Efficacy of home-based exercise programmes for people with chronic heart failure: a meta-analysis

EXERCISE IN THE PHYSICAL REHABILITATION OF CIRROTICS: A RANDOMIZED PILOT STUDY

ABSTRACT Background: Physical exercise delays the sarcopenic process and can reverse the loss of muscle strength, improve quality of life and prognosis in cirrhotic patients. Objective: The aim was to verify the effects of face-to-face versus home aerobic exercise on the variables fatigue, respiratory and peripheral muscle strength, functional capacity and quality of life in patients with compensated cirrhosis. Methods: Patients were selected by convenience, stratified and randomized into supervised face-to-face exercise (n=13) and home exercise without daily supervision (n=12). Patients were submitted to a program of aerobic physical exercises, with progressive duration of 30 to 50 minutes, twice a week for twelve weeks. Before starting the program and every four weeks, all patients in both groups were assessed for fatigue (fatigue severity scale), respiratory (Pimáx and Pemáx) and peripheral (concentric quadriceps peak torque) muscle strength, functional capacity (6-minute walking distance) and quality of life (Short Form-36 Health Survey questionnaire). Results: The face-to-face group showed reduced fatigue (P<0.001), increased inspiratory (P<0.001), expiratory (P<0.001) and peripheral (P<0.001) muscle strength of the 6MWD (P<0.001) and improved quality of life. The home group showed no significant improvement in these variables. Conclusion: A face-to-face program of moderate aerobic exercise in patients with compensated cirrhosis reduces fatigue, improves functional capacity and quality of life and increases respiratory and peripheral muscle strength. Home physical exercises do not cause the same adaptive effects in this population.

The Development Strategy of Home-Based Exercise in China Based on the SWOT-AHP Model

In view of the increasing importance of sports to people and the impact of COVID-19 on people’s lives, home-based exercise has become a popular choice for people to keep fit due to its unique advantages and its popularity is expected to keep growing in the future. Therefore, it is necessary to determine the development direction of home-based exercise and put in the corresponding efforts. However, there is currently a lack of research on all aspects of home-based exercise. The purpose of this research was to investigate the effective sustainable development strategy of home-based exercise in China through a SWOT (Strengths, Weaknesses, Opportunities and Threats) and AHP (Analytic Hierarchy Process) hybrid model. Thirteen factors corresponding to the SWOT analysis were identified through a literature review and expert opinions. The results show that in China the advantages and potential outweigh the weaknesses and threats of home-based exercise. Home-based exercise should grasp the external development opportunities and choose the SO development strategic type that combines internal strengths and external opportunities. As the core for the development of home-based exercise, this strategy should be given priority. To sum up, home-based exercise is believed to have a bright future.

Telehealth in cardiac rehabilitation: a review of current applications and future prospects for practical use

The article provides an overview of actual studies on cardiac rehabilitation using telehealth technologies, presents the types of telerehabilitation in clinical practice. The physiological mechanisms of exercise effects in rehabilitation programs in cardiovascular patients are considered in most detail. Telerehabilitation areas with potential for further study are presented.

Home-Based Cardiac Rehabilitation Alone and Hybrid With Center-Based Cardiac Rehabilitation in Heart Failure: A Systematic Review and Meta-Analysis

Background

Center‐based cardiac rehabilitation (CBCR) has been shown to improve outcomes in patients with heart failure (HF). Home‐based cardiac rehabilitation (HBCR) can be an alternative to increase access for patients who cannot participate in CBCR. Hybrid cardiac rehabilitation (CR) combines short‐term CBCR with HBCR, potentially allowing both flexibility and rigor. However, recent data comparing these initiatives have not been synthesized.

Methods and Results

We performed a meta‐analysis to compare functional capacity and health‐related quality of life (hr‐QOL) outcomes in HF for (1) HBCR and usual care, (2) hybrid CR and usual care, and (3) HBCR and CBCR. A systematic search in 5 standard databases for randomized controlled trials was performed through January 31, 2019. Summary estimates were pooled using fixed‐ or random‐effects (when I²>50%) meta‐analyses. Standardized mean differences (95% CI) were used for distinct hr‐QOL tools. We identified 31 randomized controlled trials with a total of 1791 HF participants. Among 18 studies that compared HBCR and usual care, participants in HBCR had improvement of peak oxygen uptake (2.39 mL/kg per minute; 95% CI, 0.28–4.49) and hr‐QOL (16 studies; standardized mean difference: 0.38; 95% CI, 0.19–0.57). Nine RCTs that compared hybrid CR with usual care showed that hybrid CR had greater improvements in peak oxygen uptake (9.72 mL/kg per minute; 95% CI, 5.12–14.33) but not in hr‐QOL (2 studies; standardized mean difference: 0.67; 95% CI, −0.20 to 1.54). Five studies comparing HBCR with CBCR showed similar improvements in functional capacity (0.0 mL/kg per minute; 95% CI, −1.93 to 1.92) and hr‐QOL (4 studies; standardized mean difference: 0.11; 95% CI, −0.12 to 0.34).

