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Cuccurullo SJ, Fleming TK, Petrosyan H, Hanley DF, Raghavan P. Mechanisms and benefits of cardiac rehabilitation in individuals with stroke: emerging role of its impact on improving cardiovascular and neurovascular health. Front Cardiovasc Med 2024; 11:1376616. [PMID: 38756753 PMCID: PMC11096558 DOI: 10.3389/fcvm.2024.1376616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 04/17/2024] [Indexed: 05/18/2024] Open
Abstract
Human and animal studies have demonstrated the mechanisms and benefits of aerobic exercise for both cardiovascular and neurovascular health. Aerobic exercise induces neuroplasticity and neurophysiologic reorganization of brain networks, improves cerebral blood flow, and increases whole-body VO2peak (peak oxygen consumption). The effectiveness of a structured cardiac rehabilitation (CR) program is well established and a vital part of the continuum of care for people with cardiovascular disease. Individuals post stroke exhibit decreased cardiovascular capacity which impacts their neurologic recovery and extends disability. Stroke survivors share the same risk factors as patients with cardiac disease and can therefore benefit significantly from a comprehensive CR program in addition to neurorehabilitation to address their cardiovascular health. The inclusion of individuals with stroke into a CR program, with appropriate adaptations, can significantly improve their cardiovascular health, promote functional recovery, and reduce future cardiovascular and cerebrovascular events thereby reducing the economic burden of stroke.
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Affiliation(s)
- Sara J. Cuccurullo
- Department of Physical Medicine and Rehabilitation, JFK Johnson Rehabilitation Institute at Hackensack Meridian Health, Edison, NJ, United States
| | - Talya K. Fleming
- Department of Physical Medicine and Rehabilitation, JFK Johnson Rehabilitation Institute at Hackensack Meridian Health, Edison, NJ, United States
| | - Hayk Petrosyan
- Department of Physical Medicine and Rehabilitation, JFK Johnson Rehabilitation Institute at Hackensack Meridian Health, Edison, NJ, United States
| | - Daniel F. Hanley
- Brain Injury Outcomes, Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | - Preeti Raghavan
- Department of Physical Medicine and Rehabilitation and Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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Marzolini S, Brunne A, Hébert AA, Mayo AL, MacKay C. Barriers and Facilitators to Cardiovascular Rehabilitation Programmes for People with Lower Limb Amputation: A Survey of Clinical Practice in Canada. Physiother Can 2024; 76:199-208. [PMID: 38725599 PMCID: PMC11078241 DOI: 10.3138/ptc-2022-0043] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 07/29/2022] [Accepted: 08/30/2022] [Indexed: 05/12/2024]
Abstract
Purpose This study determines barriers and facilitators to including people with lower limb amputation (LLA) in cardiovascular rehabilitation programmes (CRPs). Method Canadian CRP managers and exercise therapists were invited to complete a questionnaire. Results There were 87 respondents. Of the 32 CRP managers, 65.6% reported that people with LLA were eligible for referral, but of these, 61.9% only accepted people with LLA and cardiac disease, and 38.1% only accepted them with ≥ 1 cardiovascular risk factor. CRP eligibility progressively decreased as mobility severity increased, with 94% of programmes accepting those with mild mobility deficits but only 48% accepting those with severe deficits. Among therapists in CRPs that accepted LLAs, 54.3% reported not having an LLA participant within the past three years. Among all responding therapists and managers who were also therapists (n = 58), 43% lacked confidence in managing safety concerns, and 45%, 16%, and 7% lacked confidence in prescribing aerobic exercise to LLA with severe, moderate, and no mobility deficits respectively. There was a similar finding with prescribing resistance training. LLA-specific education had not been provided to any respondent within the past three years. The top barriers were lack of referrals (52.6%; 30) and lack of knowledge of the contraindications to exercise specific for LLA (43.1%; 31). Facilitators included the provision of a resistance-training tool kit (63.4%; 45), education on exercise safety (63.4%; 45), and indications for physician intervention/inspection (63.6%; 42). Conclusion Most of the CRPs surveyed only accept people with LLA if they have co-existing cardiac disease or cardiovascular risk factors. Few people with LLA participate. Education on CRP delivery for LLAs is needed to improve therapists' confidence and exercise safety.
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Affiliation(s)
- Susan Marzolini
- From the:
KITE Research Institute, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Amanda Brunne
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | | | - Amanda L. Mayo
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Crystal MacKay
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
- West Park Healthcare Centre, Toronto, Ontario, Canada
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Cuccurullo SJ, Fleming TK, Petrosyan H. Integrating Cardiac Rehabilitation in Stroke Recovery. Phys Med Rehabil Clin N Am 2024; 35:353-368. [PMID: 38514223 DOI: 10.1016/j.pmr.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
Stroke remains a top contributor to long-term disability in the United States and substantially limits a person's physical activity. Decreased cardiovascular capacity is a major contributing factor to activity limitations and is a significant health concern. Addressing the cardiovascular capacity of stroke survivors as part of poststroke management results in significant improvements in their endurance, functional recovery, and medical outcomes such as all-cause rehospitalization and mortality. Incorporation of a structured approach similar to the cardiac rehabilitation program, including aerobic exercise and risk factor education, can lead to improved cardiovascular function, health benefits, and quality of life in stroke survivors.
