Barriers to outpatient cardiac rehabilitation participation and adherence

Affective exercise experiences predict physical activity behaviour in cardiac outpatients within a home-based cardiac rehabilitation programme

Home-based cardiac rehabilitation (HBCR) programmes increase exercise capacity but often face poor adherence to physical activity (PA). This study tested the structural validity of the Affective Exercise Experiences Questionnaire (AFFEXX) in a cardiac population and examined the role of the novel construct of affective exercise experiences in predicting exercise behaviour during an HBCR programme. A sample of 177 patients enrolled in a 10-month HBCR programme, completed a moderate-intensity treadmill walking test, and completed the AFFEXX questionnaire and the 7-day Physical Activity Recall at the beginning and end of the programme. Structural equation modelling confirmed the structural validity of the AFFEXX, with a good fit to the data (Comparative Fit Index = 0.97, Tucker-Lewis Index = 0.95, RMSEA = 0.08). Core affective exercise experiences, which were influenced by antecedent appraisals, significantly predicted attraction-antipathy towards exercise. Multiple regression analysis indicated that follow-up PA was significantly predicted by attraction-antipathy towards exercise (b = 0.24, p = 0.001) and baseline PA (b = 0.29, p = 0.001). The model accounted for 31% of the variance in PA. The study highlights the association between attraction towards exercise and adherence to PA in participants enrolled in an HBCR programme, emphasising the importance of this novel construct.

Exergames in exercise-based cardiac rehabilitation for patients with heart failure: a systematic review

AIM

The aim of this study was to systematically review the current literature on the use of exergames as an exercise-based cardiac rehabilitation intervention for patients with heart failure.

METHODS

PubMed, SCOPUS and CINAHL Plus databases were searched from January 2007 to August 2023. Studies considered eligible for inclusion had to report one or more of the following outcomes: functional capacity (e.g. VO 2 max), quality of life, mortality, hospital admissions, physical activity level, and engagement/satisfaction of the intervention. Only studies reported in English were included. Two reviewers independently assessed studies for their eligibility.

RESULTS

Two studies (in four reports) were included. Included studies reported only data on functional capacity (6-min walking test) and on physical activity level (accelerometers). Due to the low number of included studies, no meta-analysis was performed, and results were discussed narratively.

CONCLUSION

Exergames may potentially be a promising tool for exercise-based cardiac rehabilitation in patients with heart failure; however, the low number of included studies was insufficient to drawn proper conclusions. Benefits of exergames compared with traditional interventions could be the possibility of it being delivered at home, reducing some of the barriers that patients with heart failure must face. Further studies are required to assess the efficacy of exergame interventions in patients with heart failure, and to define proper guidelines to deliver exergame interventions in this population.This systematic review was registered on PROSPERO (CRD42023446948).

Artificial intelligence-driven virtual rehabilitation for people living in the community: A scoping review

Virtual Rehabilitation (VRehab) is a promising approach to improving the physical and mental functioning of patients living in the community. The use of VRehab technology results in the generation of multi-modal datasets collected through various devices. This presents opportunities for the development of Artificial Intelligence (AI) techniques in VRehab, namely the measurement, detection, and prediction of various patients' health outcomes. The objective of this scoping review was to explore the applications and effectiveness of incorporating AI into home-based VRehab programs. PubMed/MEDLINE, Embase, IEEE Xplore, Web of Science databases, and Google Scholar were searched from inception until June 2023 for studies that applied AI for the delivery of VRehab programs to the homes of adult patients. After screening 2172 unique titles and abstracts and 51 full-text studies, 13 studies were included in the review. A variety of AI algorithms were applied to analyze data collected from various sensors and make inferences about patients' health outcomes, most involving evaluating patients' exercise quality and providing feedback to patients. The AI algorithms used in the studies were mostly fuzzy rule-based methods, template matching, and deep neural networks. Despite the growing body of literature on the use of AI in VRehab, very few studies have examined its use in patients' homes. Current research suggests that integrating AI with home-based VRehab can lead to improved rehabilitation outcomes for patients. However, further research is required to fully assess the effectiveness of various forms of AI-driven home-based VRehab, taking into account its unique challenges and using standardized metrics.

Psychosocial services provided by licensed cardiac rehabilitation programs

Background

Professional health organizations recommend that outpatient cardiac rehabilitation programs include activities to optimize the physical, mental, and social well-being of patients. The study objectives were to describe among cardiac rehabilitation programs (1) mental health assessments performed; (2) psychosocial services offered; and (3) leadership's perception of barriers to psychosocial services offerings.

Methods

A cross-sectional survey of North Carolina licensed outpatient cardiac rehabilitation programs on their 2018 services was conducted. Descriptive statistics were used to summarize survey responses. Thematic analysis of free text questions related to barriers to programmatic establishment or expansion of psychosocial services was performed by two team members until consensus was reached.

Results

Sixty-eight programs (89%) responded to the survey. Forty-eight programs (70%) indicated offering psychosocial services; however, a majority (73%) of programs reported not directly billing for those services. At program enrollment, mental health was assessed in 94% of programs of which 92% repeated the assessment at discharge. Depression was assessed with the 9-item Patient Health Questionnaire by a majority (75%) of programs. Psychosocial services included individual counseling (59%), counseling referrals (49%), and educational classes (29%). Directors reported lack of internal resources (92%) and patient beliefs (45%) as the top barriers to including or expanding psychosocial services at their facilities.

Conclusions

Cardiac rehabilitation programs routinely assess mental health but lack the resources to establish or expand psychosocial services. Interventions aimed at improving patient education and reducing stigma of mental health are important public health opportunities.

Prevalence of physical activity levels and perceived benefits of and barriers to physical activity among Jordanian patients with coronary heart disease: A cross-sectional study

Background

Many studies published in other countries have identified certain perceived benefits of and barriers to physical activity among patients with coronary heart disease. Nevertheless, there is no data about the issue relating to Jordanian patients with coronary heart disease.

Objective

This study aimed to describe the prevalence of levels of physical activity, the benefits of and barriers to physical activity as perceived by Jordanian patients with coronary heart disease, and the relationship between physical activity and perceived benefits of and barriers to physical activity. In addition, it focused on examining the influence of selected sociodemographic and health characteristics on physical activity and the perceived benefits of and barriers to physical activity.

Methods

A cross-sectional design was performed on a sample of 400 patients with coronary heart disease. They were given a list of perceived benefits of and barriers to physical activity and asked to what extent they disagreed or agreed with each.

