Design and methods of the Gentle Cardiac Rehabilitation Study--A behavioral study of tai chi exercise for patients not attending cardiac rehabilitation

Feasibility of Integrating MEditatioN inTO heaRt Disease (the MENTOR Study): A Phase II Randomized Controlled Trial

BACKGROUND

Comorbid depression and/or anxiety symptoms occur in 25% of patients attending cardiac rehabilitation (CR) programs and are associated with poorer prognosis. There is a need to evaluate psychological interventions, including meditation, that have potential to improve psychological health in CR programs.

AIMS

The aim of this study was to determine the feasibility and acceptability of integrating a meditation intervention into an existing Australian CR program for the reduction of depression and anxiety symptoms.

METHODS

This was a mixed-methods feasibility randomized controlled trial. Thirty-one patients with CVD and, at a minimum, mild depression and/or anxiety symptoms were randomized to meditation and standard CR or to standard CR alone. A 16-minute guided group meditation was delivered face-to-face once a week for 6 weeks, with daily self-guided meditation practice between sessions. Feasibility outcomes included screening, recruitment, and retention. Semistructured interviews of patients' (n = 10) and health professionals' (n = 18) perspectives of intervention participation and delivery were undertaken to assess acceptability. Between-group differences in depression, anxiety, stress, self-efficacy for mindfulness, and health status at 6 and 12 weeks were also assessed.

RESULTS AND CONCLUSION

Meditation was considered feasible, with 83% (12/15) of the intervention group completing an average of 3.13 (SD, 2.56) out of 6 group meditation sessions and 5.28 (SD, 8.50) self-guided sessions. Meditation was considered acceptable by patients, clinicians, and health managers. Between-group differences in the number of CR sessions completed favored the intervention group in per-protocol analyses (intervention group vs control group, 12 vs 9 sessions; P = .014), which suggests that meditation may be useful to improve patients' adherence to exercise-based CR program.

Social network interventions to support cardiac rehabilitation and secondary prevention in the management of people with heart disease

BACKGROUND

Globally, cardiovascular diseases (CVD, that is, coronary heart (CHD) and circulatory diseases combined) contribute to 31% of all deaths, more than any other cause. In line with guidance in the UK and globally, cardiac rehabilitation programmes are widely offered to people with heart disease, and include psychosocial, educational, health behaviour change, and risk management components. Social support and social network interventions have potential to improve outcomes of these programmes, but whether and how these interventions work is poorly understood.  OBJECTIVES: To assess the effectiveness of social network and social support interventions to support cardiac rehabilitation and secondary prevention in the management of people with heart disease. The comparator was usual care with no element of social support (i.e. secondary prevention alone or with cardiac rehabilitation).  SEARCH METHODS: We undertook a systematic search of the following databases on 9 August 2022: CENTRAL, MEDLINE, Embase, and the Web of Science. We also searched ClinicalTrials.gov and the WHO ICTRP. We reviewed the reference lists of relevant systematic reviews and included primary studies, and we contacted experts to identify additional studies.  SELECTION CRITERIA: We included randomised controlled trials (RCTs) of social network or social support interventions for people with heart disease. We included studies regardless of their duration of follow-up, and included those reported as full text, published as abstract only, and unpublished data.