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Affiliation(s)
- Sara J Cuccurullo
- Department of Physical Medicine and Rehabilitation, JFK Johnson Rehabilitation Institute at Hackensack Meridian Health, 65 James Street, Edison, NJ, USA.
| | - Talya K Fleming
- Department of Physical Medicine and Rehabilitation, JFK Johnson Rehabilitation Institute at Hackensack Meridian Health, 65 James Street, Edison, NJ, USA
| | - Hayk Petrosyan
- Department of Physical Medicine and Rehabilitation, JFK Johnson Rehabilitation Institute at Hackensack Meridian Health, 65 James Street, Edison, NJ, USA
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Du X, Brooks D, Oh P, Marzolini S. Sex Differences in Depressive Symptoms in 1308 Patients Post-Stroke at Entry to Cardiac Rehabilitation. J Cardiopulm Rehabil Prev 2024; 44:202-211. [PMID: 38300273 DOI: 10.1097/hcr.0000000000000848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
PURPOSE The objective of this study was to determine whether a sex difference exists in the prevalence of post-stroke depressive symptoms (PSDS) at entry to cardiac rehabilitation (CR) and to determine the correlates of PSDS in all patients, and in women and men separately. METHODS People post-stroke at entry to CR from database records (2006-2017) were included. Bivariate analyses identified PSDS correlates (≥16 on the Center for Epidemiologic Studies Depression Scale) in all patients and women and men separately. RESULTS Patients (n = 1308, 28.9% women), mean age of 63.9 ± 12.9 yr, were 24.2 ± 9.9 mo post-stroke at CR entry. Among all patients, 30.0% had PSDS. A greater proportion of women than men had PSDS (38.6 vs 26.6%; P < .001). Correlates of PSDS in all patients were sex (women) (OR = 1.6: 95% CI, 1.14-2.12), being unemployed, ≤60 yr old, prescribed antidepressant medication, having lower cardiorespiratory fitness (peak oxygen uptake [V̇ o2peak ]), chronic obstructive pulmonary disease (COPD), higher body mass index (BMI), no transient ischemic attack, and longer time from stroke to CR entry (>12 mo). Correlates in women were being obese (BMI ≥ 30), 51-70 yr old, prescribed antidepressant medication, and not married. Correlates in men were being ≤60 yr old, unemployed, prescribed antidepressant medication, having lower V̇ o2peak , sleep apnea, COPD, and no hypertension. CONCLUSION Women were disproportionately affected by PSDS at entry to CR in bivariate and multivariable analyses. Women and men had mostly unique correlates of PSDS, indicating tailored strategies to address PSDS are required. PSDS disproportionately affected patients with longer delay to CR entry, suggesting efforts should target timely referral to facilitate earlier and repeated assessments and management.
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Affiliation(s)
- XiaoWei Du
- Author Affiliations: Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada (Ms Du and Drs Brooks, Oh, and Marzolini); Toronto Rehabilitation Institute (KITE), University Health Network, Toronto, Ontario, Canada (Ms Du and Drs Oh and Marzolini); School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada (Dr Brooks); and Faculty of Kinesiology & Physical Education, University of Toronto, Toronto, Ontario, Canada (Drs Oh and Marzolini)
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Rehman S, Barker S, Jose K, Callisaya M, Castley H, Schultz MG, Moore MN, Simpson DB, Peterson GM, Gall S. Co-Designed Cardiac Rehabilitation for the Secondary Prevention of Stroke (CARESS): A Pilot Program Evaluation. Healthcare (Basel) 2024; 12:776. [PMID: 38610198 PMCID: PMC11012137 DOI: 10.3390/healthcare12070776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 03/22/2024] [Accepted: 03/28/2024] [Indexed: 04/14/2024] Open
Abstract
Structured health system-based programs, such as cardiac rehabilitation, may reduce the risk of recurrent stroke. This study aimed to co-design and evaluate a structured program of rehabilitation, developed based on insights from focus groups involving stroke survivors and health professionals. Conducted in Tasmania, Australia in 2019, the 7-week program comprised one hour of group exercise and one hour of education each week. Functional capacity (6 min walk test), fatigue, symptoms of depression (Patient Health Questionnaire), and lifestyle were assessed pre- and post-program, with a historical control group for comparison. Propensity score matching determined the average treatment effect (ATE) of the program. Key themes from the co-design focus groups included the need for coordinated care, improved psychosocial management, and including carers and peers in programs. Of the 23 people approached, 10 participants (70% men, mean age 67.4 ± 8.6 years) completed the program without adverse events. ATE analysis revealed improvements in functional capacity (139 m, 95% CI 44, 234) and fatigue (-5 units, 95% CI -9, -1), with a small improvement in symptoms of depression (-0.8 units, 95% CI -1.8, 0.2) compared to controls. The co-designed program demonstrated feasibility, acceptability, and positive outcomes, suggesting its potential to support stroke survivors.
