Predictors of women's exercise maintenance after cardiac rehabilitation

Research trends and hotspots in exercise rehabilitation for coronary heart disease: A bibliometric analysis

Exercise rehabilitation can improve the prognosis of patients with coronary heart disease. However, a bibliometric analysis of the global exercise rehabilitation for coronary heart disease (CHD) research topic is lacking. This study investigated the development trends and research hotspots in the field of coronary heart disease and exercise rehabilitation. CiteSpace software was used to analyze the literature on exercise therapy for CHD in the Web of Science Core Collection database. We analyzed the data of countries/institutions, journals, authors, keywords, and cited references. A total of 3485 peer-reviewed papers were found, and the number of publications on the topic has steadily increased. The most productive country is the USA (1125), followed by China (477) and England (399). The top 3 active academic institutions are Research Libraries UK (RLUK) (236), Harvard University (152), and the University of California System (118). The most commonly cited journals are Circulation (2596), The most commonly cited references are "Exercise-based cardiac rehabilitation for coronary heart disease" (75), Lavie CJ had published the most papers (48). World Health Organization was the most influential author (334 citations). The research frontier trends in this field are body composition, participation, and function. Research on the effects of physical activity or exercise on patients with CHD is a focus of continuous exploration in this field. This study provides a new scientific perspective for exercise rehabilitation and CHD research and gives researchers valuable information for detecting the current research status, hotspots, and emerging trends for further research.

Surgical revascularization in women: focus on factors worsening the prognosis

In recent years, there has been an increase in the number of women undergoing coronary artery bypass grafting (CABG). Although the evidence of gender effects on outcomes is controversial, a number of publications have reported less favorable outcomes of CABG in women. The aim of this paper was to review the literature regarding factors that worsen short- and long-term prognosis in women undergoing surgical myocardial revascularization.

Gender differences in early outcomes of CABG are largely explained by gender distribution of baseline clinical characteristics. Women, compared to men, undergo CABG at an older age and have a worse profile of cardiovascular disease (CVD) risk factors (RF), comorbidity burden, structural and functional cardiac pathology, and coronary lesions. In women, complete myocardial revascularization is less frequent than in men, venous shunts are used more frequently, and the left internal mammary artery is less frequently used as a conduit. In addition to the baseline characteristics, higher incidence of perioperative myocardial infarction (MI), higher prevalence of anxiety and depression, lower quality of life and social adaptation after CABG, and lower involvement of women in rehabilitation programs, compared to men, may contribute to a less favorable long-term prognosis after CABG in women.

There is a need for more information for physicians about the specifics of CVDs and anatomical and surgical aspects of CABG in women. It is also necessary to raise patients’ awareness of RF correction and to involve them in educational technologies. Recommendations for diagnosis and treatment of CVDs should be developed taking into account gender. Further research is also required to develop and implement sex-specific models for predicting surgical risks. Long-term follow-up is appropriate in women with recent MI and a history of diabetes mellitus. To further improve clinical outcomes of CABG in women, development of approaches that facilitate more complete revascularization and reduce the incidence of perioperative complications, such as MI and pneumonia, is needed. More answers to questions regarding gender differences in long-term outcomes of CABG may be obtained by analyzing further studies involving a larger number of female patients.

Associations between social support and physical activity in postpartum: a Norwegian multi-ethnic cohort study

BACKGROUND

Social support is associated with higher self-reported physical activity (PA) in postpartum women, but it is unknown if similar association occur when using objective PA data. The aim was to explore the associations between social support and objectively recorded moderate-to-vigorous physical activity (MVPA) postpartum, and if associations differed across ethnic groups.

METHODS

We used data from 636 women who participated in the STORK Groruddalen cohort study (2008-2010). MVPA minutes/day in bouts of ≥ 10 minutes was recorded by SenseWear Armband™ Pro³ (SWA) over 7 days, 14 weeks postpartum. Social support for PA from family or friends was measured by a modified 12-item version of the Social Support for Exercise Scale. We used single items, family support mean score (6 items) and friends' support mean score (6-items) in four separate count models, and adjusted for SWA week, age, ethnicity, education, parity, body mass index and time since birth. We tested interactions between social support and ethnicity. Analyses were performed on complete cases and imputed data.

RESULTS

Based on imputed data, we observed that women who reported low and high support from family accumulated 16.2 (IQR: 6.1-39.1) and 18.6 (IQR: 5.0-46.5) MVPA minutes/day, respectively. Women who reported low and high support from friends accumulated 18.7 (IQR: 5.9-43.6) and 16.8 (IQR: 5.0-45.8) MVPA minutes/day. We observed a 12% increase in MVPA minutes/day for each additional increase in mean family support score (IRR = 1.12, 95% CI: 1.02 to 1.25). Women reporting high level of support from family on 'discuss PA', 'co-participation' and 'take over chores' accumulated 33%, 37% and 25% more MVPA minutes/day than women reporting low level of support respectively ('discuss PA': IRR = 1.33, 95% CI: 1.03 to 1.72, 'co-participation': IRR = 1.37, 95% CI: 1.13 to 1.66 and 'take over chores': IRR = 1.25, 95% CI: 1.02 to 1.54). Associations were not modified by ethnicity. No statistically significant association between support from friends and MVPA was observed. Similar results were found in complete case analyses, with a few exceptions.

CONCLUSION

Overall family support and specific forms of support from family were associated with MVPA across ethnic groups, while support from friends was not associated with MVPA postpartum.

Prognostic factors of adherence to home-based exercise therapy in patients with chronic diseases: A systematic review and meta-analysis

Background

Patients with a chronic disease may have an increased risk of non-adherence to prescribed home-based exercise therapy. We performed a systematic review with the aim to identify variables associated with adherence to home-based exercise therapy in patients with chronic diseases and to grade the quality of evidence for the association between these prognostic factors and adherence.

Methods

Cohort studies, cross-sectional studies and the experimental arm of randomized trials were identified using a search strategy applied to PubMed, Embase, PsychINFO and CINAHL from inception until August 1, 2022. We included studies with participants ≥18 years with a chronic disease as an indication for home-based exercise therapy and providing data on prognostic factors of adherence to home-based exercise. To structure the data, we categorized the identified prognostic factors into the five WHO-domains; (1) Patient-related, (2) Social/economic, (3) Therapy-related, (4) Condition-related, and (5) Health system factors. Risk of bias was assessed using the Quality in Prognostic Studies (QUIPS) tool. Prognostic factors of adherence were identified and the quality of the evidence between the prognostic factors and adherence were graded using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework for predictor studies. We performed a meta-analysis of the obtained information.

Results

A total of 57 studies were included. Within patient-related factors moderate- and high-quality evidence suggested that more self-efficacy, exercise history, motivation and perceived behavioral control predicted higher adherence. Within social-economic factors moderate-quality evidence suggested more education and physical health to be predictive of higher adherence and within condition-related factors moderate- and low-quality evidence suggested that less comorbidities, depression and fatigue predicted higher adherence. For the domains therapy-related and health-system factors there was not enough information to determine the quality evidence of the prognostic factors.

Conclusion

These findings might aid the development of future home-based exercise programs as well as the identification of individuals who may require extra support to benefit from prescribed home-based exercise therapy.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=277003, identifier PROSPERO CRD42021277003.

Health-related information needs and preferences for information of individuals with cardiovascular disease from underserved populations: A systematic review

OBJECTIVE

This systematic review aimed to identify the information needs and preferences of individuals with CVD from underserved populations.

METHODS

Five databases were searched from data inception to February 2022. Pilot and case report studies, non-peer-reviewed literature, and studies published in a language other than English, Portuguese, or Spanish were excluded. Structured and thematic analysis of all included studies were performed. The Critical Appraisal Skills Program and the Downs and Black Checklist were used to assess the quality of the qualitative and quantitative studies, respectively.

RESULTS

Of 35,698 initial records, 19 studies were included, most in observational design and classified as "fair" quality. Underserved populations - women, people living in rural areas, ethnic minority groups, older people, and those with low socioeconomic status - presented unique needs in four main groups, with some similarities across them: information about CVD, primary and secondary prevention of CVD, CVD management, and health care, policies and practices. Across the studies there was a lack of standardization on how individuals' needs were assessed and reported.

CONCLUSION

Underserved populations with CVD have unique information needs and preferences that should be address during their care.

PRACTICAL IMPLICATION

Information from this study may assist health care professionals with the development of comprehensive strategies to improve their provision of care for specific CVD patient groups.