Conclusions

HBCR and hybrid CR significantly improved functional capacity, but only HBCR improved hr‐QOL over usual care. However, both are potential alternatives for patients who are not suitable for CBCR.

Patient-Selected Strategies for Post Cardiac Rehabilitation Exercise Adherence in Heart Failure

PURPOSE

The aim of this study was to evaluate the use of patient-selected exercise adherence strategies following cardiac rehabilitation (CR).

DESIGN

Twenty patients with heart failure (HF) were recruited and randomly assigned to the intervention or control group at completion of CR.

METHODS

The intervention included the use of six adherence strategies (logs, graphs, pedometers, phone follow-up, education, and a letter from CR staff), which were provided for 6 weeks post CR and during home-based exercise. After 6 weeks, the intervention group selected strategies to continue, and only those were provided for the last 6 weeks. At 12 weeks, patients were retested.

FINDINGS

Patients with HF demonstrated improvement in distance walked and less HF symptoms and adhered to exercise at levels recommended during CR.

CONCLUSION

Inclusion of patient-selected adherence strategies supports continued exercise and helps to sustain physiological improvements.

CLINICAL RELEVANCE

Results from this study have implications for CR programs serving HF patients and provide insight into adherence strategies.

An Exercise Counseling Intervention in Minority Adults With Heart Failure

PURPOSE

The primary aim of this study was to assess the feasibility of an exercise counseling intervention for adults of diverse race/ethnicity with heart failure (HF) and to assess its potential for improving overall physical activity, functional capacity, and HF self-care.

DESIGN

This study was a quasi-experimental, prospective, longitudinal cohort design.

METHODS

Twenty adults were enrolled and completed the 6-minute walk and standardized instruments, followed by exercise counseling using motivational interviewing. Each received an accelerometer, hand weights, and a diary to record self-care behaviors. Participants were followed via phone for 12 weeks to collect step-counts, review symptoms, and plan the following week's step goal.

FINDINGS

Results indicate that this intervention was feasible for most participants and resulted in improvements in physical activity, functional capacity, and self-care behaviors.

CONCLUSION/CLINICAL RELEVANCE

Brief exercise counseling may be an appropriate option to improve outcomes for stable patients with HF and may be tailored to fit different settings.

Home Exercise Training Improves Exercise Capacity in Cirrhosis Patients: Role of Exercise Adherence

Cirrhosis patients have reduced peak aerobic power (peak VO₂) that is associated with reduced survival. Supervised exercise training increases exercise tolerance. The effect of home-based exercise training (HET) in cirrhosis is unknown. The objective was to evaluate the safety and efficacy of 8 weeks of HET on peak VO₂, 6-minute walk distance (6MWD), muscle mass, and quality of life in cirrhosis. Random assignment to 8 weeks of HET (moderate to high intensity cycling exercise, 3 days/week) or usual care. Exercise adherence defined as completing ≥80% training sessions. Paired t-tests and analysis of covariance used for comparisons. Forty patients enrolled: 58% male, mean age 57 y, 70% Child Pugh-A. Between group increases in peak VO₂ (1.7, 95% CI: −0.33 to 3.7 ml/kg/min, p = 0.09) and 6MWD (33.7, 95% CI: 5.1 to 62.4 m, p = 0.02) were greater after HET versus usual care. Improvements even more marked in adherent subjects for peak VO₂ (2.8, 95% CI: 0.5–5.2 mL/kg/min, p = 0.02) and 6MWD (46.4, 95% CI: 12.4–80.5 m, p = 0.009). No adverse events occurred during testing or HET. Eight weeks of HET is a safe and effective intervention to improve exercise capacity in cirrhosis, with maximal benefits occurring in those who complete ≥80% of the program.