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Affiliation(s)
- Sabah Rehman
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS 7000, Australia; (S.R.); (S.B.); (K.J.); (M.C.); (M.N.M.)
| | - Seamus Barker
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS 7000, Australia; (S.R.); (S.B.); (K.J.); (M.C.); (M.N.M.)
| | - Kim Jose
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS 7000, Australia; (S.R.); (S.B.); (K.J.); (M.C.); (M.N.M.)
| | - Michele Callisaya
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS 7000, Australia; (S.R.); (S.B.); (K.J.); (M.C.); (M.N.M.)
- Peninsula Clinical School, Monash University, Frankston, VIC 3199, Australia
| | - Helen Castley
- Royal Hobart Hospital, Tasmanian Health Service, Hobart, TAS 7000, Australia;
| | - Martin G. Schultz
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS 7000, Australia; (S.R.); (S.B.); (K.J.); (M.C.); (M.N.M.)
| | - Myles N. Moore
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS 7000, Australia; (S.R.); (S.B.); (K.J.); (M.C.); (M.N.M.)
| | - Dawn B. Simpson
- College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia;
| | - Gregory M. Peterson
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS 7005, Australia
| | - Seana Gall
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS 7000, Australia; (S.R.); (S.B.); (K.J.); (M.C.); (M.N.M.)
- Faculty of Medicine, Dentistry and Health Sciences, Monash University, Melbourne, VIC 3800, Australia
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Machado N, Williams G, Olver J, Johnson L. Is early initiated cardiorespiratory fitness training within a model of stroke-integrated cardiac rehabilitation safe and feasible? J Stroke Cerebrovasc Dis 2024; 33:107493. [PMID: 38061183 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 09/21/2023] [Accepted: 11/15/2023] [Indexed: 01/23/2024] Open
Abstract
OBJECTIVE To investigate the safety and feasibility of an early initiated stroke-integrated Cardiac Rehabilitation program. METHODS People with acute first or recurrent ischaemic stroke, admitted to Epworth HealthCare were screened for eligibility and invited to participate. In addition to usual care neurorehabilitation, participants performed 1) cardiorespiratory fitness training 3-days/week during inpatient rehabilitation (Phase 1), and/or 2) 2-days/week centre-based cardiorespiratory fitness training plus education and 1-day/week home-based cardiorespiratory fitness training for 6-weeks during outpatient rehabilitation (Phase 2). Safety was determined by the number of adverse and serious adverse events. Feasibility was determined by participant recruitment, retention, and attendance rates, adherence to exercise recommendations, and participant satisfaction. RESULTS There were no study-related adverse or serious adverse events. Of 117 eligible stroke admissions, 62 (53%) were recruited, while 10 (16.1%) participants withdrew. Participants attended 189 of 201 (94%) scheduled cardiorespiratory fitness training sessions in Phase 1 and 341/381 (89.5%) scheduled sessions in Phase 2. Only 220/381 (58%) scheduled education sessions were attended. The minimum recommended cardiorespiratory fitness training intensity (40% heart rate reserve) and duration (20 minutes) was achieved by 57% and 55% of participants respectively during Phase 1, and 60% and 92% respectively during Phase 2. All respondents strongly agreed (69%) or agreed (31%) they would recommend the stroke-integrated Cardiac Rehabilitation program to other people with stroke. CONCLUSION Cardiorespiratory fitness training in line with multiple clinical practice guidelines included within a model of stroke-integrated Cardiac Rehabilitation appears to be safe and feasible in the early subacute phase post-stroke.
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Affiliation(s)
- Natasha Machado
- Rehabilitation, Epworth HealthCare, Victoria, Australia; Physiotherapy Department, Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Victoria, Australia.