Effects of 3 months of detraining following cardiac rehabilitation in patients with atrial fibrillation

Background

Atrial fibrillation negatively impacts physical fitness and health-related quality of life. We recently showed that 3 months of physiotherapist-led exercise-based cardiac rehabilitation improves physical fitness and muscle function in elderly patients with permanent atrial fibrillation and concomitant diseases. Little is, however, known about the consequences for physical fitness, physical activity level, and health-related quality of life after ending the rehabilitation period.

Methods

Prospective 3 months follow-up study of 38 patients out of 40 eligible (10 women) who, as part of a randomized controlled trial, had completed a 3 months physiotherapist-led cardiac rehabilitation resulting in improved physical fitness,. In the current study, the participants were instructed to refrain from exercise for 3 months after completion of the rehabilitation period. Primary outcome measure was physical fitness measured as highest achieved workload using an exercise tolerance test. Secondary outcome measures were muscle function (muscle endurance tests), physical activity level (questionnaire and accelerometer), and health-related quality of life, (Short Form-36), as in the preceding intervention study. We used the Wilcoxon Signed Rank test to analyse differences between the end of rehabilitation and at follow-up. The effect size was determined using Cohen’s d .

Results

Exercise capacity and exercise time significantly decresead between end of rehabilitation and at follow-up (p < .0001 for both). A significant reduction in shoulder flexion repetitions (p = .006) was observed as well as reduced health-related quality of life in the Short Form-36 dimensions Physical Function (p = .042), Mental Health (p = .030), and Mental Component Score (p = .035). There were, however, no changes regarding objective and subjective physical activity measurements.

Conclusion

In older patients with permanent atrial fibrillation, previously achieved improvements from physiotherapist-led exercise-based cardiac rehabilitation in physical fitness and muscle function were lost, and health-related quality of life was impaired after ending the rehabilitation period. A strategy for conserving improvements after a rehabilitation period is essential.

The role of anxiety sensitivity in exercise tolerance and anxiety and depressive symptoms among individuals seeking treatment in cardiopulmonary rehabilitation

The aim of the current cross-sectional study was to examine the effects of specific anxiety sensitivity (AS) dimensions (AS -Physical, -Cognitive, and -Social concerns) on exercise tolerance (i.e. 6-minute walk test) and factors that interfere with cardiopulmonary rehabilitation (CPR) and exercise adherence (i.e. depression and anxiety symptoms) among individuals seeking treatment in cardiopulmonary rehabilitation (CPR). Participants were 69 individuals (65.2% male, Mage = 63.60, SD = 12.55, Range = 27-85 years) with various cardiovascular or pulmonary conditions meeting criteria for CPR entry, who presented for an intake appointment at an outpatient phase 2 CPR clinic. Higher levels of AS-Physical and-Social concerns were significantly associated with poorer exercise tolerance and greater generalized anxiety symptoms, respectively. Though none of the AS dimensions were significant individual predictors, they were collectively associated with greater depressive symptoms. Future work should assess whether it may be useful to target AS in some patients prior to or throughout CPR.

A Systematic Review and Meta-analysis of the Outcome Expectancy Construct in Physical Activity Research

BACKGROUND

Cognition-based theories dominate physical activity (PA) research, and many include a construct broadly defined as "beliefs about the consequences of behavior" (e.g., outcome expectancies, perceived benefits) hereafter referred to as perceived consequences.

PURPOSE

With the quantity of available research on this topic, it is important to examine whether the literature supports perceived consequences as a predictor of PA.

METHODS

A meta-analysis examining longitudinal associations between perceived consequences and PA in adults was conducted. Studies were eligible if (a) perceived consequences were measured at a time point prior to PA, and (b) the target behavior was a form of PA. An omnibus meta-analysis estimating the mean effect of all included studies, and separate meta-analyses for perceived consequences content categories were conducted.

RESULTS

This search yielded 6,979 articles, of these, 110 studies met inclusion criteria. Studies were published between 1989 and 2020, with sample sizes ranging from 16 to 2,824. All studies were evaluated as moderate to high quality. A small positive bivariate association was identified (r = 0.11; 95% CI [0.09, 0.13]) between perceived consequences and PA. Significant associations were identified for time, health, self-evaluative, psychological, and affective consequences. There was no association between perceived weight-related consequences and PA.

CONCLUSIONS

The findings emphasize the variability with which existing studies have examined perceived consequences in the PA literature. Future research might examine whether these are important distinctions for understanding PA. Overall, the results suggest utility in examining perceived consequences as a predictor of PA, but constructs with more robust associations may require priority.

Impact of Musculoskeletal Limitations on Cardiac Rehabilitation Participation

Background: To help clarify a potential barrier to cardiac rehabilitation (CR) participation we sought to examine the association between musculoskeletal limitations (MSLs) and CR enrollment and participation. Methods: Consecutive CR eligible individuals hospitalized for a cardiac event (myocardial infarction, percutaneous coronary intervention, and/or coronary artery bypass graft) between the months of November 2007 and May 2008, were asked to complete a mailed survey within 2 weeks after hospital discharge, assessing demographic factors, Patient Health Questionnaire (PHQ-9), participation in CR and MSLs through a validated MSLs screening tool. CR enrollment rates were compared between patients with and without MSLs. Results: Three hundred and twenty-one (37%) of patients contacted responded to our survey, including 228 males (71%), with a mean age 68 ± 10.8 years, of whom 98% were Caucasian. Eighty-two percent of responders reported a musculoskeletal disorder at the time of hospital discharge. Arthritis was the most frequent diagnosis (45%). Muscle or joint pain sufficient to limit the ability to do moderate exercise was reported in 52% of the respondents. Problems with balance affected 37%, of whom 45% reported a fall within the previous year. No significant difference in CR enrollment was observed in respondents with and without MSLs [OR = 0.98, 95% CI (0.88-1.09), p = 0.750]. Similar results were found when severity and number of MSLs were taken into account. However, we found that when compared to those without MSLs, the presence of MSLs was associated with lower CR participation (OR = 0.80, 95%, CI: 0.65-0.97, p = 0.0252). Conclusion: Despite a high prevalence of MSLs among CR-eligible patients, we found no association between MSLs and CR enrollment. However, patients with MSLs attended significantly fewer CR sessions as compared to patients without them. CR programs should consider providing additional support and interventions to patients with MSLs in order to optimize their adherence to prescribed CR sessions.

Predictors of Exercise Maintenance 6 Months After Comprehensive Cardiac Rehabilitation

PURPOSE

The objectives of this study were (1) to assess the effects of a comprehensive education intervention on maintenance of knowledge, exercise behavior, heart-healthy food intake, self-efficacy, and health literacy 6 mo after comprehensive cardiac rehabilitation (CR), and (2) to identify predictors of exercise maintenance 6 mo after comprehensive CR.

METHODS

A prospective longitudinal study was conducted to test the effects of a structured educational curriculum in three CR programs in Canada. Participants completed surveys pre-, post-CR and 6 mo post-discharge to assess knowledge, heart-healthy food intake, self-efficacy, and health literacy. Exercise behavior was measured by number of steps/d using a pedometer.

RESULTS

One hundred twenty participants completed the final survey. Increases in disease-related knowledge and self-efficacy, as well as behavior changes (increases in exercise and heart-healthy food intake), were achieved in comprehensive CR and sustained 6 mo post-program. Exercise maintenance was predicted by changes in heart-healthy food intake, self-efficacy, health literacy, and exercise-related knowledge.

CONCLUSIONS

In this three-site study focusing on patient education for CR patients in Canada, the benefits of an education intervention in maintaining knowledge, exercise, healthy food intake, and self-efficacy were supported.

Heart up! RCT protocol to increase physical activity in cardiac patients who report hopelessness: Amended for the COVID-19 pandemic

Hopelessness is associated with decreased physical activity (PA) and increased adverse events and death in patients with ischemic heart disease (IHD). Rates of PA in patients with IHD continue to be low in both hospital-based cardiac rehabilitation and home settings. While researchers have investigated strategies to increase PA among patients with IHD, interventions to promote PA specifically in IHD patients who report hopelessness are lacking. We describe the protocol for a NIH-funded randomized controlled trial designed to establish the effectiveness of a 6-week intervention (Heart Up!) to promote increased PA in IHD patients who report hopelessness. Participants (n = 225) are randomized to one of three groups: (1) motivational social support (MSS) from a nurse, (2) MSS from a nurse plus significant other support (SOS), or (3) attention control. Aims are to: (1) test the effectiveness of 6 weeks of MSS and MSS with SOS on increasing mean minutes per day of moderate to vigorous PA; (2) determine the effects of change in moderate to vigorous PA on hopelessness; and (3) determine if perceived social support and motivation (exercise self-regulation) mediate the effects of the intervention on PA. A total of 69 participants have been enrolled to date. The protocol has been consistently and accurately used by research personnel. We address the protocol challenges presented by the COVID-19 pandemic and steps taken to maintain fidelity to the intervention. Findings from this study could transform care for IHD patients who report hopelessness by promoting self-management of important PA goals that can contribute to better health outcomes.