DATA COLLECTION AND ANALYSIS

Using Covidence, two review authors independently screened all identified titles. We retrieved full-text study reports and publications marked 'included', and two review authors independently screened these, and conducted data extraction. Two authors independently assessed risk of bias, and assessed the certainty of the evidence using GRADE. Primary outcomes were all-cause mortality, cardiovascular-related mortality, all-cause hospital admission, cardiovascular-related hospital admission, and health-related quality of life (HRQoL) measured at > 12 months follow-up.  MAIN RESULTS: We included 54 RCTs (126 publications) reporting data for a total of 11,445 people with heart disease. The median follow-up was seven months and median sample size was 96 participants. Of included study participants, 6414 (56%) were male, and the mean age ranged from 48.6 to 76.3 years. Studies included heart failure (41%), mixed cardiac disease (31%), post-myocardial infarction (13%), post-revascularisation (7%), CHD (7%), and cardiac X syndrome (1%) patients. The median intervention duration was 12 weeks. We identified notable diversity in social network and social support interventions, across what was delivered, how, and by whom.  We assessed risk of bias (RoB) in primary outcomes at > 12 months follow-up as either 'low' (2/15 studies), 'some concerns' (11/15), or 'high' (2/15). 'Some concerns' or 'high' RoB resulted from insufficient detail on blinding of outcome assessors, data missingness, and absence of pre-agreed statistical analysis plans. In particular, HRQoL outcomes were at high RoB. Using the GRADE method, we assessed the certainty of evidence as low or very low across outcomes. Social network or social support interventions had no clear effect on all-cause mortality (risk ratio (RR) 0.75, 95% confidence interval (CI) 0.49 to 1.13, I2 = 40%) or cardiovascular-related mortality (RR 0.85, 95% CI 0.66 to 1.10, I2 = 0%) at > 12 months follow-up. The evidence suggests that social network or social support interventions for heart disease may result in little to no difference in all-cause hospital admission (RR 1.03, 95% CI 0.86 to 1.22, I2 = 0%), or cardiovascular-related hospital admission (RR 0.92, 95% CI 0.77 to 1.10, I2 = 16%), with a low level of certainty. The evidence was very uncertain regarding the impact of social network interventions on HRQoL at > 12 months follow-up (SF-36 physical component score: mean difference (MD) 31.53, 95% CI -28.65 to 91.71, I2 = 100%, 2 trials/comparisons, 166 participants; mental component score MD 30.62, 95% CI -33.88 to 95.13, I2 = 100%, 2 trials/comparisons, 166 participants).  Regarding secondary outcomes, there may be a decrease in both systolic and diastolic blood pressure with social network or social support interventions. There was no evidence of impact found on psychological well-being, smoking, cholesterol, myocardial infarction, revascularisation, return to work/education, social isolation or connectedness, patient satisfaction, or adverse events.  Results of meta-regression did not suggest that the intervention effect was related to risk of bias, intervention type, duration, setting, and delivery mode, population type, study location, participant age, or percentage of male participants.  AUTHORS' CONCLUSIONS: We found no strong evidence for the effectiveness of such interventions, although modest effects were identified in relation to blood pressure. While the data presented in this review are indicative of potential for positive effects, the review also highlights the lack of sufficient evidence to conclusively support such interventions for people with heart disease. Further high-quality, well-reported RCTs are required to fully explore the potential of social support interventions in this context. Future reporting of social network and social support interventions for people with heart disease needs to be significantly clearer, and more effectively theorised, in order to ascertain causal pathways and effect on outcomes.

Prevalence of US Adults With Cardiovascular Disease Reporting Barriers to Clinician Office Visits: IMPLICATIONS FOR ACCESSIBLE MODELS FOR CARDIAC REHABILITATION

PURPOSE

Despite known health benefits of cardiac rehabilitation (CR) for patients with cardiovascular disease (CVD), only a quarter of eligible patients attend. Among CR barriers are physical (eg, walking) and in-person attendance limitations. The purpose of this study was to determine the prevalence of difficulty walking and dependence on another person to attend medical appointments among people with and without CVD using national survey data.

METHODS

We compared the prevalence of difficulty walking and difficulty attending medical appointments alone among adults with and without CVD using national survey data from the Behavioral Risk Factor Surveillance System (BRFSS) from 2015-2019. We used logistic regression and Rao-Scott χ2 analysis while controlling for several social determinants of health as covariates.