| | - Gavin Williams
- Rehabilitation, Epworth HealthCare, Victoria, Australia; Physiotherapy Department, Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Victoria, Australia
| | - John Olver
- Rehabilitation, Epworth HealthCare, Victoria, Australia; Physiotherapy Department, Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Victoria, Australia; Department of Medicine, Monash University, Victoria, Australia
| | - Liam Johnson
- Rehabilitation, Epworth HealthCare, Victoria, Australia; Physiotherapy Department, Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Victoria, Australia; Faculty of Health Sciences, School of Behavioural and Health Sciences, Australian Catholic University, Victoria, Australia
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Jiang H, Mei Y, Lin B, Wang W, Wang X, Zhao Z, Zhang ZX. Perspectives of cardiac rehabilitation in patients who had a stroke: a protocol for a qualitative study review. BMJ Open 2023; 13:e071964. [PMID: 37536962 PMCID: PMC10401236 DOI: 10.1136/bmjopen-2023-071964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 07/19/2023] [Indexed: 08/05/2023] Open
Abstract
INTRODUCTION Stroke has a high incidence and disability rate, and its recurrence and readmission rates are rising, making it the second-leading cause of mortality in the globe. Cardiac rehabilitation is a well-known, evidence-based strategy that might serve as an additional preventative programme. Prior quantitative research has proven the positive results and high practicability of cardiac rehabilitation for patients who had a stroke, however, cardiac rehabilitation is not yet a routine component of stroke rehabilitation worldwide. It might be useful to conduct meta-integration of previous qualitative studies to understand if existing cardiac rehabilitation programme meets the needs of patients who had a stroke. Therefore, the purpose of this study is to combine systematically the perspectives on benefits, barriers and facilitating factors of cardiac rehabilitation in patients who had a stroke. METHODS AND ANALYSIS There will be a search of PubMed, Web of Science, Embase, Scopus, CINAHL and PsycINFO databases. In addition, grey literature from Google Scholar, OpenGrey, PyARXiv, bioRxiv and medRxiv will also be searched. Included studies will be qualitative studies or findings from mixed-method research involving patients who engage in CR after a stroke. Regardless of the publishing date and context, English-language articles will be reviewed. Two impartial reviewers will screen studies and extract data from the included studies. According to the Joanna Briggs Institute Centre for Evidence-Based Health Care Quality Evaluation Criteria for qualitative research, the methodology of the included literature will be examined. For data synthesis, the pooling meta-integration approach and Noblit and Hare's seven steps of meta-ethnography will be used. ETHICS AND DISSEMINATION Because there will be no collection of primary data, this systematic review is exempt from the need that gets ethical approval. The findings of the review will be made public by publishing them in scholarly journals and presenting them at scientific conferences. PROSPERO REGISTRATION NUMBER CRD42023387534.
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Affiliation(s)
- Hu Jiang
- School of Nursing and Health, Zhengzhou University, Zhengzhou, China
- The Third Affiliated Hospital of Zunyi Medical University (The First People's Hospital of Zunyi), Zunyi, China
| | - Yongxia Mei
- School of Nursing and Health, Zhengzhou University, Zhengzhou, China
| | - Beilei Lin
- School of Nursing and Health, Zhengzhou University, Zhengzhou, China
| | - Wenna Wang
- School of Nursing and Health, Zhengzhou University, Zhengzhou, China
| | - Xiaoxuan Wang
- School of Nursing and Health, Zhengzhou University, Zhengzhou, China
| | - Zhixin Zhao
- School of Nursing and Health, Zhengzhou University, Zhengzhou, China
| | - Zhen-Xiang Zhang
- School of Nursing and Health, Zhengzhou University, Zhengzhou, China
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Marzolini S, da Silva JN, Capone A, Barry-Hickey D, Pikula A, MacDonald SL, Munce S, Mastrangelo D, Oh P. Sex differences and predictors of completion of a 6-month exercise-based cardiac rehabilitation program in 1,536 people following stroke. J Stroke Cerebrovasc Dis 2023; 32:107129. [PMID: 37087771 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 04/04/2023] [Accepted: 04/06/2023] [Indexed: 04/25/2023] Open
Abstract
OBJECTIVE To retrospectively examine sex-differences and predictors of completion in consecutively-referred patients to a 6-month exercise-based cardiac rehabilitation program (CRP) from 2006 to 2017. MATERIALS/METHODS People with hemiplegic gait participated in stroke-adapted-CRP; otherwise, traditional-CRP. Reasons for non-completion were ascertained by interview. Regression-analyses were conducted to determine non-completion in all patients and women and men separately. RESULTS There were 1536 patients (30.3% women), mean age 64.5 ± 12.5 with 23% initiating the stroke-adapted-CRP. Overall, 75.1% completed the CRP (87.3% stroke-adapted-CRP vs 71.5% traditional-CRP; p < .001). There was no difference in completion between women and men (74.5% vs 75.4%; p=0.7), or in attendance to pre-scheduled sessions (p=0.6) or reasons for non-completion (p > .05, all). The only sex difference in completion by age (decade) occurred in those <41 years (59% women vs 85% men; p=.02). Baseline predictors of non-completion among all patients included not being enrolled in the stroke-adapted-CRP, lower V̇O2peak, smoking, diabetes (prescribed insulin) and depression but not sex (p=.5) or age (p=.15). Unique predictors in women vs men were younger age, lower V̇O2peak, smoking, diabetes (prescribed insulin), depression, and cancer diagnoses. Unique to men was having >1 stroke and diabetes (any anti-diabetes medication). The strongest predictor of non-completion among all models was not being enrolled in stroke-adapted-CRP. CONCLUSIONS While there were no sex-differences in adherence to the CRP, women and men have mostly unique predictors of non-completion. Younger women are at greatest risk for non-completion. Practitioners should provide sex-specific, tailored strategies for enhancing completion with a focus on younger women and offering a stroke-adapted-CRP with close attention to those with diabetes.