Influence of Affect on Physical Activity: An Integrative Review

Affective states, such as feelings of anger and excitement, are linked to health outcomes and behaviors. The benefits of physical activity for individual affect is known; however, how affect influences physical activity participation is less understood. Using Whittemore and Knafl's framework, this integrative review examines the influence of affect on adult physical activity. using six databases, 19 articles published between 1997 and 2019. Themes found include support for the influence of positive affect on increased physical activity, a temporal aspect of affect, a variety of measurement tools, and varying uses of theoretical frameworks across studies. Advanced practice nurses and registered nurses may improve patient health behaviors, such as physical activity, by incorporating affect-focused assessments. Review findings support consideration of affect in physical activity counseling. Further research using theory-driven methods and consistent affect assessments is needed to test the complex relationship between affect and physical activity.

Low 6-Minute Walk Distance and Muscle Mass Predict Drop out in Cardiac Rehabilitation

Cardiac rehabilitation after percutaneous coronary intervention decreases recurrence and mortality but has a high dropout rate. The aim of this study is to identify dropout predictors by comparing the characteristics of complete and dropout patients in cardiac rehabilitation. The study included 593 patients (455 men and 138 women) who received percutaneous coronary intervention and were enrolled in a 1-year cardiac rehabilitation program consisting of home-based cardiac rehabilitation with three center visits. Dropout was defined as participation in the first center visit but not the second or third center visits. Blood lipids, quality of life, socioeconomic status, and 6-minute walk distance measurements at the first visit were compared between participants who completed and dropped out of cardiac rehabilitation. For both men and women, the dropout rate significantly correlated with a low 6-minute walk distance and low muscle mass ratio. The dropout rate was significantly higher for men, but not women, with low education and low income. However, the dropout rate was decreased for women, but not men, with low blood pressure and triglycerides. An improved understanding of the characteristics of participants and the cardiac rehabilitation dropout rate are expected to contribute to the development of cardiac rehabilitation strategies that decrease patient dropout.

The Effectiveness of Interventions to Maintain Exercise and Physical Activity in Post-Cardiac Rehabilitation Populations: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

PURPOSE

Cardiac rehabilitation is a medically supervised program addressing health behavior changes and promoting self-management among individuals with heart disease. This includes initiation of regular physical activity. However, long-term physical activity after cardiac rehabilitation among this population remains a challenge.

METHODS

This study was a systematic review and meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Randomized controlled trials were identified by searching multiple databases and were selected if they evaluated an intervention with a physical activity or exercise component among individuals who completed cardiac rehabilitation. A descriptive synthesis was performed for all studies and means and standard deviations were used for meta-analysis when possible. Risk of bias, heterogeneity, and publication bias were assessed.

RESULTS

Twenty-five studies met the inclusion criteria and 19 were included in the meta-analysis. The mean age of participants across studies was 60 yr and 80% were male. Descriptive synthesis of the studies combined with meta-analysis results provided evidence of increased physical activity among intervention groups compared with control groups at follow-up.

CONCLUSION

There is evidence to support the effectiveness of interventions aimed at maintaining physical activity and exercise among adults who have completed cardiac rehabilitation.

The Added Value of a Behavioral Medicine Intervention in Physiotherapy on Adherence and Physical Fitness in Exercise-Based Cardiac Rehabilitation (ECRA): A Randomised, Controlled Trial

PURPOSE

Despite beneficial effects, adherence to exercise-based cardiac rehabilitation (exCR) is low in patients with coronary artery disease (CAD). The aim of this study was to investigate adherence to and the effects of a behavioral medicine intervention in physiotherapy (BMIP) added to routine exCR care on the primary outcome of physical fitness compared with routine exCR care.

PATIENTS AND METHODS

In a randomized, controlled trial, 170 patients with CAD (136 men), mean age 62.3 (7.9) years, were included at a Swedish university hospital. Patients were randomized 1:1 to routine exCR care (RC) or to a BMIP added to routine exCR care for four months, with a long-term follow-up at 12 months. The outcome assessment included submaximal aerobic exercise capacity, muscle endurance and self-reported physical activity and physical capacity.

RESULTS

The four-month follow-up showed improvements in all outcomes for both groups, but changes did not differ significantly between the groups. Patients in the BMIP group were more adherent to exCR recommendations compared with the RC group (31% vs 19%) and a non-significant tendency towards the maintenance of submaximal aerobic exercise capacity over time was seen in the BMIP group, whereas patients in the RC group appeared to deteriorate.

CONCLUSION

Both groups improved significantly at the four-month follow-up, while the 12-month follow-up showed a non-significant tendency towards better long-term effects on submaximal aerobic exercise capacity and exercise adherence for a BMIP compared with RC. In spite of this, a better understanding of the role of a BMIP in enhancing adherence is needed.

The effect of an expanded long-term periodization exercise training on physical fitness in patients with coronary artery disease: study protocol for a randomized controlled trial

Background

Benefits from cardiac rehabilitation (CR) programs are evidence-based and widely recognized. Less than 50% of people who participate in hospital-based CR programs maintain an exercise regime for as long as six months after completion. Little is known about interventions making the patients continue to exercise after the hospital-based formal program has ended. Methods to ensure sustained benefits of CR need to be tackled. Exercise periodization is a method typically used in sports training, but the impact of periodized exercise to yield optimal beneficial effects in cardiac patients is unclear. Therefore, the purpose of this trial is to evaluate the effects of a long-term exercise periodization on health-related physical fitness components such as cardiorespiratory endurance, muscular strength, skeletal muscle function, and body composition.

Methods

Fifty patients with coronary artery disease will be recruited among those who underwent the hospital-based CR phase. These patients will be randomized (1:1) into one of the following exercise groups: (1) periodized group; and (2) non-periodized group (exercise prescription based on standard guidelines). There will be four assessment time points: at baseline, and 3, 6, and 12 months after starting the exercise training program. At each time point, maximal and submaximal cardiorespiratory fitness, skeletal muscle deoxygenation dynamics, body composition by dual energy radiographic absorptiometry, functional fitness, maximal isometric and dynamic strength, physical activity, and quality of life will be assessed. This experimental design will last for 48 weeks with a frequency of three times per week for both groups.

Discussion

Most medium- to long-term exercise-based CR programs do not employ periodization or exercise progression. Randomized controlled trials are necessary to evaluate long-term periodization outcomes and assess the length of change observed in supervised CR programs. This study will contribute to generate evidence-based exercise prescription approaches to prolong the exercise training after the end of hospital-based CR programs.

Trial registration

ClinicalTrials.gov, NCT03335319. Registered on 22 October 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3292-9) contains supplementary material, which is available to authorized users.

Pre-Operative Frailty Status Is Associated with Cardiac Rehabilitation Completion: A Retrospective Cohort Study

While previous investigations have demonstrated the benefit of cardiac rehabilitation (CR) on outcomes after cardiac surgery, the association between pre-operative frailty and post-operative CR completion is unclear. The purpose of this retrospective cohort study was to determine if pre-operative frailty scores impacted CR completion post-operatively and if CR completion influenced frailty scores in 114 cardiac surgery patients. Frailty was assessed with the use of the Clinical Frailty Scale (CFS), the Modified Fried Criteria (MFC), the Short Physical Performance Battery (SPPB), and the Functional Frailty Index (FFI). A Mann-Whitney test was used to compare frailty scores between CR completers and non-completers and changes in frailty scores from baseline to 1-year post-operation. CR non-completers were more frail than CR completers at pre-operative baseline based on the CFS (p = 0.01), MFC (p < 0.001), SPPB (p = 0.007), and the FFI (p < 0.001). A change in frailty scores from baseline to 1-year post-operation was not detected in either group using any of the four frailty assessments. However, greater improvements from baseline to 1-year post-operation in two MFC domains (cognitive impairment and low physical activity) and the physical domain of the FFI were found in CR completers as compared to CR non-completers. These data suggest that pre-operative frailty assessments have the potential to identify participants who are less likely to attend and complete CR. The data also suggest that frailty assessment tools need further refinement, as physical domains of frailty function appear to be more sensitive to change following CR than other domains of frailty.

Coronary Artery Disease Patient Perspectives on Exercise Participation

PURPOSE

Participation in exercise programs postmyocardial infarction is highly protective against future events and mortality. Unfortunately, uptake and maintenance of exercise participation has been documented as being low. This is thought to be due to a myriad of barriers. Qualitative research is a powerful tool to explain behaviors. We sought to summarize existing qualitative literature exploring patient perspectives of participation in exercise after a cardiac event.