RESULTS

Of 2 212 973 respondents, 200 087 (9.04%) had CVD. The odds of individuals with CVD experiencing either difficulty walking or difficulty attending medical appointments alone were >3 times greater than the odds for individuals without CVD. In all adults with CVD, 42% reported difficulty walking and 20% reported dependence on another person to attend medical appointments. In all adults with CVD, 46% reported difficulty with one or both difficulties compared with 14% of adults without CVD.

CONCLUSIONS

We estimate that 11.9 million Americans with self-reported CVD have difficulty walking, or are dependent on another person to attend medical appointments, or both. Alternative models of CR that adapt to these limitations are needed to increase attendance of CR so that all adults with CVD can improve their health outcomes.

Tai Chi practice and change in exercise habits in survivors of acute coronary syndromes: Is mindfulness a possible mechanism?

BACKGROUND

Mechanisms by which mind-body practice may improve exercise behaviors in patients with coronary heart disease (CHD) are unknown.

PURPOSE

To identify predictors of exercise behaviors developed in response to a tai chi intervention.

METHODS

We conducted an exploratory analysis using data from a pilot study of tai chi for physically inactive patients with CHD. We used Latent Class Analysis to identify patterns of moderate to vigorous physical activity (MVPA) (accelerometry-assessed, average min/week) over the 9-month study period. Logistic regression was used to evaluate associations between MVPA patterns and changes in exercise self-efficacy (Self-efficacy for exercise scale), social support (Multidimensional Scale of Perceived Social Support), resilience (Brief Resilience Survey), and mindfulness (Five Facets of Mindfulness) at 6 months.

RESULTS

Data supported a 3-class model over time: 31% of participants were in class 1 (high and sustained MVPA, > 200 min/week), 21% were in class 2 (low and decreasing MVPA, < 100 > 50 min/week), and 48% in class 3 (low and stable MVPA, < 50 min/week). Higher mindfulness scores at 6 months were associated with a high and sustained MVPA pattern (b = 1.89, SE = 0.15, p = .01). Social support was inversely associated with low and decreasing MVPA (b = -0.72, SE = 0.34, p = .04). No associations were noted with the other factors.

CONCLUSIONS

Improvements in mindfulness were associated with a distinct high and sustained MVPA pattern. Although only hypothesis-generating, these findings suggest that improvements in mindfulness skills could be a mechanism for the possible effect of Tai Chi in the promotion of MVPA.

Resilience of patients with chronic diseases: A systematic review

The purpose of this research was to contribute to the development of a resilience-promoting programme for patients with chronic diseases. A systematic review of literature concerning resilience interventions for patients with chronic diseases was conducted by searching PubMed (including Medline), Science Direct, Web of Science, PsycARTICLES, CINAHL Plus, Embase, and the Cochrane Database for articles featuring the terms "resilience," "resiliency," "resilient," "cancer," "stroke," "heart disease," "diabetes" and "COPD" and published between 8 January 2017 and 15 January 2017. We included all English studies relevant to the topic; however, we excluded: (1) nonrandomised controlled trials and (2) those that mentioned the term "resilience" but did not apply it in their analysis. Seventeen studies-10 on cancer, four on cardiovascular diseases and three on diabetes-were deemed suitable for analysis. We found that, in these studies, (1) diverse definitions of resilience were applied, (2) various intervention durations were used and (3) complex programmes were applied within the resilience-improving programmes. Our research encourages efforts to operationalise the construct of resilience, so it can be applied in clinical settings, and for the development of more systematic intervention programmes.

Tai Chi for heart attack survivors: qualitative insights

OBJECTIVES

Cardiac rehabilitation (CR) programmes are standard of care for patients following a coronary event. While such exercise-based secondary prevention programme do offer benefits, they are used by less than 30% of eligible patients and attrition within these programmes is high. This project is a nested qualitative assessment of a pilot programme considering Tai Chi (TC) as an alternative to CR. We hypothesised that TC may overcome several key barriers to CR.