Results

Jordanian patients with coronary heart disease perceived various benefits of and barriers to physical activity. Most of these benefits were physiologically related (average mean = 5.7, SD = 0.7). The most substantial barriers to physical activity as perceived by the patients were "feeling anxiety," "not enough time," "lack of interest," "bad weather," and "feeling of being uncomfortable." Sociodemographic and health characteristics that significantly influenced perceived barriers to physical activity were age, gender, health perception, chest pain frequency, education, job, caring responsibilities, ability to travel alone, smoking, and previous and current physical activity behavior.

Conclusion

This study demonstrates that patients with coronary heart disease have perceived physiological benefits of physical activity and have perceived motivational, physical health, and environmental barriers to physical activity, which is significant in developing intervention strategies that aim to maximize patients' participation in physical activity and overcome barriers to physical activity.

Recurrence risk prediction of acute coronary syndrome per patient as a personalized ACS recurrence risk: a retrospective study

Acute coronary syndrome (ACS) has been one of the most important issues in global public health. The high recurrence risk of patients with coronary heart disease (CHD) has led to the importance of post-discharge care and secondary prevention of CHD. Previous studies provided binary results of ACS recurrence risk; however, studies providing the recurrence risk of an individual patient are rare. In this study, we conducted a model which provides the recurrence risk probability for each patient, along with the binary result, with two datasets from the Korea Health Insurance Review and Assessment Service and Chungbuk National University Hospital. The total data of 6,535 patients who had been diagnosed with ACS were used to build a machine learning model by using logistic regression. Data including age, gender, procedure codes, procedure reason, prescription drug codes, and condition codes were used as the model predictors. The model performance showed 0.893, 0.894, 0.851, 0.869, and 0.921 for accuracy, precision, recall, F1-score, and AUC, respectively. Our model provides the ACS recurrence probability of each patient as a personalized ACS recurrence risk, which may help motivate the patient to reduce their own ACS recurrence risk. The model also shows that acute transmural myocardial infarction of an unspecified site, and other sites and acute transmural myocardial infarction of an unspecified site contributed most significantly to ACS recurrence with an odds ratio of 97.908 as a procedure reason code and with an odds ratio of 58.215 as a condition code, respectively.

A Structured Review of Commercially Available Cardiac Rehabilitation mHealth Applications Using the Mobile Application Rating Scale

PURPOSE

This study systematically evaluated the quality and functionalities of patient-facing, commercially available mobile health (mHealth) apps for cardiac rehabilitation (CR).

METHODS

We performed our search in two of the most widely used commercial mobile app stores: Apple iTunes Appstore and Google Play Store (Android apps). Six search terms were used to query relevant CR apps: "cardiac rehabilitation," "heart disease and remote therapy," "heart failure exercise," "heart therapy and cardiac recovery," "cardiac recovery," and "heart therapy." App quality was evaluated using the Mobile Application Rating Scale (MARS). App functionality was evaluated using the IQVIA functionality scale, and app content was evaluated against the American Heart Association guidelines for CR. Apps meeting our inclusion criteria were downloaded and evaluated by two to three reviewers, and interclass correlations between reviewers were calculated.

RESULTS

We reviewed 3121 apps and nine apps met our inclusion criteria. On average, the apps scored a 3.0 on the MARS (5-point Likert scale) for overall quality. The two top-ranking mHealth apps for CR for all three quality, functionality, and consistency with evidence-based guidelines were My Cardiac Coach and Love My Heart for Women, both of which scored ≥4.0 for behavior change.

CONCLUSION

Overall, the quality and functionality of free apps for mobile CR was high, with two apps performing the best across all three quality categories. High-quality CR apps are available that can expand access to CR for patients with cardiovascular disease.

A Half-Century of Evidence-Based Cardiac Rehabilitation: A Historical Review

OBJECTIVE

To review the achievements of cardiac exercise rehabilitation programs retrospectively and to identify continuing challenges to their success.

METHODS

A review of files accumulated while working with the Toronto Rehabilitation Center, updated by articles identified by PUB-MED, OVID, and Google Scholar through February 2019.

RESULTS

After the early lead of Israeli physicians, cardiac rehabilitation began in Ontario during the 1960s and quickly attracted a large case load. Recurrence rates of the patients recruited were low relative to those receiving standard medical treatment, even after allowing for differences in risk factors at entry to programs. Controlled trials began but were individually of insufficient in size to show a significant reduction in recurrences or mortality. Subsequently, multiple meta-analyses demonstrated a 20% to 25% reduction of all-cause and cardiac mortality over the first few years of follow-up in patients who persisted with their rehabilitation. Compliance continued a problem at many centers, but special features of the Toronto cardiac rehabilitation program sustained a compliance of 82.8% over 3 years. Although vigorous exercise increased the immediate risks of a recurrence 5- to 10-fold, this was more than offset by the long-term benefits of enhanced physical condition, and cardiac deaths were a rarity during either supervised or home-based exercise sessions. About a half of patients developed a depression immediately after infarction, but if encouraged to persist with prescribed exercise, their quality of life progressively improved. Among the wide variety of mechanisms underlying the benefits of exercise, gains of aerobic power seemed particularly important. With sustained training, the physical condition of some younger patients progressed to the point of participating successfully in marathon events. Older patients also benefited from sustained training, but for them, optimal results were likely associated with less rigorous physical demands.

CONCLUSIONS

Research conducted in Toronto and elsewhere has established the benefits of exercise-centered cardiac rehabilitation. However, there remains a need to define the optimum timing of program onset, and the frequency, intensity, and duration of supervised training sessions. Return to blue-collar occupations also needs to be boosted, and the limited participation of eligible patients in available programs remains a continuing challenge.

Support Life Club: A New Model Based on Social Media Group Chats and Social Activities That Can Improve Adherence and Clinical Outcomes in Patients Receiving Cardiac Rehabilitation

AIM

To describe a new model, the Support Life Club (SLC), for participants of Phase II cardiac rehabilitation (CR) programs and to evaluate this model for adherence, completion rates, and clinical outcomes.

METHODS

This retrospective study involved 391 consecutive patients who participated in an outpatient CR program between September 2016 and May 2020. The intervention group (SLC) was comprised of 198 patients who participated in education, WeChat-based group activity as well as outdoor activities, while the control group (non-intervention) was comprised of 193 cases. All patients attended a 12-week supervised outpatient CR program (three sessions per week, each lasting 40min). The intervention and control groups were compared for completion rates, Cardiopulmonary Exercise Test (CPET) results, Six-minute Walk Test (6MWT) distances, and Patient Health Questionnaire-9 (PHQ-9) scores.