METHODS

We updated and built upon a previous systematic review and meta-synthesis by identifying qualitative literature that was not previously captured. We used grounded formal theory to synthesize the qualitative findings in the selected literature. This process led to the development of a comprehensive conceptual framework for understanding the determinants of exercise participation.

RESULTS

We found that external, internal, and cultural factors work together as umbrella themes to influence exercise initiation and continued participation in patients who have experienced a cardiac event. Internal factors expand into physical, cognitive, and emotional domains, which include fear, motivation, and mood. External factors include the domains of pragmatic and social considerations such as safety, accessibility, and social support networks. Cognitive and social domains were the most frequently cited factors influencing participation in exercise programs.

CONCLUSIONS

The framework we outline allows for a more complete understanding of the factors that influence the exercise behaviors of patients with coronary artery disease. Cardiac rehabilitation programs should consider the key factors and capitalize on this knowledge, making these facilitators rather than barriers to exercise participation.

"As du Coeur" study: a randomized controlled trial on physical activity maintenance in cardiovascular patients

Background

The benefits of supervised physical activity programs in cardiac rehabilitation have been amply demonstrated, but the quantity of physical activity often declines quickly once supervision ends. This trial assesses the effectiveness of an experimental intervention drawing on habit formation theory to maintain physical activity.

Methods

Cardiovascular patients (N = 47) were randomly assigned to one of two groups. The first group participated in two supervised physical activity (SPA) sessions per week for 20 weeks. The second group was offered a progressively autonomous physical activity (PAPA) program as follows: the same supervised program as the SPA group for 10 weeks and then a further 10 weeks with one supervised session replaced by a strategy to build and sustain the habit of autonomous physical activity. The International Physical Activity Questionnaire (IPAQ; Craig et al. Med Sci Sports Exerc 35(8):1381–1395, 2003) was used to measure the quantity of physical activity, which was the primary outcome. The number of participants was limited, and we thus took multiple IPAQ measurements (at 0, 5, 7, 9 and 12 months after the start of the intervention) and used a mixed model for analysis. Physical condition, automaticity of the physical activity behavior, motivation, and quality of life were examined for changes.

Results

No significant between-group differences were noted for physical activity behaviors after the program, physical condition, motivation, or behavioral automaticity. The PAPA group nevertheless completed more PA sessions during the intervention, and their quality of life was significantly higher than that of the SPA group at 12 months.

Conclusion

Although the number of supervised sessions was lower, the progressively autonomous PA program resulted in the same or even higher positive outcomes than the fully supervised PA program.

Trial registration

Current Controlled Trials ISRCTN77313697, retrospectively registered on 20 November 2015.

MedFit App, a Behavior-Changing, Theoretically Informed Mobile App for Patient Self-Management of Cardiovascular Disease: User-Centered Development

Background

The MedFit app is designed to facilitate participation of people with cardiovascular disease (CVD) in an exercise-based rehabilitation program remotely. This paper details the development for the MedFit app.

Objective

The aim of this research was to develop a behavior change, theoretically informed exercise rehabilitation mobile app for adults with CVD by following the early stages of the formative research: development and feasibility testing.

Methods

Adhering to the mobile health (mHealth) development evaluation framework, the stages of the formative research process including (1) development and (2) feasibility were undertaken. The content and format of the MedFit app were developed based on (1) theory, (2) usability testing, and (3) content design.

Results

A systematic review of the literature was undertaken to identify the most appropriate theories from which to develop the app. This led to the creation of the MedFit app. The app went through iterative rounds of usability focus group testing with adults with CVD to provide feedback on the app. This process was framed by the unified theory of acceptance and use of technology model. Feedback was then translated into feasible technical improvements to be executed through close collaboration with the technical team, who adapted and made modifications to the app based on this codesign process.

Conclusions

The formative research process of the app development involved theoretical underpinning, usability testing, and content design. mHealth interventions may play a key role in the future of health care, potentially addressing the barriers to participation in cardiac rehabilitation. This work will provide guidance for future research aiming to develop mobile apps by incorporating a best practice framework for mHealth intervention development and a user-centered design approach.

Impact of Obesity and Other Chronic Conditions on Lifestyle Exercise During the Year After Completion of Cardiac Rehabilitation

PURPOSE

Patients who attend cardiac rehabilitation programs have a high prevalence of multiple chronic conditions (MCCs). The extent to which different constellations of MCC influence lifestyle exercise in the year after completion of an outpatient phase 2 cardiac rehabilitation program (CRP) is unknown. Our objective was to examine the effects of MCC on lifestyle exercise in the year after completion of a CRP.

METHODS

The effects of different constellations of comorbidities on objectively measured lifestyle exercise were examined using data from a randomized controlled trial testing lifestyle behavior change interventions in patients with cardiac events (n = 379) who completed a phase 2 CRP. Adjusting for important covariates, the relationships between the primary outcome, exercise amount, and the presence of common chronic conditions (hypertension, obesity, diabetes, and arthritis) were studied using robust linear mixed-effects models.

RESULTS

Diabetes, hypertension, obesity, and their dyads, triads, and quads have a negative impact on amount of exercise. For example, the cooccurrences of obesity and hypertension reduced lifestyle exercise by 2.83 hours per month (95% CI, 1.33-4.33) after adjustment for the effects of covariates. The presence of obesity was a major factor in the comorbid constellations affecting lifestyle exercise.

CONCLUSIONS

The presence of obesity and other chronic conditions negatively impacts lifestyle exercise in the year after a CRP. The magnitude of the effect depends on the comorbidities. Different constellations of comorbid conditions can be used to identify those persons at greatest risk for not exercising after cardiac rehabilitation.

[Cardiac rehabilitation in women]

Coronary artery disease (CAD) occurs later in life in women when compared to men (10 years later). The FAST-MI study has shown that the profile of women with CAD has changed in the past 15 years, they are younger, more obese, and usually smokers. Whatever the age at which CAD occurs in women, the prognosis tends to be worse than in men, despite a higher frequency of acute coronary syndrome (ACS) with angiographically normal coronary arteries in women. In women without significant lesion at coronary angiography, the WISE study has shown abnormalities of the coronary vasomotricy. Despite its beneficial effect on morbidity and mortality, cardiac rehabilitation is underused particularly in women. Indeed, several factors do not encourage a woman to follow a cardiac rehabilitation program, even after an ACS. These factors may be cultural, domestic, familial, orthopedic, or even the fear of exercising. Therefore, physicians have to be particularly convincing in women, in order to have them participating in rehabilitation programs. Physical capacity is lower in women when compared to men. However, the weaker the physical capacity, the better the benefit of cardiac rehabilitation. Physical endurance training continuously or in interval, associated to muscle strengthening can improve the physical capacity in women. Vascular risk factors correction is also an important step for the management of women with CAD. Therapeutic education and several available workshops help women to better understand their disease and to improve their self-management when they return home. Anxiety, depression, and sexual dysfunction frequently deteriorate the quality of life of our patients. Therefore, psychological management is also essential in our departments.

Why are adult women physically active? A systematic review of prospective cohort studies to identify intrapersonal, social environmental and physical environmental determinants

OBJECTIVE

This study aims to systematically review available evidence from prospective cohort studies to identify intrapersonal, social environmental and physical environmental determinants of moderate-to-vigorous intensity physical activity (MVPA) among working-age women.

METHODS

Six databases were searched to identify all prospective cohort studies that reported on intrapersonal (e.g. self-efficacy and socioeconomic status [SES]), social (e.g. crime, area SES and social support) and/or physical (e.g. weather, work and recreation) environmental determinants of MVPA in working-age (mean 18-65 years) women. A qualitative synthesis including harvest plots was completed.

PROSPERO

CRD42014009750 RESULTS: Searching identified 17,387 potential articles; 97 were used in the analysis. The majority (n = 87 studies) reported on ≥1 intrapersonal determinant. Very few (n = 34) examined factors in the social or physical environments, and none looked at social policy. Positive and consistent influencers included higher self-efficacy (n = 18/23), self-rated health (n = 8/13) and intentions (n = 10/11) and perceived behavioural control (n = 5/7) to be physically active. Having children in the household was negatively related to MVPA (n = 9/15).

CONCLUSIONS

Physical activity intervention studies should consider a woman's level of self-efficacy and perceived behavioural control to be physically active. Additional studies are needed on the impact of children in the household, having a spouse/partner and using group goal setting. More evidence is needed to evaluate the impact of environmental factors.

Gender-specific issues in cardiac rehabilitation: do women with ischaemic heart disease need specially tailored programmes?