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Affiliation(s)
- Susan Marzolini
- KITE Research Institute, Toronto Rehabilitation Institute-University Health Network, Toronto, ON, Canada; Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Department of Exercise Sciences, Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada.
| | - Juliana Nunes da Silva
- KITE Research Institute, Toronto Rehabilitation Institute-University Health Network, Toronto, ON, Canada; Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Alessia Capone
- Department of Exercise Sciences, Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
| | - Danielle Barry-Hickey
- KITE Research Institute, Toronto Rehabilitation Institute-University Health Network, Toronto, ON, Canada
| | - Aleksandra Pikula
- Department of Medicine, Division of Neurology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Neurovascular Unit, University Health Network Toronto Western Hospital, Toronto, ON, Canada; Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Shannon L MacDonald
- KITE Research Institute, Toronto Rehabilitation Institute-University Health Network, Toronto, ON, Canada; Department of Medicine, Division of Neurology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Sinai Health, Toronto, ON, Canada
| | - Sarah Munce
- KITE Research Institute, Toronto Rehabilitation Institute-University Health Network, Toronto, ON, Canada; Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada
| | - David Mastrangelo
- KITE Research Institute, Toronto Rehabilitation Institute-University Health Network, Toronto, ON, Canada
| | - Paul Oh
- KITE Research Institute, Toronto Rehabilitation Institute-University Health Network, Toronto, ON, Canada; Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Department of Exercise Sciences, Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
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Freene N, Wallett H, Flynn A, Preston E, Cowans S, Lueck C, Niyonsenga T, Mohanty I, Davey R. Cardiovascular Rehabilitation for transient ischaemic Attack and Mild Stroke: the CRAMS effectiveness-implementation hybrid study protocol. BMC Health Serv Res 2022; 22:1391. [PMID: 36419153 PMCID: PMC9682670 DOI: 10.1186/s12913-022-08797-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 11/05/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Internationally, stroke and cardiac rehabilitation clinicians agree that current cardiac rehabilitation models are a suitable secondary prevention program for people following a transient ischaemic attack (TIA) or mild stroke. There is strong evidence for exercise-based cardiac rehabilitation in people with heart disease, however, the evidence for cardiac rehabilitation post-TIA or stroke is limited. Here we will explore the effectiveness and implementation of an integrated (TIA, mild stroke, heart disease) traditional exercise-based cardiovascular rehabilitation (CVR) program for people with TIA or mild stroke over 6-months. METHODS This type 1 effectiveness-implementation hybrid study will use a 2-arm single-centre assessor-blind randomised controlled trial design, recruiting 140 participants. Adults who have had a TIA or mild stroke in the last 12-months will be recruited by health professionals from hospital and primary healthcare services. Participants will be assessed and randomly allocated (1:1) to the 6-week CVR program or the usual care 6-month wait-list control group. Distance completed in the 6-min walk test will be the primary effectiveness outcome, with outcomes collected at baseline, 6-weeks (complete CVR) and 6-months in both groups. Other effectiveness outcome measures include unplanned cardiovascular disease-related emergency department and hospital admissions, daily minutes of accelerometer moderate-to-vigorous physical activity, body mass index, waist circumference, blood pressure, quality of life, anxiety and depression. Implementation outcomes will be assessed using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework, including a cost-effectiveness analysis. Semi-structured interviews will be conducted with participants and CVR program health professionals, investigating the acceptability, value, and impact of the CVR program. Qualitative analyses will be guided by the Consolidated Framework for Implementation Research. DISCUSSION Few studies have assessed the effectiveness of cardiac rehabilitation for people with TIA and mild stroke, and no studies appear to have investigated the cost-effectiveness or implementation determinants of such programs. If successful, the CVR program will improve health outcomes and quality of life of people who have had a TIA or mild stroke, guiding future research, policy, and clinical practice, reducing the risk of repeat heart attacks and strokes for this population. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12621001586808 , Registered 19 November 2021.