RESULTS

Patients in the intervention group attended at least 75% of the exercise training sessions more often than those in the control group (72.5% vs 40.41%, adjusted odds ratio (OR): 27.385; 95% CI: 10.2 to 73.6; P = 0.0000). Analysis of variance (2 × 2 ANOVA) revealed a significant group-by-time interaction in PHQ9 and 6MWT test results (p = 0.000).

CONCLUSION

The addition of SLC to a cardiac rehabilitation program resulted in better outcomes for PHQ9 and 6MWT tests and may be a useful strategy to improve exercise adherence.

Effects of Home-Based Cardiac Rehabilitation on Time to Enrollment and Functional Status in Patients With Ischemic Heart Disease

Background

Cardiac rehabilitation is an established performance measure for adults with ischemic heart disease, but patient participation is remarkably low. Home‐based cardiac rehabilitation (HBCR) may be more practical and feasible, but evidence regarding its efficacy is limited. We sought to compare the effects of HBCR versus facility‐based cardiac rehabilitation (FBCR) on functional status in patients with ischemic heart disease.

Methods and Results

This was a pragmatic trial of 237 selected patients with a recent ischemic heart disease event, who enrolled in HBCR or FBCR between August 2015 and September 2017. The primary outcome was 3‐month change in distance completed on a 6‐minute walk test. Secondary outcomes included rehospitalization as well as patient‐reported physical activity, quality of life, and self‐efficacy. Characteristics of the 116 patients enrolled in FBCR and 121 enrolled in HBCR were similar, except the mean time from index event to enrollment was shorter for HBCR (25 versus 77 days; P<0.001). As compared with patients undergoing FBCR, those in HBCR achieved greater 3‐month gains in 6‐minute walk test distance (+95 versus +41 m; P<0.001). After adjusting for demographics, comorbid conditions, and indication, the mean change in 6‐minute walk test distance remained significantly greater for patients enrolled in HBCR (+101 versus +40 m; P<0.001). HBCR participants reported greater improvements in quality of life and physical activity but less improvement in exercise self‐efficacy. There were no deaths or cardiovascular hospitalizations.

Conclusions

Patients enrolled in HBCR achieved greater 3‐month functional gains than those enrolled in FBCR. Our data suggest that HBCR may safely derive equivalent benefits in exercise capacity and overall program efficacy in selected patients.

Registration

URL: https://www.clini​caltr​ials.gov; Unique identifier: NCT02105246.

The Impact of Socio-environmental Barriers on the Process of Engagement in Cardiac Rehabilitation Programs

Cardiac rehabilitation (CR) is a multi-disciplinary intervention designed to stabilise, slow, or reverse CVD, restore health following a cardiac event and facilitate the prevention of further events. The Model of Therapeutic Engagement (MTE) is a comprehensive conceptual model for explaining the process of engagement in rehabilitation. Of concern is that the role of socio-environmental factors is absent from explaining individual engagement in the MTE. There is also a lack of prospective studies investigating the impact of socio-environmental barriers on engagement in CR programs over time. This study aimed to expand the MTE, by illuminating the role of socio-environmental barriers in a three-stage process of engagement in CR programs. A prospective study was conducted, with 217 individuals recruited from the Cardiology Ward in the Gold Coast University Hospital (GCUH) and the Robina Cardiac Rehabilitation Centre. The collected data were examined using a structural equation model that added socio-environmental factors into the MTE, using multi-group analyses. In this study, we found that socio-environmental factors were not associated with intention to engage in the CR program, but were related to actual attendance and maintenance of participation in CR programs. Knowing how these socio-environmental barriers affect the process of engagement at different stages may help to tailor more accessible CR programs for the population.

Underutilization of Hospital-based Cardiac Rehabilitation after Acute Myocardial Infarction in Korea

BACKGROUND

Cardiac rehabilitation (CR) after acute myocardial infarction (AMI) is recommended as a mandatory intervention in several national clinical practice guidelines published in America, Europe, and Korea to reduce recurrence and mortality. However, underutilization of CR is an established worldwide issue. In Korea, the promotion of CR is expected due to coverage by National Health Insurance. Nevertheless, the national status of CR use has not been reported. This retrospective cohort study aimed to investigate the current status of CR use in patients with AMI using nationwide data from the National Health Insurance Service of Korea.

METHODS

Patients with AMI admitted with the diagnosis of 'I21' code (from International Classification of Diseases, 10th revision, Clinical Modification) from July 1st, 2017 to June 30th, 2018 were included. CR use was defined as CR treatment or evaluation being performed during an outpatient follow-up period within 6 months after discharge. Participation rate and density were calculated nationally and by administrative division. Logistic regression analysis was performed to identify the influencing factors of CR participation.

RESULTS

Nationally, 1.5% of AMI patients (960/64,982) underwent CR during outpatient treatment after discharge. CR density was approximately 10. Logistic regression analysis revealed that influencing factors included old age, female sex, rural residence, and low Charlson comorbidity index.

CONCLUSION

Hospital-based CR after AMI is underutilized despite its coverage by the National Health Insurance. More CR facilities have to be installed according to the needs of CR in various regions.

The feasibility of implementing high-intensity interval training in cardiac rehabilitation settings: a retrospective analysis

Background

Cardiovascular disease is the leading cause of death worldwide. Notwithstanding the well-known benefits of cardiac rehabilitation (CR), adherence to CR remains low, particularly in women. High-intensity interval training (HIIT) has received specific attention as an emerging exercise-training paradigm that addresses frequently cited barriers to CR (i.e. lack of motivation/enjoyment and time, perceiving exercise regime as tiring/boring) and improves cardiovascular risk factors. Previous studies have examined the safety of HIIT in CR; there is little evidence on the feasibility of HIIT in CR. The aims of this study were to evaluate the feasibility of HIIT within a CR setting and examine the sex differences regarding the feasibility of such programming.

Methods

Patients attended an on-site HIIT CR program (10-min warm-up, 25 min of interspersed high-intensity [HI - 4 min at 85–95% HRpeak] and lower intensity [LO - 3 min at 60–70% HRpeak] intervals, 10-min cool-down) twice weekly for 10 weeks. Heart rate (HR) and the Borg rating of perceived exertion (RPE) scale (6–20 points) were recorded at each session. Feasibility was assessed by: [1] attendance and compliance: the number of sessions attended and the compliance to the prescribed HI and LO HR ranges; [2] the patient experience: patients’ perceived effort, program difficulty, if the program was challenging and satisfying; and, [3] safety. Descriptive statistics were used to report the means and their variations. Mann-Whitney U tests and Chi-square analyses were performed to examine sex-differences.

