mrs. Siegelman.

"We are talking about doing some conjoint community service here in Bermuda. We are looking into prevention of spinal cord injuries and brain injuries. We have a lot of people who come to Boston for rehabilitation as a result of accidents on the road."