METHODS

A semistructured focus group agenda was used to assess three key domains of feasibility: (1) patients' experiences, (2) reasons/barriers for not having attended CR and (3) any improvements in physical activity and other secondary outcomes (quality of life, weight, sleep). A thematic analysis was used to better understand the key concepts.

RESULTS

This high-risk group of patients reported that they enjoyed TC exercise, and felt confident and safe doing it. TC practice was reported to support other types of physical activity allowing for a generalisation of positive effects.

DISCUSSION

This analysis is consistent with published reports of TC practice improving mood and psychological well-being. Qualitative methods allowed us to find emergent experiential reports of behaviour change factors found in established behaviour change theories.

Efficacy of Tai Chi and qigong for the prevention of stroke and stroke risk factors: A systematic review with meta-analysis

BACKGROUND

This review aims to summarize the evidence of Tai Chi and qigong interventions for the primary prevention of stroke, including the effects on populations with major stroke risk factors.

METHODS

A systematic literature search was conducted on January 16, 2017 using the PubMed, Scopus, Cochrane Library, and CINAHL databases. Randomized controlled trials examining the efficacy of Tai Chi or qigong for stroke prevention and stroke risk factors were included. Risk of bias was assessed using the Cochrane Risk of Bias tool.

RESULTS

Twenty-one trials with n = 1604 patients with hypertension, hyperlipidaemia, diabetes, overweight or obesity, or metabolic syndrome were included. No trials were found that examined the effects of Tai Chi/qigong on stroke incidence. Meta-analyses revealed significant, but not robust, benefits of Tai Chi/qigong over no interventions for hypertension (systolic blood pressure: -15.55 mm Hg (95% CI: -21.16; -9.95); diastolic blood pressure: -10.66 mm Hg (95% CI: -14.90, -6.43); the homeostatic model assessment (HOMA) index (-2.86%; 95% CI: -5.35, -0.38) and fasting blood glucose (-9.6 mg/dL; 95% CI: -17.28, -1.91), and for the body mass index compared with exercise controls (-1.65 kg/m; 95% CI: -3.11, -0.20). Risk of bias was unclear or high for the majority of trials and domains, and heterogeneity between trials was high. Only 6 trials adequately reported safety. No recommendation for the use of Tai Chi/qigong for the prevention of stroke can be given.

CONCLUSION

Although Tai Chi and qigong show some potential more robust studies are required to provide conclusive evidence on the efficacy and safety of Tai Chi and qigong for reducing major stroke risk factors.

Tai Chi Is a Promising Exercise Option for Patients With Coronary Heart Disease Declining Cardiac Rehabilitation

BACKGROUND

More than 60% of patients decline participation in cardiac rehabilitation after a myocardial infarction. Options to improve physical activity (PA) and other risk factors in these high-risk individuals are limited. We conducted a phase 2 randomized controlled trial to determine feasibility, safety, acceptability, and estimates of effect of tai chi on PA, fitness, weight, and quality of life.

METHODS AND RESULTS

Patients with coronary heart disease declining cardiac rehabilitation enrollment were randomized to a "LITE" (2 sessions/week for 12 weeks) or to a "PLUS" (3 sessions/week for 12 weeks, then maintenance classes for 12 additional weeks) condition. PA (accelerometry), weight, and quality of life (Health Survey Short Form) were measured at baseline and 3, 6, and 9 months after baseline; aerobic fitness (stress test) was measured at 3 months. Twenty-nine participants (13 PLUS and 16 LITE) were enrolled. Retention at 9 months was 90% (LITE) and 88% (PLUS). No serious tai chi-related adverse events occurred. Significant mean between group differences in favor of the PLUS group were observed at 3 and 6 months for moderate-to-vigorous PA (100.33 min/week [95% confidence interval, 15.70-184.95 min/week] and 111.62 min/week; [95% confidence interval, 26.17-197.07 min/week], respectively, with a trend toward significance at 9 months), percentage change in weight, and quality of life. No changes in aerobic fitness were observed within and between groups.