Ischaemic heart disease (IHD) has changed from a disease of middle-aged men in the late 1970s to a disease of elderly women in the 2000s. Most clinical studies during the past three decades have been conducted with men. Cardiac rehabilitation programmes were also developed with special regard to improving the rate of return to work in middle-aged men. The rehabilitation needs of older patients and women in particular have been largely neglected. The aim of this review is briefly to outline our present knowledge on gender issues in cardiac rehabilitation, and to specify barriers with regard to physical activities especially in (older) women. Coping with a cardiac event, women tend to minimize or play down the impact of their health situation and avoid burdening their social contacts. After a first cardiac event, women report greater psychological distress and lower self-efficacy and self-esteem. In addition, older age, lower exercise levels and reduced functional capacity or co-morbid conditions such as osteoporosis and urinary incontinence are barriers to physical activities in women with IHD. Recent studies on psychosocial intervention revealed less favourable results in women compared with men. These findings have not yet been well explained. This emphasizes our current lack of knowledge about the processes and determinants of successful psychosocial interventions in men and women with IHD. A large (European) trial on gender-specific coping styles, needs, and preferences of older women, and the effects of psychosocial intervention is proposed.

Protocol of the "As du Coeur" study: a randomized controlled trial on physical activity maintenance in cardiovascular patients

BACKGROUND

Although the benefits of supervised physical activity programs in cardiac rehabilitation have been well documented, the amount of physical activity often drops quickly after the end of the supervised period. This trial (registered as ISRCTN77313697 ) will evaluate the effectiveness of an experimental intervention based on habit formation theory applied to physical activity maintenance.

METHODS/DESIGN

Cardiovascular patients (N = 56) will be individually randomized into two groups. Two supervised physical activity (SPA) sessions per week will be offered to the first group for 20 weeks. Progressively autonomous physical activity (PAPA) will be offered to the second group as follows: 10 weeks of the same supervised program as the SPA group followed by 10 more weeks in which one supervised session will be replaced by a strategy to build and sustain the habit of autonomous practice of physical activity. The primary outcome is the amount of physical activity measured by the International Physical Activity Questionnaire (IPAQ; Craig et al., Med Sci Sport Exercises 35(8):1381-95, 2003). To compensate for the limited capacity to recruit subjects, multiple IPAQ measurements will be made (at T0, T5, T7, T9 and T12 months after the start of the intervention) and analyzed using the mixed model approach. We will also assess changes in physical and physiological indicators, automaticity of the physical activity behavior, motivation and quality of life. Last, we will assess the cost-effectiveness for each type of program.

DISCUSSION

If proven to be effective, the PAPA intervention, which requires fewer supervised sessions, should provide a cost-effective solution to the problem of physical activity maintenance in cardiac rehabilitation.

Ecologically optimizing exercise maintenance in men and women post-cardiac rehabilitation: Protocol for a randomized controlled trial of efficacy with economics (ECO-PCR)

BACKGROUND

Exercise-based cardiac rehabilitation (CR) participation results in increased cardio-metabolic fitness, which is associated with reduced mortality. However, many graduates fail to maintain exercise post-program. ECO-PCR investigates the efficacy and cost-effectiveness of a social ecologically-based intervention to increase long-term exercise maintenance following the completion of CR.

METHODS/DESIGN

A three-site, 2-group, parallel randomized controlled trial is underway. 412 male and 192 female (N=604) supervised CR participants are being recruited just before CR graduation. Participants are randomized (1:1 concealed allocation) to intervention or usual care. A 50-week exercise facilitator intervention has been designed to assist CR graduates in the transition from structured, supervised exercise to self-managed home- or community-based (e.g., Heart Wise Exercise programs) exercise. The intervention consists of 8 telephone contacts over the 50week period: 3 individual and 5 group. Assessments occur at CR graduation, and 26, 52 and 78weeks post-randomization. The primary outcome is change in minutes of accelerometer-measured moderate to vigorous-intensity physical activity (MVPA) from CR graduation to 52weeks post-randomization. Secondary measures include exercise capacity, quality of life, and cardiovascular risk factors. Analyses will be undertaken based on intention-to-treat. For the primary outcome, an analysis of variance will be computed to test the change in minutes of MVPA in each group between CR graduation and 52week follow-up (2 [arm]×2 [time]). Secondary objectives will be assessed using mixed-model repeated measures analyses to compare differences between groups over time. Mean costs and quality-adjusted life years for each arm will be estimated.

Women's Social Support and Social Network after Their First Myocardial Infarction; A 4-Year Follow-Up with Focus on Cardiac Rehabilitation

Background: Knowledge about women's recovery following a myocardial infarction (MI) with focus on how their social support and network change over time as a result of participation in a cardiac rehabilitation programme (CRP) is not well established.

Aim: The aim of this study was to describe and compare social support and network changes over a 4-year period in women with a first MI, based on socio-demographic and situational data.

Method: A longitudinal, comparative study with a non-randomised design including pre- and post-tests (1 and 4 years after MI) was carried out in 18 hospitals in Sweden. Consecutively chosen women ( N = 240) answered a questionnaire on the subject of social support and network.

Results: The women who participated in a CRP were mainly dependent upon professional support during the first year after MI ( p < 0.0001), while those who declined to participate in a CRP needed professional support throughout the whole 4-year period ( p = 0.001). Participation in CRP was dependent on the women's age, those under 60 years ( p = 0.050).

Conclusion: There is a need to develop CRPs that are specifically designed for women based on their age and family relationships. Nurses' training programmes should place greater emphasis on cardiac rehabilitation from the perspective of women with focus on professional support.

Usefulness of Cardiac Rehabilitation After Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of myocardial infarction; however, the role of cardiac rehabilitation (CR) for patients with SCAD has not been well defined. To further understand CR in patients with SCAD, we studied a large cohort of patients with confirmed SCAD enrolled in the Mayo Clinic SCAD Registry from January 2010 to December 2014 (n = 354). Demographics, clinical characteristics, mental health status, and details about CR participation and experience were collected through medical record review and questionnaires. Participants at time of SCAD were 46 ± 10 years old; 96% were women. Most (76%) attended ≥1 CR sessions, averaging 18 ± 12 sessions. Most reported CR-related physical and emotional benefits (82% and 75%, respectively). Of the CR nonparticipants, 57 of 85 reported not participating because CR was not recommended by their health care provider. Other reasons included inadequate transportation (10 of 85), no insurance coverage (7 of 85), cost (2 of 85), no energy (2 of 85), being too ill (2 of 85), and miscellaneous comments (5 of 85). In conclusion, 3 of 4 of patients with SCAD participated in CR, most of whom reported benefit. Lack of recommendation for CR by a health care provider was the primary reason patients did not participate.

Utilization of a free fitness center-based exercise referral program among women with chronic disease risk factors

Physical activity (PA) reduces the risk for a number of chronic diseases including heart disease, hypertension, hyperlipidemia, and diabetes mellitus type 2. However, most Americans do not meet expert recommendations for exercise, and minorities and low-income persons are the most inactive. Community-based approaches to promoting PA include primary care exercise referral programs. This study examines patient characteristics associated with utilization of a community health center-based exercise referral program. Adult female patients of a community health center with an affiliated fitness center, in Boston, MA, were included in the study if they received a referral to the fitness center from their primary care provider. Demographic and medical information was abstracted from the medical chart, and fitness records were abstracted to measure activation of a fitness center membership (creation of an account denoting at least an initial visit) and utilization over time. Overall, 503 (40%) of the 1,254 referred women in the study sample activated their membership. Black women were almost 60% more likely to activate their membership (adjusted OR 1.6, 95% CI 1.2-2.2), and women with higher co-morbidity counts were almost 45% more likely to activate (adjusted OR 1.4, 95% CI 1.0-2.0). Once activated, a minority of women participated at levels likely to improve cardiometabolic fitness. Of the 503 activations, 96 (19%) had no participation, 359 (71%) had low participation, and only 48 (10%) had high participation. No independent predictors of participation were identified. These findings suggest that program design may benefit from developing activation, initial participation, and retention strategies that address population-specific barriers.

Application of the Transtheoretical Model to Exercise Behavior and Physical Activity in Patients after Open Heart Surgery

PURPOSE

To assess exercise behavior and physical activity levels after open heart surgery.

METHODS

This prospective cohort study included 130 patients (70.8% male, aged 61.0 ± 12.2 years, 53.8% coronary bypass grafting) who underwent open heart surgery. The exercise behavior and physical activity of these patients were assessed at the 3- and 6-month follow-up appointments. Additional interviews were also conducted to further assess exercise behavior. Physical activity duration and metabolic equivalents were calculated from self-reported questionnaire responses. Moreover, possible related demographic factors, clinical features, participation in cardiac rehabilitation programs, and physical activity levels were additionally evaluated.