Results

A total of 151 patients (33% women, 57.5 ± 9.1 years) attended the HIIT program and completed 16 ± 5 classes with a low attrition rate (11.3%). Most patients met or exceeded the prescribed target HR for the HI (80%) and LO (84%) intervals, respectively. Patients reported a “somewhat hard” RPE for HI (14 ± 2 points) and “very light” for LO (10 ± 2 points) intervals. All patients were satisfied with the program and found it challenging. Most patients found HIIT to be difficult (7 ± 2 points, scale range 0–10 points), yet safe (97%). Three vasovagal episodes occurred and more women dropped-out of the program than men (p < 0.01).

Conclusions

HIIT is a feasible, safe and well-received exercise paradigm in a CR setting.

Association of Cardiac Rehabilitation With Decreased Hospitalizations and Mortality After Ventricular Assist Device Implantation

OBJECTIVES

This study characterized cardiac rehabilitation (CR) use in ventricular assist device (VAD) recipients in the United States and the association of CR with 1-year hospitalization and mortality by using the 2013 to 2015 Medicare files.

BACKGROUND

Exercise-based CR is indicated in patients with heart failure with reduced ejection fraction, but no data exist regarding CR participation after VAD implantation.

METHODS

The study included Medicare beneficiaries enrolled for disability or age >65 years. The investigators identified VAD recipients by diagnosis codes and cumulated CR sessions occurring within 1 year after VAD implantation. Multivariable-adjusted Andersen-Gill models were used to evaluate the association of CR with 1-year hospitalization risk, and Cox regression was used to evaluate the association of CR with 1-year mortality.

RESULTS

There were 1,164 VADs implanted in Medicare beneficiaries in the United States in 2014. CR use was low, with 348 patients (30%) participating in CR programs. The Midwest had the highest proportion of VAD recipients who began CR (38%), whereas the Northeast had the lowest proportion of CR participants (25%). Each 5-year increase in age was associated with attending an additional 1.6 CR sessions (95% confidence interval [CI]: 0.7 to 2.5; p < 0.001). CR participation was associated with a 23% lower 1-year hospitalization risk (95% CI: 11% to 33%; p < 0.001) and a 47% lower 1-year mortality risk (95% CI: 18% to 66%; p < 0.01) after multivariable adjustment.

CONCLUSIONS

Approximately one-third of VAD recipients attend CR. Although it is not possible to account fully for unmeasured confounding, VAD recipients who participate in CR appear to have lower risks for hospitalization and mortality.

eHealth to improve patient outcome in rehabilitating myocardial infarction patients

INTRODUCTION

Cardiac rehabilitation is aimed at risk factor modification and improving quality of life. eHealth has a couple of potential benefits to improve this aim. The primary purpose of this review is to summarize available literature for eHealth strategies that have been investigated in randomized controlled trials in post-myocardial infarction (MI) patients. The second purpose of this review is to investigate the clinical effectiveness in post-MI patients. Areas covered: The literature was searched using PubMed. Randomized controlled trials (RCTs) describing interventions in patients that had experienced an ST-elevation myocardial infarction or non-ST acute coronary syndrome were eligible for inclusion. Fifteen full-texts were included and their results are described in this review. These RCTs described interventions that used remote coaching or remote monitoring in post-MI patients. Most interventions resulted in an improved cardiovascular risk profile. Remote coaching had a positive effect on activity and dietary intake. Expert opinion: eHealth might be clinically beneficial in post-MI patients, particularly for risk estimation. Moreover, eHealth as a tool for remote coaching on activity is a good addition to traditional cardiac rehabilitation programs. Further research needs to corroborate these findings.

Are physical fitness outcomes in patients attending cardiac rehabilitation determined by the mode of delivery?

Background

Cardiac rehabilitation (CR) is a well-evidenced and effective secondary intervention proven to reduce mortality and readmission in patients with cardiovascular disease. Improving physical fitness outcomes is a key target for CR programmes, with supervised group-based exercise dominating the mode of the delivery. However, the method of traditional supervised CR fails to attract many patients and may not be the only way of improving physical fitness.

Methods

Using real-world routine clinical data from the National Audit of Cardiac Rehabilitation across a 5-year period, this study evaluates the extent of association between physical fitness outcomes, incremental shuttle walk and 6 min walk test, and mode of delivery, delivered as traditional supervised versus facilitated self-delivered.

Results

The proportion of patients receiving each mode were 80.6% supervised with 19.4% to self-delivered. The study analysis comprised of 10 142 patients who were included in the two models. The self-delivered group contained a greater proportion of females and older patients. The regression model showed no clinical or statistical significance between mode of delivery and post-CR physical fitness outcomes.

Conclusions

This study is unique as it has identified through a routine clinical population that regardless of the mode of delivery of rehabilitation, patients improve their physical fitness outcomes at meaningful levels. This study provides a strong evidence base for patients to be offered greater choice in the mode of CR delivery as improvements in physical fitness are comparable.

Group Enrollment and Open Gym Format Decreases Cardiac Rehabilitation Wait Times

PURPOSE

Wait times for the first cardiac rehabilitation (CR) session are inversely related to CR participation rates. We hypothesized that changing from individually scheduled appointments to a group enrollment and open gym format, in which patients were enrolled during group intake sessions and could arrive for subsequent CR sessions any time during open gym periods, would decrease wait times.

METHODS

A total of 603 patients enrolled in CR at Vanderbilt University Medical Center from July 2012 to December 2014 were included in the study. We evaluated the effect of changing to a group enrollment and open gym format after adjusting for referral diagnosis, insurance status, seasonality, and other factors. We compared outcomes, including exercise capacity and quality of life, between the 2 groups.

RESULTS

Patients in the group enrollment and open gym format had significantly lower average wait times than those receiving individual appointments (14.9 vs 19.5 days, P < .001). After multivariable adjustment, the new CR delivery model was associated with a 22% (3.7 days) decrease in average wait times (95% CI, 1.9-5.6, P < .001). Patients completing CR had equally beneficial changes in 6-minute walk distance and Patient Health Questionnaire scores between the 2 groups, although there was no significant difference in participation rates or the number of sessions attended.

CONCLUSIONS

Implementation of a group enrollment and open gym format was associated with a significant decrease in wait times for first CR sessions. This CR delivery model may be an option for programs seeking to decrease wait times.