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Affiliation(s)
- Nicole Freene
- grid.1039.b0000 0004 0385 7472Physiotherapy, Faculty of Health, University of Canberra, Bruce, ACT Australia ,grid.1039.b0000 0004 0385 7472Health Research Institute, University of Canberra, Bruce, ACT Australia
| | - Hannah Wallett
- grid.1039.b0000 0004 0385 7472Physiotherapy, Faculty of Health, University of Canberra, Bruce, ACT Australia
| | - Allyson Flynn
- grid.1039.b0000 0004 0385 7472Physiotherapy, Faculty of Health, University of Canberra, Bruce, ACT Australia
| | - Elisabeth Preston
- grid.1039.b0000 0004 0385 7472Physiotherapy, Faculty of Health, University of Canberra, Bruce, ACT Australia
| | - Shahla Cowans
- Neurology, Canberra Health Services, Garran, ACT Australia
| | | | - Theophile Niyonsenga
- grid.1039.b0000 0004 0385 7472Health Research Institute, University of Canberra, Bruce, ACT Australia
| | - Itismita Mohanty
- grid.1039.b0000 0004 0385 7472Health Research Institute, University of Canberra, Bruce, ACT Australia
| | - Rachel Davey
- grid.1039.b0000 0004 0385 7472Health Research Institute, University of Canberra, Bruce, ACT Australia
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Perspectives of Stroke and Cardiac Clinicians on Cardiac Rehabilitation Post-TIA or Mild Stroke. J Cardiopulm Rehabil Prev 2022; 42:377-379. [PMID: 36044762 DOI: 10.1097/hcr.0000000000000729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Pack QR, Shea M, Brawner CA, Headley S, Hutchinson J, Madera H, Keteyian SJ. Exercise Prescription Methods and Attitudes in Cardiac Rehabilitation: A NATIONAL SURVEY. J Cardiopulm Rehabil Prev 2022; 42:359-365. [PMID: 35185145 PMCID: PMC9385888 DOI: 10.1097/hcr.0000000000000680] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE High-quality exercise training improves outcomes in cardiac rehabilitation (CR), but little is known about how most programs prescribe exercise. Thus, the aim was to describe how current CR programs prescribe exercise. METHODS We conducted a 33-item anonymous survey of CR program directors registered with the American Association of Cardiovascular and Pulmonary Rehabilitation. We assessed the time, mode, and intensity of exercise prescribed, as well as attitudes about maximal exercise testing and exercise prescription. Results were summarized using descriptive statistics. Open-ended responses were coded and quantitated thematically. RESULTS Of 1470 program directors, 246 (16.7%) completed the survey. In a typical session of CR, a median of 5, 35, 10, and 5 min was spent on warm-up, aerobic exercise, resistance training, and cooldown, respectively. The primary aerobic modality was the treadmill (55%) or seated dual-action step machine (40%). Maximal exercise testing and high-intensity interval training (HIIT) were infrequently reported (17 and 8% of patients, respectively). The most common method to prescribe exercise intensity was ratings of perceived exertion followed by resting heart rate +20-30 bpm, although 55 unique formulas for establishing a target heart rate or range (THRR) were reported. Moreover, variation in exercise prescription between staff members in the same program was reported in 40% of programs. Program directors reported both strongly favorable and unfavorable opinions toward maximal exercise testing, HIIT, and use of THRR. CONCLUSIONS Cardiac rehabilitation program directors reported generally consistent exercise time and modes, but widely divergent methods and opinions toward prescribing exercise intensity. Our results suggest a need to better study and standardize exercise intensity in CR.
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Affiliation(s)
- Quinn R. Pack
- Division of Cardiovascular Medicine, University of Massachusetts Medical School – Baystate, Springfield, MA
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School – Baystate, Springfield, MA
- Department of Medicine, University of Massachusetts Medical School – Baystate, Springfield, MA
| | - Meredith Shea
- Division of Cardiovascular Medicine, University of Massachusetts Medical School – Baystate, Springfield, MA
- Springfield College Department of Exercise Science and Athletic Training Springfield MA
- Mayo Clinic Arizona, Scottsdale AZ
| | | | - Samuel Headley
- Springfield College Department of Exercise Science and Athletic Training Springfield MA
| | - Jasmin Hutchinson
- Springfield College Department of Exercise Science and Athletic Training Springfield MA
| | - Hayden Madera
- Center for Cardiac Fitness, The Miriam Hospital, Providence, RI
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Lennon O, Crystal A, Kwan M, Tierney C, Gallagher A, Murphy S. Perspectives and Experiences of Cardiac Rehabilitation after Stroke—A Qualitative Study. Healthcare (Basel) 2022; 10:healthcare10081579. [PMID: 36011236 PMCID: PMC9408632 DOI: 10.3390/healthcare10081579] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/15/2022] [Accepted: 08/18/2022] [Indexed: 11/30/2022] Open
Abstract
Cardiac rehabilitation (CR) after stroke has been proven to be a safe and feasible secondary prevention intervention. Limited qualitative data capture people’s experiences and perceptions of attending CR following stroke, but with none addressing translational aspects when CR is delivered as routine clinical care. Using a phenomenological, qualitative approach, four semi-structured focus groups were conducted with 15 individuals (60% male) who had completed CR during their stroke care pathway. Our inductive thematic analysis identified five themes. The first centred on recognising stroke as a cardiovascular disease and the applicability of CR post-stroke. The second addressed how peer understanding, camaraderie, and medical supervision created a safe and supportive environment. The third identified how the programme-built confidence supported longer-term healthy lifestyle choices in physical activity, diet, and smoking. The penultimate theme addressed the period from hospital discharge to attending CR as a time of uncertainty where many participants experienced cognitive difficulties, mood disturbances, and mental fatigue without adequate support. Lastly, participants identified unmet needs in their care pathway that included a lack of information about their referral to CR, the programme content, and accessing local supports ahead of CR. Ongoing and unmet needs both during and after CR related to self-management of secondary prevention medications, neurological issues, post-stroke fatigue, and the lack of structured support following CR completion.