RESULTS

Six months after hospital discharge, most patients were in the action (39.2%) and maintenance (37.7%) stages. Other subjects were in the precontemplation (11.5%), contemplation (5.4%), and preparation (6.2%) stages. The average physical activity level was 332.6 ± 377.1 min/week and 1198.1 ± 1396.9 KJ/week. Subjects in the action and maintenance stages exercised an average of 399.4 ± 397.6 min/week, significantly longer than those in other stages (116.2 ± 176.2 min/week, p = 0.02). Subjects that participated in outpatient cardiac rehabilitation programs after discharge may have the better exercise habit. Gender had no significant effect on exercise behavior 6 months after hospital discharge.

CONCLUSIONS

Most subjects following open heart surgery may maintain regular exercise behavior at 6 months after hospital discharge. Physical activity levels sufficient for cardiac health were achieved by subjects in the active and maintenance stages. Outpatient cardiac rehabilitation programs are valuable for encouraging exercise behavior after heart surgery.

KEY WORDS

Exercise behavior; Open heart surgery; Physical activity; Transtheoretical model.

Telehealth exercise-based cardiac rehabilitation: a systematic review and meta-analysis

OBJECTIVE

Despite proven effectiveness, participation in traditional supervised exercise-based cardiac rehabilitation (exCR) remains low. Telehealth interventions that use information and communication technologies to enable remote exCR programme delivery can overcome common access barriers while preserving clinical supervision and individualised exercise prescription. This meta-analysis aimed to determine the benefits of telehealth exCR on exercise capacity and other modifiable cardiovascular risk factors compared with traditional exCR and usual care, among patients with coronary heart disease (CHD).

METHODS

CINAHL, The Cochrane Library, Embase, MEDLINE, PubMed and PsycINFO were searched from inception through 31 May 2015 for randomised controlled trials comparing telehealth exCR with centre-based exCR or usual care among patients with CHD. Outcomes included maximal aerobic exercise capacity, modifiable cardiovascular risk factors and exercise adherence.

RESULTS

11 trials (n=1189) met eligibility criteria and were included in the review. Physical activity level was higher following telehealth exCR than after usual care. Compared with centre-based exCR, telehealth exCR was more effective for enhancing physical activity level, exercise adherence, diastolic blood pressure and low-density lipoprotein cholesterol. Telehealth and centre-based exCR were comparably effective for improving maximal aerobic exercise capacity and other modifiable cardiovascular risk factors.

CONCLUSIONS

Telehealth exCR appears to be at least as effective as centre-based exCR for improving modifiable cardiovascular risk factors and functional capacity, and could enhance exCR utilisation by providing additional options for patients who cannot attend centre-based exCR. Telehealth exCR must now capitalise on technological advances to provide more comprehensive, responsive and interactive interventions.

Evaluating the Heart Wise Exercise™ program: a model for safe community exercise programming

Background

Greater availability of community exercise facilities is recommended to promote physical activity in the large number of people with chronic disease. The Heart Wise Exercise (HWE) program encourages existing community-based exercise facilities to build capacity to serve such patients, by working with interested facilities to ensure they meet safety criteria, and educating exercise leaders.

Methods

Using a piloted checklist, 45 HWE programs were audited for the six HWE criteria (outlined below) in the greater Ottawa and Toronto areas of Ontario, Canada. A survey was also administered to a convenience sample of HWE program participants (N = 127).

Results

Criteria 1: 71 % of leaders encouraged daily aerobic exercise; participants reported engaging in 194 min/week of aerobic exercise. Criteria 2: 100 % of programs incorporated a warm-up and cool-down, and 84 % encouraged self-monitoring during class. Criteria 3: 98 % of programs offered options for participants to exercise at their appropriate intensity. Criteria 4: HWE participants reported having chronic conditions including arthritis (41 %), osteoporosis (26 %) diabetes (8 %), heart disease (6 %) and chronic obstructive pulmonary disease (6 %). Criteria 5: 93 % of instructors offered health screening for participants. Criteria 6: 100 % of sites had automated external defibrillators, and 90 % of the instructors were aware of the documented emergency plan. The exercise leaders reported being ‘knowledgeable/comfortable/confident’ in providing exercise guidance to, and having clients with chronic health conditions; directing clients to other services; offering exercise intensity options; helping clients listen to their bodies; and, encouraging clients to provide information regarding their health. The participants reported being, on average, ‘somewhat happy’ to ‘very happy’ with HWE locations; program dates and times; leaders’ knowledge of disease and exercise; exercise intensity; cost; and, social aspect.

Conclusions

HWE programs are safe and appropriate for persons with varying chronic health conditions, and participants are satisfied with and will likely continue attending their HWE classes. Future efforts should be directed at increasing awareness of HWE programs among referring healthcare professionals and participants at risk of chronic conditions. The HWE training program should emphasize that HWE leaders regularly encourage self-monitoring and daily aerobic exercise, which is well-known to reduce the burden of many chronic diseases.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-2866-7) contains supplementary material, which is available to authorized users.

Environmental Resources in Maintenance of Physical Activity 6 Months Following Cardiac Rehabilitation

This study examined differences in weekly time spent in physical activity by level of perceived environmental resources, 6 months following graduation from cardiac rehabilitation. A descriptive, longitudinal design used standardized measures to evaluate perceived environmental resources and physical activity levels. Repeated measures analysis of variance was used to examine mean differences in weekly time spent in physical activity by level of perceived environmental resources. Adults 51 to 86 years old (N = 150) diagnosed with coronary heart disease were included. There was a significant change over time in physical activity as measured by minutes per week, F(2, 148) = 7.915, p = .001, where activity increased between baseline and 3 months, and then dropped slightly at 6 months. This change over time differed by the level of perceived neighborhood resources, F(2, 148) = 3.545, p = .032. Home and neighborhood resources may positively influence physical activity maintenance following cardiac rehabilitation.

Using Visual Methods to Understand Physical Activity Maintenance following Cardiac Rehabilitation

Few studies have explored the factors associated with long-term maintenance of exercise following cardiac rehabilitation. The present study used auto-photography and interviews to explore the factors that influence motivation and continued participation in physical activity among post cardiac rehabilitation patients. Twenty-three semi-structured interviews were conducted alongside participant-selected photographs or drawings with participants that had continued participation in physical activity for at least two years following the cardiac rehabilitation programme. Participants were recruited from circuit training classes in East Sussex in the UK. Thematic content analysis revealed seven main themes: fear of death and ill health avoidance, critical incidents, overcoming aging, social influences, being able to enjoy life, provision of routine and structure, enjoyment and psychological well-being. Fear of death, illness avoidance, overcoming aging, and being able to enjoy life were powerful motives for continued participation in exercise. The social nature of the exercise class was also identified as a key facilitator of continued participation. Group-based exercise suited those that continued exercise participation post cardiac rehabilitation and fostered adherence.

Long-term Exercise Adherence After High-intensity Interval Training in Cardiac Rehabilitation: A Randomized Study

BACKGROUND AND PURPOSE

Exercise adherence in general is reported to be problematic after cardiac rehabilitation. Additionally, vigorous exercise is associated with impaired exercise adherence. As high-intensity interval training (HIT) is frequently used as a therapy to patients with coronary artery disease in cardiac rehabilitation, the objective was to assess long-term exercise adherence following an HIT cardiac rehabilitation programme.

METHODS

A multicentre randomized study was carried out. Eligible participants were adults who had previously attended a 12-week HIT cardiac rehabilitation programme, as either a home-based or hospital-based HIT (treadmill exercise or group exercise). The primary outcome was change in peak oxygen uptake; secondary outcomes were self-reported and objectively measured physical activity.

RESULTS

Out of 83 eligible participants, 76 were available for assessment (68 men/8 women, mean age 59 (8) years) at a one-year follow-up. Peak oxygen uptake was significantly elevated above baseline values, (treadmill exercise: 35.8 (6.4) vs. 37.4 (7.4) ml kg(-1)  min(-1) , group exercise: 32.7 (6.5) vs. 34.1 (5.8) ml kg(-1)  min(-1) and home-based exercise: 34.5 (4.9) vs. 36.7 (5.8) ml kg(-1)  min(-1) at baseline and follow-up, respectively), with no significant differences between groups. The majority of the participants (>90%) met the recommended daily level of 30 minutes of moderate physical activity. The home-based group showed a strong trend towards increased physical activity compared with the hospital-based groups.

DISCUSSION

The results from this study have shown that both home-based and hospital-based HIT in cardiac rehabilitation induce promising long-term exercise adherence, with maintenance of peak oxygen uptake significantly above baseline values at a one-year follow-up. The implication for physiotherapy practice is that HIT in cardiac rehabilitation induces satisfactory long-term exercise adherence.