Evidence to service gap: cardiac rehabilitation and secondary prevention in rural and remote Western Australia

BACKGROUND

Cardiovascular disease (CVD), a leading cause of morbidity and mortality, has similar incidence in metropolitan and rural areas but poorer cardiovascular outcomes for residents living in rural and remote Australia. Cardiac Rehabilitation (CR) is an evidence-based intervention that helps reduce subsequent cardiovascular events and rehospitalisation. Unfortunately CR attendance rates are as low as 10-30% with rural/remote populations under-represented. This in-depth assessment investigated the provision of CR and secondary prevention services in Western Australia (WA) with a focus on rural and remote populations.

METHODS

CR and Aboriginal Community Controlled Health Services were identified through the Directory of Western Australian Cardiac Rehabilitation and Secondary Prevention Services 2012. Structured interviews with CR coordinators included questions specific to program delivery, content, referral and attendance.

RESULTS

Of the 38 CR services identified, 23 (61%) were located in rural (n = 11, 29%) and remote (n = 12, 32%) regions. Interviews with coordinators from 34 CR services (10 rural, 12 remote, 12 metropolitan) found 77% of rural/remote services were hospital-based, with no service providing a comprehensive home-based or alternative method of program delivery. The majority of rural (60%) and remote (80%) services provided CR through chronic condition exercise programs compared with 17% of metropolitan services; only 27% of rural/remote programs provided education classes. Rural/remote coordinators were overwhelmingly physiotherapists, and only 50% of rural and 33% of remote programs had face-to-face access to multidisciplinary support. Patient referral and attendance rates differed greatly across WA and referrals to rural/remote services generally numbered less than 5 per month. Program evaluation was reported by 33% of rural/remote coordinators.

CONCLUSION

Geography, population density and service availability limits patient access to CR services in rural/remote WA. Current inadequacies in delivering comprehensive centre-based CR in rural/remote settings impedes management of cardiovascular risk and opportunities for event reduction. Health pathways that ensure referral and continuity of care are needed, with emerging technology-based CR support to supplement centre-based CR services requiring assessment. Implementing systematic data collection across services to establish benchmarks and enable service monitoring and evaluation is needed.

Influence of Depression on Utilization of Cardiac Rehabilitation Postmyocardial Infarction: A STUDY OF 158 991 MEDICARE BENEFICIARIES

PURPOSE

On the basis of several small studies, depression is often considered a barrier to cardiac rehabilitation (CR) enrollment and program completion. The purpose of this research was to examine the association between depression diagnosis and participation in CR in a large sample of Medicare beneficiaries with recent myocardial infarction (MI).

METHODS

This was a retrospective study of Medicare beneficiaries with an MI during 2008 (N = 158 991). CR enrollment was determined by the Carrier and Outpatient files using the Healthcare Common Procedure Coding System #93797 or #93798. Depression diagnosis was obtained from the International Classification of Diseases, Ninth Revision (ICD-9) codes in the Medicare Provider Analysis and Review (MEDPAR), Outpatient and Carrier Files. The association between depression diagnosis and CR attendance was evaluated using multivariable logistic regression.

RESULTS

Overall, 14% (n = 22 735) of the study population attended CR within 1 year of MI diagnosis. Twenty-eight percent (n = 43 827) had a diagnosis of depression, with 96% of cases documented before enrollment in CR. Twenty-eight percent with a diagnosis of depression compared with 9% without depression attended CR. In adjusted analysis, patients with depression were 3.9 (99% CI, 3.7-4.2) times more likely to attend CR compared with those without depression. Program completion (≥25 sessions) was more common in those with depression (56%) than in those without (35%) (P < .001).

CONCLUSIONS

Diagnosis of depression in Medicare beneficiaries was strongly associated with attending CR and attending more sessions of CR compared with those without depression. Depression is not a barrier to CR participation after MI in Medicare beneficiaries.

Factors Associated With Utilization of Cardiac Rehabilitation Among Patients With Ischemic Heart Disease in the Veterans Health Administration: A QUALITATIVE STUDY

BACKGROUND

Cardiac rehabilitation (CR) programs reduce morbidity and mortality in patients with ischemic heart disease but are vastly underutilized in the United States, including the Veterans Health Administration (VA) Healthcare System. Numerous barriers affecting utilization have been identified in other health care systems, but the specific factors affecting Veterans are unknown. We sought to identify barriers and facilitators associated with utilization of CR in VA facilities.

METHODS

We performed a qualitative study of 56 VA patients, providers, and CR program managers at 30 VA facilities across the United States. We conducted semistructured interviews with key informants to explore their attitudes and knowledge toward CR. Interviews were conducted until thematic saturation occurred. Analyses using grounded theory to identify key themes were conducted using the qualitative data analysis package ATLAS.ti.

RESULTS

We identified 6 themes as barriers and 5 as facilitators. The most common barriers to participation in CR were patient transportation issues (68%), lack of patient willingness to participate (41%), and no access to a nearby VA hospital with a CR program (30%). The most common facilitators were involvement of a dedicated provider or "clinical champion" (50%), provider knowledge of or experience with CR (48%), and patient desire for additional medical support (32%).

CONCLUSIONS

Our findings suggest that addressing access issues and educating and activating providers on CR may increase utilization of CR programs. Targeting these specific factors may improve utilization of CR programs.

A prospective study examining the influence of cardiac rehabilitation on the sedentary time of highly sedentary, physically inactive patients

OBJECTIVES

Prolonged sedentary time is recognized as a distinct health risk, and mortality risks are expected to be greatest for individuals with low exercise levels. It is unknown whether participation in exercise-based cardiac rehabilitation (CR) programs influences sedentary behaviour particularly among those patients expected to be at greatest mortality risk. This study examined the influence of CR participation on sedentary behaviour and identified the proportion and characteristics (socio-demographic and clinical) of patients who do not meet exercise recommendations and have prolonged sedentary times.

METHODS

A prospective study was conducted among patients of an exercise-based CR program and assessments performed at baseline and 3 months. Physical activity and sedentary behaviour information were collected by self-report, and convergent validity was examined on an accelerometer-wearing subsample.

RESULTS

Of 468 CR patients approached, 130 participants were recruited with an average sedentary time of 8hours/day. Sedentary behaviour remained consistent at follow-up (relative change= -2.4%, P=0.07) notwithstanding a greater proportion meeting exercise recommendations (relative change= 57.4%). 19.2% of participants were classified to have prolonged sedentary time and not meet exercise recommendations at baseline. No significant differences were found between the characteristics of high-risk individuals and lower risk subgroups. Findings were consistent among the accelerometer-derived subgroup and the overall sample despite poor to moderate convergent validity.