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Affiliation(s)
- Olive Lennon
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, D04 V1W8 Dublin, Ireland
- Correspondence: ; Tel.: +35-31-7166-508
| | - Alexandra Crystal
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, D04 V1W8 Dublin, Ireland
| | - Michelle Kwan
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, D04 V1W8 Dublin, Ireland
| | - Caoimhe Tierney
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, D04 V1W8 Dublin, Ireland
| | - Anne Gallagher
- Heart House, Mater Misericordiae University Hospital, D07 KH4C Dublin, Ireland
| | - Sean Murphy
- Stroke Services, Mater Misericordiae University Hospital, D07 R2WY Dublin, Ireland
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Post pandemic research priorities: A consensus statement from the HL-PIVOT. Prog Cardiovasc Dis 2022; 73:2-16. [PMID: 35842068 PMCID: PMC9278010 DOI: 10.1016/j.pcad.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 07/09/2022] [Indexed: 11/20/2022]
Abstract
We have been amid unhealthy living and related chronic disease pandemics for several decades. These longstanding crises have troublingly synergized with the coronavirus disease 2019 (COVID-19) pandemic. The need to establish research priorities in response to COVID-19 can be used to address broad health and wellbeing, social and economic impacts for the future is emerging. Accordingly, this paper sets out a series of research priorities that could inform interdisciplinary collaboration between clinical sciences, public health, business, technology, economics, healthcare providers, and the exercise science/sports medicine communities, among others. A five-step methodology was used to generate and evaluate the research priorities with a focus on broad health and well-being impacts. The methodology was deployed by an international and interdisciplinary team from the Healthy Living for Pandemic Event Protection (HL- PIVOT) network. This team were all engaged in responding to the Pandemic either on the 'front-line' and/or in leadership positions ensuring the currency and authenticity of the process. Eight research priorities were identified clustered into two groups: i) Societal & Environmental, and ii) Clinical. Our eight research priorities are presented with insight from previously published research priorities from other groups.
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Marzolini S, Banks L, Oh PI. Sex Differences in Predictors of Completion of a 6-month Adapted Cardiac Rehabilitation Program for People with Type 2 Diabetes and No Known Cardiac Disease. Can J Diabetes 2021; 46:277-286.e1. [DOI: 10.1016/j.jcjd.2021.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 10/19/2021] [Accepted: 11/01/2021] [Indexed: 11/16/2022]
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Jeffares I, Merriman NA, Doyle F, Horgan F, Hickey A. Inclusion of stroke patients in expanded cardiac rehabilitation services: a cross-national qualitative study with cardiac and stroke rehabilitation professionals. Disabil Rehabil 2021; 44:3610-3622. [PMID: 33529535 DOI: 10.1080/09638288.2021.1874548] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE This qualitative study explored healthcare professionals' views in relation to the potential expansion of cardiac rehabilitation services to include stroke patients, thereby becoming a cardiovascular rehabilitation model. DESIGN AND METHODS 23 semi-structured interviews were completed with hospital and community-based stroke and cardiac rehabilitation professionals in Switzerland (n = 7) and Ireland (n = 19). The sample comprised physiotherapists, occupational therapists, speech and language therapists, stroke physicians, cardiologists, psychologists, dieticians and nurses. Interviews were audio-recorded and the transcripts were analysed in NVivo using inductive Thematic Analysis. RESULTS Barriers and facilitators to cardiovascular rehabilitation were captured under four broad themes; (i) Cardiac rehabilitation as "low-hanging fruit," (ii) Cognitive impairment ("the elephant in the room"), (iii) Adapted cardiac rehabilitation for mild stroke, and (iv) Resistance to change. CONCLUSIONS Hybrid cardiac rehabilitation programmes could be tailored to deliver stroke-specific education, exercises and multidisciplinary expertise. Post-stroke cognitive impairment was identified as a key barrier to participation in cardiac rehabilitation. A cognitive rehabilitation intervention could potentially be delivered as part of cardiac rehabilitation, to address the cognitive needs of stroke and cardiac patients.Implications for rehabilitationThe cardiac rehabilitation model has the potential to be expanded to include mild stroke patients given the commonality of secondary prevention needs.Up to half of stroke survivors are affected by post-stroke cognitive impairment, consequently mild stroke patients may not be such an "easy fit" for cardiac rehabilitation.A cardiovascular programme which includes common rehabilitation modules, in addition to stroke- and cardiac-specific content is recommended.A cognitive rehabilitation module could potentially be added as part of the cardiac rehabilitation programme to address the cognitive needs of stroke and cardiac patients.