Cardiac rehabilitation for people with heart disease: an overview of Cochrane systematic reviews

BACKGROUND

Overviews are a new approach to summarising evidence and synthesising results from related systematic reviews.

OBJECTIVES

To conduct an overview of Cochrane systematic reviews to provide a contemporary review of the evidence for delivery of cardiac rehabilitation, to identify opportunities for merging or splitting existing Cochrane reviews, and to identify current evidence gaps to inform new cardiac rehabilitation systematic review titles.

METHODS

We searched The Cochrane Database of Systematic Reviews (2014, Issue 10) to identify systematic reviews that addressed the objectives of this overview. We assessed the quality of included reviews using the Revised Assessment of Multiple Systematic Reviews (R-AMSTAR) measurement tool and the quality of the evidence for reported outcomes using the GRADE framework. The focus of the data presentation was descriptive with detailed tabular presentations of review level and trial level characteristics and results.

MAIN RESULTS

We found six Cochrane systematic reviews and judged them to be of high methodological quality. They included 148 randomised controlled trials (RCTs) in 98,093 participants. Compared with usual care alone, the addition of exercise-based cardiac rehabilitation in low-risk people after myocardial infarction or percutaneous coronary intervention or with heart failure appeared to have no impact on mortality, but did reduce hospital admissions and improved health-related quality of life. Psychological- and education-based interventions alone appeared to have little or no impact on mortality or morbidity but may have improved health-related quality of life. Home- and centre-based programmes were equally effective in improving quality of life outcomes at similar healthcare costs. Selected interventions can increase the uptake of cardiac rehabilitation programmes whilst there is currently only weak evidence to support interventions that improve adherence to cardiac rehabilitation programmes. The quality of the primary RCTs in the included systematic reviews was variable, and limitations in the methodological quality of the RCTs led to downgrading of the quality of the evidence, which varied widely by review and by outcome.

AUTHORS' CONCLUSIONS

Exercise-based cardiac rehabilitation is an effective and safe therapy to be used in the management of clinically stable people following myocardial infarction or percutaneous coronary intervention or who have heart failure. Future RCTs of cardiac rehabilitation need to improve their reporting methods and reflect the real world practice better including the recruitment of higher risk people and consideration of contemporary models of cardiac rehabilitation delivery, and identify effective interventions for enhancing adherence to rehabilitation.

The remote exercise monitoring trial for exercise-based cardiac rehabilitation (REMOTE-CR): a randomised controlled trial protocol

BACKGROUND

Exercise is an essential component of contemporary cardiac rehabilitation programs for the secondary prevention of coronary heart disease. Despite the benefits associated with regular exercise, adherence with supervised exercise-based cardiac rehabilitation remains low. Increasingly powerful mobile technologies, such as smartphones and wireless physiological sensors, may extend the capability of exercise-based cardiac rehabilitation by enabling real-time exercise monitoring for those with coronary heart disease. This study compares the effectiveness of technology-assisted, home-based, remote monitored exercise-based cardiac rehabilitation (REMOTE) to standard supervised exercise-based cardiac rehabilitation in New Zealand adults with a diagnosis of coronary heart disease.

METHODS/DESIGN

A two-arm, parallel, non-inferiority, randomised controlled trial will be conducted at two sites in New Zealand. One hundred and sixty two participants will be randomised at a 1:1 ratio to receive a 12-week program of technology-assisted, home-based, remote monitored exercise-based cardiac rehabilitation (intervention), or an 8-12 program of standard supervised exercise-based cardiac rehabilitation (control).The primary outcome is post-treatment maximal oxygen uptake (V̇O2max). Secondary outcomes include cardiovascular risk factors (blood lipid and glucose concentrations, blood pressure, anthropometry), self-efficacy, intentions and motivation to be active, objectively measured physical activity, self-reported leisure time exercise and health-related quality of life. Cost information will also be collected to compare the two modes of delivery. All outcomes are assessed at baseline, post-treatment, and 6 months, except for V̇O2max, blood lipid and glucose concentrations, which are assessed at baseline and post-treatment only.

DISCUSSION

This novel study will compare the effectiveness of technology-supported exercise-based cardiac rehabilitation to a traditional supervised approach. If the REMOTE program proves to be as effective as traditional cardiac rehabilitation, it has potential to augment current practice by increasing access for those who cannot utilise existing services.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials RegistryStudy ID number: ACTRN12614000843651. Registered 7 August 2014.

Correlates of objectively measured physical activity in cardiac patients

Cardiac patients would benefit from increasing their physical activity (PA) levels. Understanding of factors that influence cardiac patients' PA participation would benefit the development of effective interventions. Therefore, the purpose of this study was to determine correlates of objectively-measured PA in cardiac patients. Participants were 65 cardiac patients (74% male, 95% white), age 58.6±10.6 years. The amount of time spent in PA was measured by ActiGraph GT3X accelerometers for 7 days prior to joining cardiac rehabilitation programs (CRP). A total of 25 potential determinants of PA across multiple domains (demographic, clinical, psychosocial, and behavioral) were measured via self-reported questionnaire and clinical examinations. Backward elimination model selection procedures were performed to examine associations of potential determinants with total PA (min/day) and moderate-to-vigorous PA (MVPA) (min/day). Patients spent 153.8±62.8 and 8.4±8.1 min/day in total PA and MVPA, respectively. Across four domains, ten and five potential correlates were found to be significant in univariate analyses for MVPA and total PA, respectively. In the final model, functional capacity, PA readiness, and participation in regular exercise were positively associated with MVPA (R(2) =26.6%). Functional capacity and PA readiness were also positively associated with total PA (R(2) =15.9%). Future initiatives to increase PA levels in cardiac patients could be improved by considering patients' functional capacity, PA readiness, and exercise history in designing interventions.

Promoting patient uptake and adherence in cardiac rehabilitation

BACKGROUND

Cardiac rehabilitation is an important component of recovery from coronary events but uptake and adherence to such programs are below recommended levels. In 2010, our Cochrane review identified some evidence that interventions to increase uptake of cardiac rehabilitation can be effective but there was insufficient evidence to provide recommendations on intervention to increase adherence. In this review, we update the previously published Cochrane review.

OBJECTIVES

To determine the effects, both harms and benefits, of interventions to increase patient uptake of, or adherence to, cardiac rehabilitation.

SEARCH METHODS

We performed an updated search in January 2013 to identify studies published after publication of the previous systematic review. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 12, 2012), MEDLINE (Ovid), EMBASE (Ovid), CINAHL EBSCO, Conference Proceedings Citation Index - Science (CPCI-S) on Web of Science (Thomson Reuters), and National Health Service (NHS) Centre for Reviews and Dissemination (CRD) databases (Health Technology Assessment (HTA) and Database of Abstracts of Reviews of Effects (DARE)) on The Cochrane Library (Issue 4, 2012). We also checked reference lists of identified systematic reviews and randomised controlled trials (RCTs) for additional studies. We applied no language restrictions.

SELECTION CRITERIA

Adults with myocardial infarction, coronary artery bypass graft, percutaneous transluminal coronary angioplasty, heart failure, angina, or coronary heart disease eligible for cardiac rehabilitation and RCTs or quasi-randomized trials of interventions to increase uptake or adherence to cardiac rehabilitation or any of its component parts. We only included studies reporting a primary outcome.

DATA COLLECTION AND ANALYSIS

At least three authors independently screened titles and abstracts of all identified references for eligibility and obtained full papers of potentially relevant trials. At least two authors checked the selection. Three authors assessed included studies for risk of bias.

MAIN RESULTS

The updated search identified seven new studies (880 participants) of interventions to improve uptake of cardiac rehabilitation and one new study (260 participants) of interventions to increase adherence. When added to the previous version of this review, we included 18 studies (2505 participants), 10 studies (1338 participants) of interventions to improve uptake of cardiac rehabilitation and eight studies (1167 participants) of interventions to increase adherence. We assessed the majority of studies as having high or unclear risk of bias. Meta-analysis was not possible due to multiple sources of heterogeneity. Eight of 10 studies demonstrated increased uptake of cardiac rehabilitation. Successful interventions to improve uptake of cardiac rehabilitation included: structured nurse- or therapist-led contacts, early appointments after discharge, motivational letters, gender-specific programs, and intermediate phase programs for older patients. Three of eight studies demonstrated improvement in adherence to cardiac rehabilitation. Successful interventions included: self monitoring of activity, action planning, and tailored counselling by cardiac rehabilitation staff. Data were limited on mortality and morbidity but did not demonstrate a difference in cardiovascular events or mortality except for one study that noted an increased rate of revascularization in the intervention group. None of the studies found a difference in health-related quality of life and there was no evidence of adverse events. No studies reported on costs or healthcare utilization.