CONCLUSIONS

These results suggest that the exercise-focus of CR may not reduce sedentary behaviours. Future studies are needed to determine whether sedentary behaviour-specific reduction strategies are more effective than traditional exercise-based strategies and lead to meaningful improvements in clinical outcomes.

Implementing resistance training in the rehabilitation of coronary heart disease: A systematic review and meta-analysis

BACKGROUND

Resistance training has demonstrated efficacy in cardiac rehabilitation programs, but the optimal prescription of resistance training is unknown. This systematic review with meta-analysis compared the effectiveness of cardiac rehabilitation consisting of resistance training either alone (RT) or in combination with aerobic training (CT) with aerobic training only (AT) on outcomes of physical function. Further, resistance training intensity and intervention duration were examined to identify if these factors moderate efficacy.

METHODS

Six electronic databases were searched to identify studies investigating RT, coronary heart disease and physical function. The overall quality of evidence was assessed using the GRADE approach. Meta-analyses were performed when possible and qualitative analysis was performed for the remaining data.

RESULTS

Improvements in peak oxygen uptake (WMD: 0.61, 95% CI: 0.20-1.10), peak work capacity (SMD: 0.38, 95% CI: 0.11-0.64) and muscular strength (SMD: 0.65, 95% CI: 0.43-0.87) significantly favoured CT over AT with moderate quality evidence. There was no evidence of a difference in effect when comparing RT and AT. Shorter duration CT was superior to shorter duration AT for improving peak oxygen uptake and muscular strength (low quality evidence) while longer duration CT was only superior to longer duration AT in improving muscular strength (moderate quality evidence).

CONCLUSIONS

CT is more beneficial than AT alone for improving physical function. Although preliminary findings are promising, more high-quality evidence is required to determine the efficacy of high intensity resistance training. Shorter duration interventions that include resistance training might allow patients to return to their normal activities of daily living earlier.

Caring for Patients with Chronic Heart Failure: The Trajectory Model

The purpose of this paper is to examine gaps in our understanding of the heart failure experience and describe the use of Trajectory of Chronic Illness Theory to bridge these gaps. New pharmacotherapeutic strategies have improved survival in heart failure, but research has consistently shown that clinical outcomes in these patients do not depend on physiologic variables alone. Psychological, behavioral, environmental, social and socioeconomic variables also contribute to a patient's ability to manage chronic illness. However, we have not yet identified the essential elements in helping patients engage in self-management and adhere to increasingly complex medical regimens. Theoretical models facilitate disciplinary integration, providing a comprehensive and cohesive foundation for building better science. The Trajectory of Chronic Illness Theory is particularly salient for heart failure because of its emphasis on patients' ability to manage a chronic illness. By using theory to explore gaps in our understanding of the heart failure experience, investigators may be able to develop more targeted interventions to help patients manage heart failure.

Cardiac Rehabilitation for Aboriginal and Torres Strait Islander people in Western Australia

BACKGROUND

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality in Australia. Australian Aboriginal and Torres Strait Islander (Indigenous) people have higher levels of CVD compared with non-Indigenous people. Cardiac Rehabilitation (CR) is an evidence-based intervention that can assist with reducing subsequent cardiovascular events and rehospitalisation. Unfortunately, attendance rates at traditional CR programs, both globally and in Australia, are estimated to be as low as 10-30 % and Indigenous people are known to be particularly under-represented. An in-depth assessment was undertaken to investigate the provision of CR and secondary preveniton services in Western Australia (WA) with a focus on rural, remote and Indigenous populations. This paper reports on the findings for Indigenous people.

METHODS

Cardiac rehabilitation and Aboriginal Medical Services (n = 38) were identified for interview through the Heart Foundation Directory of Western Australian Cardiac Rehabilitation and Secondary Prevention Services 2012. Semi-structured interviews with CR coordinators were conducted and included questions specific to Indigenous people.

RESULTS

Interviews with coordinators from 34 CR services (10 rural, 12 remote, 12 metropolitan) were conducted. Identification of Indigenous status was reported by 65 % of coordinators; referral and attendance rates of Indigenous patients differed greatly across WA. Efforts to meet the cultural needs of Indigenous patients varied and included case management (32 %), specific educational materials (35 %), use of a buddy or mentoring system (27 %), and access to an Aboriginal Health Worker (71 %). Staff cultural awareness training was available for 97 % and CR guidelines were utilised by 77 % of services.

CONCLUSION

The under-representation of Indigenous Australians participating in CR, as reported in the literature and more specifically in this study, mandates a concerted effort to improve services to better meet the needs of Indigenous patients with CVD as part of closing the gap in life expectancy. Improving access to culturally appropriate CR and secondary prevention in WA must be an important component of this effort given the high rates of premature cardiovascular disease affecting Indigenous people. Our findings also highlight the importance of good systematic data collection across services. Health pathways that ensure continuity of care and alternative methods of CR delivery with dedicated resources are needed.

Improving Cardiac Rehabilitation: A View from the United Kingdom

Cardiac rehabilitation has assumed more prominence over the past decade, due largely to an increase in user demand, an improvement in the evidence base and an enhancement of its status. This paper presents a view from the United Kingdom and suggests some ways in which cardiac rehabilitation can be improved by focusing on a number of key issues: service organisation and delivery, process and outcome measurement, performance management, and education, training and continuing professional development. The paper concludes that there is a need to make cardiac rehabilitation more widely available using creative and flexible approaches to enhance access, participation and adherence.

Factors Associated with Non-Attendance at a Secondary Prevention Clinic for Cardiac Patients

Background: A randomised controlled trial was undertaken to test the effectiveness of a secondary prevention clinic. Secondary prevention programs can improve prognosis after an acute cardiac illness. It is therefore important to encourage high participation rates. Aim: The present study was a post-hoc analysis to identify factors associated with patients’ non-attendance at the clinic. Methods: We compared the baseline socio-demographic and clinical characteristics of 83 (73.5% male) non-attending patients and a random sample of 96 (85.4% male) attending patients. Self-reported data were gathered during interviews conducted on an average of 30 months after hospital admission to investigate long-term outcomes of the clinic. Results: Using logistic regression analysis, we found that non-attendance was significantly and independently associated with being female, being under 60 years of age, having no history of high cholesterol and having no angina prior to the event. In bivariate analyses, non-attendance was also associated with being born overseas and not having private health insurance. Conclusions: Likely non-attending patients should be identified early and more effective strategies should be devised to facilitate their participation in secondary prevention programs.