CONCLUSIONS

In this community sample of patients with coronary heart disease declining enrollment in cardiac rehabilitation, a 6-month tai chi program was safe and improved PA, weight, and quality of life compared with a 3-month intervention. Tai chi could be an effective option to improve PA in this high-risk population.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT02165254.

The Mind Body-Wellness in Supportive Housing (Mi-WiSH) study: Design and rationale of a cluster randomized controlled trial of Tai Chi in senior housing

Supporting the health of growing numbers of frail older adults living in subsidized housing requires interventions that can combat frailty, improve residents' functional abilities, and reduce their health care costs. Tai Chi is an increasingly popular multimodal mind-body exercise that incorporates physical, cognitive, social, and meditative components in the same activity and offers a promising intervention for ameliorating many of the conditions that lead to poor health and excessive health care utilization. The Mind Body-Wellness in Supportive Housing (Mi-WiSH) study is an ongoing two-arm cluster randomized, attention-controlled trial designed to examine the impact of Tai Chi on functional indicators of health and health care utilization. We are enrolling participants from 16 urban subsidized housing facilities (n=320 participants), conducting the Tai Chi intervention or education classes and social calls (attention control) in consenting subjects within the facilities for one year, and assessing these subjects at baseline, 6months, and 1year. Physical function (quantified by the Short Physical Performance Battery), and health care utilization (emergency visits, hospitalizations, skilled nursing and nursing home admissions), assessed at 12months are co-primary outcomes. Our discussion highlights our strategy to balance pragmatic and explanatory features into the study design, describes efforts to enhance site recruitment and participant adherence, and summarizes our broader goal of post study dissemination if effectiveness and cost-effectiveness are demonstrated, by preparing training and protocol manuals for use in housing facilities across the U.S.

Protocol for the MATCH study (Mindfulness and Tai Chi for cancer health): A preference-based multi-site randomized comparative effectiveness trial (CET) of Mindfulness-Based Cancer Recovery (MBCR) vs. Tai Chi/Qigong (TCQ) for cancer survivors

PURPOSE

A growing number of cancer survivors suffer high levels of distress, depression and stress, as well as sleep disturbance, pain and fatigue. Two different mind-body interventions helpful for treating these problems are Mindfulness-Based Cancer Recovery (MBCR) and Tai Chi/Qigong (TCQ). However, while both interventions show efficacy compared to usual care, they have never been evaluated in the same study or directly compared. This study will be the first to incorporate innovative design features including patient choice while evaluating two interventions to treat distressed cancer survivors. It will also allow for secondary analyses of which program best targets specific symptoms in particular groups of survivors, based on preferences and baseline characteristics.

METHODS AND SIGNIFICANCE

The design is a preference-based multi-site randomized comparative effectiveness trial. Participants (N=600) with a preference for either MBCR or TCQ will receive their preferred intervention; while those without a preference will be randomized into either intervention. Further, within the preference and non-preference groups, participants will be randomized into immediate intervention or wait-list control. Total mood disturbance on the Profile of mood states (POMS) post-intervention is the primary outcome. Other measures taken pre- and post-intervention and at 6-month follow-up include quality of life, psychological functioning, cancer-related symptoms and physical functioning. Exploratory analyses investigate biomarkers (cortisol, cytokines, blood pressure/Heart Rate Variability, telomere length, gene expression), which may uncover potentially important effects on key biological regulatory and antineoplastic functions. Health economic measures will determine potential savings to the health system.

Bienfaits du tai-chi sur la santé

Objectif

Résumer les données probantes sur les bienfaits du tai-chi sur la santé.

Sources d’information

Une revue de la littérature sur les bienfaits du tai-chi sur 25 affections différentes, de même que sur la santé en général et sur la forme physique, a été effectuée afin d’actualiser une revue des revues systématiques effectuée en 2014. Les revues systématiques et les essais cliniques récents ont été évalués et organisés en 5 groupes : données excellentes, bonnes, acceptables ou préliminaires, étayant un bienfait ou n’étayant aucun bienfait direct.