AUTHORS' CONCLUSIONS

We found only weak evidence to suggest that interventions to increase the uptake of cardiac rehabilitation are effective. Practice recommendations for increasing adherence to cardiac rehabilitation cannot be made. Interventions targeting patient-identified barriers may increase the likelihood of success. Further high-quality research is still needed. 

A qualitative descriptive study of risk reduction for coronary disease among the Hong Kong Chinese

OBJECTIVES

Achieving optimal control and reduction in coronary heart disease (CHD) risks in Hong Kong (HK) remains significant and requires exploring. This article addresses the ability to reduce CHD risks among the HK Chinese.

DESIGN AND SAMPLE

Through secondary analysis, a qualitative descriptive design using focus group interviews and content analysis were adopted. Older and younger adults were invited for the study.

MEASURES

An interview schedule was used to guide discussions during focus group interviews.

RESULTS

Four categories emerged from the data: planning of health actions, control of risk-reducing behavior, perceived opportunities for understanding CHD, and chest pain appraisal.

CONCLUSIONS

Local culture and population needs play a central role in disease perception and prevention. The findings are essential to target strategies for initiating health acts for younger adults and establish public education resources that underscore understanding of CHD risk, symptom recognition, and disease management, particularly among those middle-aged and older people at high risk and with the diseased populations.

Social-cognitive theory predictors of exercise behavior in endometrial cancer survivors

OBJECTIVE

This study evaluated whether social-cognitive theory (SCT) variables, as measured by questionnaire and ecological momentary assessment (EMA), predicted exercise in endometrial cancer survivors.

METHOD

One hundred posttreatment endometrial cancer survivors received a 6-month home-based exercise intervention. EMAs were conducted by using hand-held computers for 10- to 12-day periods every 2 months. Participants rated morning self-efficacy and positive and negative outcome expectations by using the computer, recorded exercise information in real time and at night, and wore accelerometers. At the midpoint of each assessment period, participants completed SCT questionnaires. Using linear mixed-effects models, the authors tested whether morning SCT variables predicted minutes of exercise that day (Question 1) and whether exercise minutes at time point Tj could be predicted by questionnaire measures of SCT variables from time point Tj-1 (Question 2).

RESULTS

Morning self-efficacy significantly predicted that day's exercise minutes (p < .0001). Morning positive outcome expectations were also associated with exercise minutes (p = .0003), but the relationship was attenuated when self-efficacy was included in the model (p = .4032). Morning negative outcome expectations were not associated with exercise minutes. Of the questionnaire measures of SCT variables, only exercise self-efficacy predicted exercise at the next time point (p = .003).

CONCLUSIONS

The consistency of the relationship between self-efficacy and exercise minutes over short (same day) and longer (Tj to Tj-1) time periods provides support for a causal relationship. The strength of the relationship between morning self-efficacy and exercise minutes suggest that real-time interventions that target daily variation in self-efficacy may benefit endometrial cancer survivors' exercise adherence.

Determinants of Leisure-time Physical Activity and Future Intention to Practice in Spanish College Students

Few studies analyze determinants and patterns of physical activity among college students, so it has not been possible to carry out effective interventions to promote this practice. The aim of this study was to analyze the associations between some personal, social, and environmental determinants, practice of physical activity and future intention to practice in a sample of 639 university students (321 men and 318 women), mean age 21.43 years (± 2.78). Physical fitness self-perception, physical activity history, and coach's support to practice physical activity have a direct effect on the practice of physical activity and an indirect effect on future intention to practice, both in men and women. The practice of physical activity has also a direct effect on future intention to practice. Likewise, the participation in sport competitions predicts practice of physical activity and future intention in men, whereas being a member of a sports club predicts practice and future intention in women.

Physical activity behavior two to six years following cardiac rehabilitation: a socioecological analysis

BACKGROUND

Cardiac rehabilitation (CR) promotes long-term positive health behaviours, such as physical activity (PA), in patients following a cardiovascular event. We have limited knowledge of long-term PA and its correlates. Therefore, this research examined both PA behaviour and socioecological correlates among elderly graduates 2-6 years following CR.

HYPOTHESIS

CR graduates will have a moderate PA level in the long term. Greater PA will be associated with various multilevel correlates.

METHODS

This was a retrospective, cross-sectional study which quantified PA using the Physical Activity Scale for the Elderly (PASE) and collected information about socioecological correlates at the intrapersonal, interpersonal and health service levels. Both univariate and multivariate analyses assessed PA and PA correlates.

RESULTS

The majority of the 584 participants were older (69.8 ± 9.8), male (80.3%), and well educated (75.4% ≥ some post-secondary). Average time since CR graduation was 41.5 ± 11.5 months. Seventy five percent of CR graduates reported current weekly PA levels that met, or exceeded, Canadian PA guidelines (>150 minutes of moderate-vigorous PA). Univariate analyses identified 13 PASE score correlates. Multivariate analyses identified age, PA enjoyment, current work status, CR staff support, location of primary residence, and perceived health as significantly associated with higher PASE scores (p < 0.001).

CONCLUSIONS

Three and a half years post-CR graduates had high PA levels. Greater PA was associated with several modifiable multilevel correlates at all levels of influence. Understanding correlates of long-term PA behaviour among CR graduates will help identify groups at risk for nonadherence and assist with continued program development.

Tai Chi as an adjunct physical activity for adults aged 45 years and older enrolled in phase III cardiac rehabilitation

BACKGROUND

Cardiac rehabilitation improves physical, cognitive and psychosocial functioning, yet services are greatly underutilized with increasing patterns of attrition over time. Tai Chi has been suggested as a possible adjunct to cardiac rehabilitation exercise training.

AIM

To describe differences in physical, cognitive and psychosocial functioning among adults ≥ 45 years old attending phase III cardiac rehabilitation, who have or have not self-selected Tai Chi exercise as an adjunct physical activity.

METHODS

A cross-sectional design compared subjects attending group-based Wu style Tai Chi classes plus cardiac rehabilitation, with cardiac rehabilitation only. Subjects had a battery of physical and cognitive functioning tests administered to examine aerobic endurance, balance, strength, and flexibility, verbal retrieval/recall, attention, concentration and tracking. Subjects completed a health survey to ascertain cardiac event information, medical history, and psychosocial functioning (i.e. health-related quality of life, stress, depressive symptoms, social support, and Tai Chi self-efficacy).

RESULTS

A total of 51 subjects (75% married, 84% college-educated, 96% White/European-American) participated. Subjects were on average 70 (± 8) years old and had attended cardiac rehabilitation for 45 (± 37) months. Approximately 45% (n = 23) attended Tai Chi classes plus cardiac rehabilitation, while 55% (n = 28) attended cardiac rehabilitation only. Subjects attending Tai Chi plus cardiac rehabilitation had better balance, perceived physical health, and Tai Chi self-efficacy compared to those attending cardiac rehabilitation only (p ≤ 0.03).

CONCLUSION

Tai Chi can be easily implemented in any community/cardiac rehabilitation facility, and may offer adults additional options after a cardiac event.

Cardiac rehabilitation and the therapeutic environment: the importance of physical, social, and symbolic safety for programme participation among women

AIM

To report an exploration of the multidimensionality of safety in cardiac rehabilitation programmes as perceived by women who were enrolled in the Women's Cardiovascular Health Initiative in Toronto, Canada.

BACKGROUND

Cardiovascular disease is the leading cause of death among women. Although cardiac rehabilitation is clinically effective, significantly fewer women than men participate in available programmes. The literature identifies factors affecting women's cardiac rehabilitation participation, and provides possible explanations for this gender disparity. Although safety is mentioned among the barriers to women's cardiac rehabilitation participation, the extent to which safety contributes to programme participation, completion, and maintenance remains under-explored in the cardiac rehabilitation literature.

DESIGN

We conducted an exploratory qualitative study to examine the role safety and place play for women engaged in cardiac prevention and rehabilitation at the Women's Cardiovascular Health Initiative. Methods.  From 2005-2006, 14 participants engaged in semi-structured, qualitative interviews lasting 30-90 minutes. Discussions addressed women's experiences at the Women's Cardiovascular Health Initiative. Interview transcripts were analysed using thematic analysis.

FINDINGS

Three themes were developed: 'Safety', which was sub-categorized according to physical, social, and symbolic interpretations of safety, 'searching for a sense of place', and 'confidence and empowerment'.

CONCLUSION

Feeling physically, socially, and symbolically safe in one's cardiac rehabilitation environment may contribute to programme adherence and exercise maintenance for women. Focusing on comprehensive notions of safety in future cardiac rehabilitation research could offer insight into why many women do not maintain an exercise regimen in currently structured cardiac rehabilitation and community programmes.