Prevalence of physical activity and sedentary behavior among adults with cardiovascular disease in the United States

BACKGROUND

Physical activity (PA) is recommended for primary and secondary prevention of cardiovascular disease (CVD). This study described the prevalence of self-reported and accelerometer-measured PA and sedentary behavior, using a nationally representative sample from the United States, a subset of whom had CVD, including angina, coronary heart disease (CHD), congestive heart failure (CHF), and myocardial infarction (MI).

METHODS

Using the most recently available accelerometer data (combined 2003-2006) from the National Health and Nutrition Examination Survey, the study sample included 680 adults with CVD, who completed a questionnaire and wore an ActiGraph accelerometer for 1 week. A group without CVD (n = 1000) was also selected as the referent, with similar age, gender, and race/ethnic distributions as those with CVD (angina, CHD, CHF, MI) to compare PA and sedentary behavior estimates. Percentages and means were weighted to reflect the US population from 2003 to 2006.

RESULTS

Among those with CVD, the proportion of individuals who engaged in self-reported past-month, moderate-intensity leisure activity ranged from 39.7% (CHF) to 53.8% (CHD) and vigorous-intensity leisure activity from 12.9% (CHF) to 18.4% (CHD), with walking being the most commonly reported activity. Television watching ≥4 h/d ranged from 36.2% (MI) to 44.8% (CHF). Using accelerometry, moderate- to vigorous-intensity PA ranged from 8.6 (CHF) to 11.4 min/d (angina). Sedentary behavior ranged from 9.6 (angina) to 10.1 h/d (CHF). All 4 CVD groups had lower leisure activity and moderate- to vigorous-intensity PA, and higher television watching and sedentary behavior, when compared with the referent group.

CONCLUSIONS

Further efforts are needed to encourage PA and reduce sedentary behavior for secondary prevention of CVD.

Outpatient cardiac rehabilitation use after coronary bypass surgery in the west of Iran

PURPOSE

Determinants of outpatient cardiac rehabilitation (CR) use in low- and middle-income countries are not well-known. This study analyzed CR use after coronary bypass surgery by gender and geography and effects of systematic referral, program model, and insurance types on CR participation in the west of Iran.

METHODS

This observational study was conducted in Imam-Ali University Hospital in Kermanshah (KSH), the only CR center in the region (2002-2012). There were 2 CR programs: hospital-based and hybrid (combination of home-based and intermittent hospital-based sessions). Patients were divided into groups who lived inside and outside KSH (O-KSH). Referral, participation, and completion rates and program selection were compared by geography, gender, and insurance types. The effects of systematic referral (as of June 2011) were also analyzed.

RESULTS

Of 4735 patients, 44.6% were referred for, 18.7% enrolled in, and 16.5% completed CR. In KSH compared with O-KSH, referral rates were 58.0% versus 30.7% and participation rates were 27.0% versus 10.2%, respectively (P < .001, in both cases). Participation rate in women was lower than that in men (15.6% vs 20.0%, respectively; P = .001). Systematic referral increased participation, especially in women and O-KSH (P < .001, in both cases). The O-KSH patients and those with unfavorable insurance mostly selected the hybrid program (P < .001, in both cases). Among participants, completion rates based on gender and geography were similar.

CONCLUSIONS

Referral and participation rates of coronary bypass surgery patients in CR were low in the west of Iran, especially in women and O-KSH. Systematic referral along with the hybrid program increased them significantly.

[Cardiac rehabilitation after coronary artery bypass surgery]

Ischemic heart disease is the leading cause of death worldwide with an increase in the incidence in younger populations. Today revascularization strategies are capable of alleviating acute ischemia and/or chronic ischemia. These can be performed percutaneously or through surgery. Even if we improve myocardial perfusion by these methods, the main determinant in maintaining patency of coronary arteries and bypass is a correctly instituted secondary prevention. This is the main focus of cardiac rehabilitation proposals. Although much has been published about the role of cardiac rehabilitation after percutaneous revascularization, there is little work able to synthesize the current state of cardiac rehabilitation in patients undergoing coronary artery bypass surgery. The aim of this paper is to review the effect of rehabilitation in the return to work, survival, functional capacity, depression and anxiety, as well as compare centralized vs. home rehabilitation in this patient population.

Access to cardiac rehabilitation does not equate to attendance

BACKGROUND/AIMS

Timely access to appropriate cardiac care is critical for optimizing positive outcomes after a cardiac event. Attendance at cardiac rehabilitation (CR) remains less than optimal (10%-30%). Our aim was to derive an objective, comparable, geographic measure reflecting access to cardiac services after a cardiac event in Australia.

METHODS

An expert panel defined a single patient care pathway and a hierarchy of the minimum health services for CR and secondary prevention. Using geographic information systems a numeric/alpha index was modelled to describe access before and after a cardiac event. The aftercare phase was modelled into five alphabetical categories: from category A (access to medical service, pharmacy, CR, pathology within 1 h) to category E (no services available within 1 h).

RESULTS

Approximately 96% or 19 million people lived within 1 h of the four basic services to support CR and secondary prevention, including 96% of older Australians and 75% of the indigenous population. Conversely, 14% (64,000) indigenous people resided in population locations that had poor access to health services that support CR after a cardiac event.

CONCLUSION

Results demonstrated that the majority of Australians had excellent 'geographic' access to services to support CR and secondary prevention. Therefore, it appears that it is not the distance to services that affects attendance. Our 'geographic' lens has identified that more research on socioeconomic, sociological or psychological aspects to attendance is needed.

Cardiac rehabilitation: beginning at the bedside

PURPOSE

Despite well-documented positive benefits, cardiac rehabilitation (CR) is an underutilized resource for patients following a cardiac event or intervention. Bias in the CR referral process has led to programs designed to ensure that all eligible patients receive a referral. The purpose of the current investigation was to describe the implementation of a nurse-delivered automatic bedside referral process and to examine the effectiveness on referral and intake rates for CR.

METHODS

In 2007, an automatic CR referral system was implemented at the University of Ottawa Heart Institute. A nurse-delivered automatic bedside referral process was implemented in 2008. A CR nurse screened all inpatient charts, discussed CR benefits and program options with patients, triaged the patient to the appropriate program, and facilitated booking of the CR intake appointment. Data were analyzed to determine the effectiveness of this approach.

RESULTS

Only 15.5% to 19.7% of eligible patients participated in CR program prior to 2006. Implementation of an automatic referral process increased participation to 26.7%. The nurse-delivered bedside automatic referral process increased participation to 32.6%. The proportion of patients receiving CR referrals almost tripled following the implementation of the nurse-delivered referral process from 26.7% in 2003 to 79.0% in 2008.