Message principal

Au cours des 45 dernières années, plus de 500 essais et 120 revues systématiques ont été publiés sur les bienfaits du tai-chi sur la santé. Les revues systématiques sur le tai-chi pour différentes affections ont donné lieu à d’excellentes données étayant un bienfait pour la prévention des chutes, l’arthrose, la maladie de Parkinson, la réadaptation dans les cas de maladie pulmonaire obstructive chronique et l’amélioration de la capacité cognitive chez les personnes âgées. Il existe de bonnes données étayant un bienfait pour la dépression, la réadaptation cardiaque et après un AVC et la démence. Les données étayant un bienfait pour l’amélioration de la qualité de vie des patients atteints de cancer, de fibromyalgie, d’hypertension et d’ostéoporose sont acceptables. Les données actuelles étayent l’absence d’un bienfait direct pour le diabète, la polyarthrite rhumatoïde ou l’insuffisance cardiaque chronique. Les revues systématiques portant sur les bienfaits sur la santé en général et la forme physique font état d’excellentes données étayant un bienfait pour l’amélioration de l’équilibre et de la capacité aérobique chez les personnes en mauvaise forme physique. Les données étayant une plus grande force dans les membres inférieurs sont bonnes. Les données étayant une amélioration du bien-être et du sommeil sont acceptables. Aucune étude n’a révélé que le tai-chi aggravait une affection. Une récente revue systématique sur l’innocuité du tai-chi a révélé que les événements indésirables étaient habituellement mineurs et principalement de nature musculosquelettique; aucun événement indésirable grave lié au tai-chi n’a été rapporté.

Conclusion

Il existe d’abondantes données étayant les effets du tai-chi sur la santé et la forme physique. En s’appuyant sur ces données, les médecins peuvent maintenant faire des recommandations éclairées à leurs patients, en précisant que le tai-chi fait toujours l’objet de recherches. Aussi, toute affection clinique doit faire l’objet d’un suivi médical continu.

Health benefits of tai chi: What is the evidence?

OBJECTIVE

To summarize the evidence on the health benefits of tai chi.

SOURCES OF INFORMATION

A literature review was conducted on the benefits of tai chi for 25 specific conditions, as well as for general health and fitness, to update a 2014 review of systematic reviews. Systematic reviews and recent clinical trials were assessed and organized into 5 different groups: evidence of benefit as excellent, good, fair, or preliminary, or evidence of no direct benefit.

MAIN MESSAGE

During the past 45 years more than 500 trials and 120 systematic reviews have been published on the health benefits of tai chi. Systematic reviews of tai chi for specific conditions indicate excellent evidence of benefit for preventing falls, osteoarthritis, Parkinson disease, rehabilitation for chronic obstructive pulmonary disease, and improving cognitive capacity in older adults. There is good evidence of benefit for depression, cardiac and stroke rehabilitation, and dementia. There is fair evidence of benefit for improving quality of life for cancer patients, fibromyalgia, hypertension, and osteoporosis. Current evidence indicates no direct benefit for diabetes, rheumatoid arthritis, or chronic heart failure. Systematic reviews of general health and fitness benefits show excellent evidence of benefit for improving balance and aerobic capacity in those with poor fitness. There is good evidence for increased strength in the lower limbs. There is fair evidence for increased well-being and improved sleep. There were no studies that found tai chi worsened a condition. A recent systematic review on the safety of tai chi found adverse events were typically minor and primarily musculoskeletal; no intervention-related serious adverse events have been reported.

CONCLUSION

There is abundant evidence on the health and fitness effects of tai chi. Based on this, physicians can now offer evidence-based recommendations to their patients, noting that tai chi is still an area of active research, and patients should continue to receive medical follow-up for any clinical conditions.