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Affiliation(s)
- Isabelle Jeffares
- Department of Health Psychology, Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Niamh A Merriman
- Department of Health Psychology, Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Frank Doyle
- Department of Health Psychology, Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Frances Horgan
- School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Anne Hickey
- Department of Health Psychology, Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
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Jung C, Ye DH, Lee SH. Integrating Cardiac Rehabilitation with Neurorehabilitation in a Patient with Ischemic Stroke after Cardiac Surgery: a Case Report. BRAIN & NEUROREHABILITATION 2020; 14:e2. [PMID: 36742109 PMCID: PMC9879410 DOI: 10.12786/bn.2021.14.e2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 11/01/2020] [Accepted: 11/03/2020] [Indexed: 11/08/2022] Open
Abstract
Stroke and cardiac disorders are difficult to approach separately. Stroke survivors commonly have cardiovascular comorbidities and vice versa. These patients often need both neurorehabilitation and cardiac rehabilitation; therefore, this is an important issue in the rehabilitation process. However, no consensus has been reached on the integration of cardiac rehabilitation and neurorehabilitation. We report the case of a 52-year-old male patient who had ischemic stroke after mitral valvuloplasty. The patient underwent 3 weeks of inpatient neurorehabilitation, and then transited to 6 weeks of outpatient cardiac rehabilitation and occupational therapy. After 9 weeks of well-integrated rehabilitation, the patient experienced neurologic recovery and improvement in his cardiopulmonary fitness. Like this case, successful integrated rehabilitation will contribute to enhancing patients' functional recovery.
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Affiliation(s)
- Chul Jung
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Hyun Ye
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Hak Lee
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Marzolini S, Ghisi GLDM, Hébert AA, Ahden S, Oh P. Cardiac Rehabilitation in Canada During COVID-19. CJC Open 2020; 3:152-158. [PMID: 33521613 PMCID: PMC7833488 DOI: 10.1016/j.cjco.2020.09.021] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 09/27/2020] [Indexed: 12/13/2022] Open
Abstract
Background Cardiac rehabilitation programs (CRPs) had to change quickly in response to a shift in clinical priorities related to to the coronavirus disease 2019 (COVID-19). Yet, no study has examined the effect of COVID-19 on CRPs and if there has been an adequate transition to alternative programming. Methods To examine the status of CRPs during the COVID-19 pandemic, a web-based questionnaire was completed by CRP managers from April 23rd to May 14th, 2020. Results Overall, 114 representatives of 144 CRPs (79.1% of Canadian programs) responded. Of respondents, 41.2% (n = 47) reported CRP closure; primary reasons were staff redeployment and facility closure (41% of 51 responses, for both). Redeployment occurred in open CRPs and closed CRPs (30% ± 34% and 47% ± 38% of employees, respectively; P = 0.05) and reduced hours in 17.8% ± 31% and 22.5% ± 33% for remaining employees; P = 0.56. Of open CRPs, 84.8% accepted referrals for medically high-risk patients pre-COVID-19; this level fell to only 43.5% during the COVID-19 pandemic, P < 0.001. There was a significant reduction in patients with cognitive/communication/mobility deficits who were eligible to participate during the COVID-19 pandemic. Of respondents, 57%-82.6% reported safety concerns related to prescribing exercise to medically high-risk and vulnerable populations. CRPs transitioned from group-based to one-to-one delivery models->80% by phone and/or e-mail. Any tele-rehabilitation (one-to-one/group) was also used by 32.7% and 43.5% of CRPs to deliver exercise and education, respectively (mostly one-to-one). Resource barriers cited by open and closed CRPs were related to technology-no tele-rehabilitation, lack of equipment and patient access (35% of all barriers)-and 25.3% of barriers were owing to greater demands on staff time. Conclusions Within 2-months of COVID-19 being declared a pandemic, 41.2% of CRPs were closed and almost half of employees redeployed. Less time-efficient one-to-one models of remote care, mostly by phone/e-mail, were adopted. Vulnerable populations were disproportionately affected, becoming ineligible owing to safety concerns. Strategies to open closed CRPs, admission of high-risk/vulnerable populations, and offering of group-based tele-rehabilitation should be a national priority.
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Affiliation(s)
- Susan Marzolini
- KITE Research Institute, Toronto Rehab-University Health Network, Toronto, Ontario, Canada.,Healthy Living for Pandemic Event Protection (HL - PIVOT) Network, Toronto, Ontario, Canada.,Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada.,Rehabilitation Sciences Institute, University of Toronto, Toronto, Onatario, Canada
| | | | - Andrée-Anne Hébert
- Programme de Prévention Secondaire et Réadaptation Cardiovasculaire (PREV), Centre Intégré de Santé et Services Sociaux (CISSS) de Chaudière-Appalaches, Lévis, Québec, Canada
| | - Shobhit Ahden
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Paul Oh
- KITE Research Institute, Toronto Rehab-University Health Network, Toronto, Ontario, Canada
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