CONCLUSIONS

A nurse-delivered automatic bedside referral process had a positive impact on both referral and intake to CR. Future challenges for CR programs will be to ensure optimal participation in programs, while managing the growth associated with increased rates of involvement.

Effects of a psychoeducational intervention for secondary prevention in Korean patients with coronary artery disease: a pilot study

This intervention study was designed to examine whether a 12-week psychoeducational intervention influenced recurrent cardiac events, symptom experience and treatment adherence of patients with coronary artery disease. Fifty-eight patients were randomized to either the intervention or the control group. Measures were taken at baseline, after intervention, and at 6-month follow-up. Recurrent cardiac events included revascularization, rehospitalization, emergency room visits and mortality. Symptom experiences were measured using the Seattle Angina Questionnaire-Korean and Hospital Anxiety and Depression Scale. Treatment adherence included health behaviours, routine check-up and medication adherence. At 6-month follow-up, the intervention group had significantly better physical functions and lower anxiety and depressive symptoms. Treatment adherence was also significantly higher in the intervention group than the control group. No significant difference was noticed in the incidence of recurrent cardiac events between the groups. A longer follow-up study is needed to determine the long-term effects on the prevention of recurrent cardiac events.

Recruitment to clinical trials of exercise: challenges in the peripheral arterial disease population

OBJECTIVES

To describe recruitment to a randomised controlled trial of a 12-week (twice-weekly) supervised exercise programme for patients with peripheral arterial disease (PAD). PAD is a chronic, progressive disease with a significant cardiovascular and cerebrovascular risk burden, and exercise is an effective primary management approach.

METHOD

Potential patients were identified from the Non-Invasive Vascular Laboratory records and invited to participate in the study. On successful completion of an incremental treadmill exercise test, patients were allocated at random to a control (usual care) or an exercise group.

RESULTS

Between November 2006 and June 2009, 548 patients were identified. Of the 156 patients who met the inclusion criteria, 40 (26%) declined to participate. Of the 71 patients who underwent exercise testing, 23 (32%) did not complete the test. The final enrolment number was 44 (44/156; 28%). Eleven patients (11/28; 39%) subsequently withdrew from the exercise programme.

CONCLUSION

Recruitment to clinical trials of exercise presents significant challenges in the PAD population due to the presence of co-existing cardiovascular and cerebrovascular disease, a reluctance to exercise due to leg pain, and an acceptance of reduced mobility as part of ageing. Early identification in primary care before the onset of significant comorbidity may ameliorate some of these issues.

Neuromuscular electrical stimulation for muscle weakness in adults with advanced disease

BACKGROUND

Patients with progressive diseases often experience muscle weakness, which impacts adversely on levels of independence and quality of life. In those who are unable or unwilling to undertake traditional forms of exercise, neuromuscular electrical stimulation (NMES) may provide an alternative method of enhancing leg muscle strength. Programmes appear to be well tolerated and have led to improvements in muscle function, exercise capacity and quality of life. However, estimates regarding the effectiveness of NMES from individual studies lack power and precision.

PRIMARY OBJECTIVE

to evaluate the effectiveness of NMES for improving muscle strength in adults with advanced disease.

SECONDARY OBJECTIVE

to examine the acceptability and safety of NMES, and changes in muscle function (strength or endurance), muscle mass, exercise capacity, breathlessness and health-related quality of life.

SEARCH METHODS

Studies were identified from searches of The Cochrane Library, MEDLINE, EMBASE, CINAHL and PsycINFO databases to July 2012, citation searches, conference proceedings and previous systematic reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in adults with advanced chronic obstructive pulmonary disease (COPD), chronic heart failure, cancer or human immunodeficiency virus/acquired immunodeficency syndrome (HIV/AIDS) comparing a programme of NMES as a sole or adjunct intervention to no treatment, placebo NMES or an active control. We imposed no language restriction.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data on study design, participants, interventions and outcomes. We assessed risk of bias using the Cochrane Collaboration's tool. We calculated mean differences (MD) or standardised mean differences (SMD) between intervention and control groups for outcomes with sufficient data; for other outcomes we described findings from individual studies.

MAIN RESULTS

Eleven studies involving a total of 218 participants met the inclusion criteria across COPD, chronic heart failure and thoracic cancer. NMES significantly improved quadriceps strength by a SMD of 0.9 (95% confidence interval (CI) 0.33 to 1.46), equating to approximately 25 Newton metres (Nm) (95% CI 9 to 41). Mean differences across various walking tests, favouring NMES, were 40 m (95% CI -4 to 84) for the six-minute walk test, 69 m (95% CI 19 to 119) for the incremental shuttle walk test and 160 m (95% CI 34 to 287) for the endurance shuttle walk test. Limited evidence was available for the assessment of other secondary outcomes.

AUTHORS' CONCLUSIONS

NMES appears an effective means of improving muscle weakness in adults with progressive diseases such as COPD, chronic heart failure and cancer. Further research is required to clarify its place in clinical practice, by determining the optimal parameters for a NMES programme, the patients most likely to benefit, and its impact on morbidity and service use.

A Systematic Review of Perceived Barriers and Motivators to Physical Activity after Stroke

Background and purpose

Physical fitness is impaired after stroke, may contribute to disability, yet is amenable to improvement through regular physical activity. To facilitate uptake and maintenance of physical activity, it is essential to understand stroke survivors' perceived barriers and motivators. Therefore, we undertook a systematic review of perceived barriers and motivators to physical activity after stroke.

Methods

Electronic searches of EMBASE, Medline, CINAHL, and PsychInfo were performed. We included peer-reviewed journal articles, in English, between 1 January 1966 and 30 August 2010 reporting stroke survivors' perceived barriers and motivators to physical activity.

Results

Searches identified 73 807 citations of which 57 full articles were retrieved. Six articles were included, providing data on 174 stroke survivors (range 10 to 83 per article). Two reported barriers and motivators, two reported only motivators, and two reported only barriers. Five were qualitative articles and one was quantitative. The most commonly reported barriers were lack of motivation, environmental factors (e.g. transport), health concerns, and stroke impairments. The most commonly reported motivators were social support and the need to be able to perform daily tasks.

Conclusion

This review has furthered our understanding of the perceived barriers and motivators to physical activity after a stroke. This review will enable the development of tailored interventions to target barriers, while building upon perceived motivators to increase and maintain stroke survivors' physical activity.