Home-based cardiac rehabilitation improves quality of life, aerobic capacity, and readmission rates in patients with chronic heart failure

BACKGROUND

Exercise tolerance and cardiac output have a major impact on the quality of life (QOL) of patients experiencing heart failure (HF). Home-based cardiac rehabilitation can significantly improve not only exercise tolerance but also peak oxygen uptake ((Equation is included in full-text article.)peak), and the QOL in patients with HF. The aim of this prospective study was to evaluate the beneficial effects of home-based cardiac rehabilitation on the quality of medical care in patients with chronic HF.

METHODS

This study was a randomized prospective trial. HF patients with a left ventricular ejection fraction (LVEF) of less than 50% were included in this study. We randomly assigned patients to the control group (n = 18) and the interventional group (n = 19). Within the interventional group, we arranged individualized rehabilitation programs, including home-based cardiac rehabilitation, diet education, and management of daily activity over a 3-month period. Information such as general data, laboratory data, Cardiopulmonary Exercise Test (CPET) results, Six-minute Walk Test (6MWT) results, and the scores for the Minnesota Living with Heart Failure Questionnaire (MLHFQ) before and after the intervention, was collected from all patients in this study.

RESULTS

Patients enrolled in the home-based cardiac rehabilitation programs displayed statistically significant improvement in (Equation is included in full-text article.)peak (18.2 ± 4.1 vs 20.9 ± 6.6 mL/kg/min, P = .02), maximal 6-Minute Walking Distance (6MWD) (421 ± 90 vs 462 ± 74 m, P = .03), anaerobic threshold (12.4 ± 2.5 vs 13.4 ± 2.6 mL/kg/min, P = .005), and QOL. In summary, patients receiving home-based cardiac rehabilitation experienced a 14.2% increase in (Equation is included in full-text article.)peak, a 37% increase in QOL score, and an improvement of 41 m on the 6MWD test. The 90-day readmission rate for patients reduced to 5% from 14% after receiving cardiac rehabilitation.

CONCLUSION

Home-based cardiac rehabilitation offered the most improved results in functional capacity, QOL, and a reduced the rate of readmission within 90 days.

E-coaching: New future for cardiac rehabilitation? A systematic review

OBJECTIVE

To provide an evidence-based overview of the effectiveness of e-coaching as a cardiac rehabilitation program (CRP).

METHODS

Pubmed, Embase, PEDro and CINAHL were searched to identify relevant RCTs. The e-coaching programs were divided into basic or complex depending on their content. Two reviewers independently assessed the methodological quality and extracted the data. A best-evidence synthesis was used to summarize the results.

RESULTS

19 RCTs were included. Detailed descriptions of the e-coaching programs were lacking. Complex e-coaching was more effective than usual-care for physical capacity (moderate evidence for short-, and mid-term; strong evidence for long-term), for clinical status (limited evidence for short- and mid-term; moderate evidence for the long-term), and for psychosocial health (moderate evidence for short-term; strong evidence for mid-, and long-term). For basic e-coaching only limited or no evidence for effectiveness was found.

CONCLUSION

Promising results were found for the effectiveness of complex e-coaching as a CRP to improve a patients' physical capacity, clinical status and psychosocial health.

PRACTICE IMPLICATIONS

The content of the e-coaching programs were not clearly described. This makes it difficult to identify which components of e-coaching are most effective and should be further developed to deliver the most optimal care for cardiac rehabilitation patients.

Peripheral muscle training with resistance exercise bands in patients with chronic heart failure. Long-term effects on walking distance and quality of life; a pilot study

Aims

This study aimed to describe a method of peripheral muscle training with resistance bands in patients with chronic heart failure (CHF) and to evaluate its effects on the 6 min walk test and quality of life up to 12 months using a home‐based programme.

Methods and results

Twenty‐two patients with stable CHF (19 men and 3 women), mean age 63.2 years (SD 8.1), New York Heart Association class II–III were randomized to individual home‐based training (HT group), or home‐based training with a group‐based start‐up in a hospital setting (GT group). A 6 min walk test, the Minnesota Living with Heart Failure Questionnaire (MLHFQ), and Short Form with 36 items (SF‐36) were administered at baseline and after 3, 6, 9, and 12 months. Exercise training resulted in statistically significant increased walking distance in both groups. The HT group increased on average 107 (80) m from baseline to 12 months, and the GT group by 100 (96) m. Health‐related quality of life, measured with MLHFQ and SF‐36, reached statistically significant improvements in both groups but at different time points. There were no statistically significant differences between groups on any parameters or follow‐ups.

Conclusions

Long‐term home‐based peripheral muscle training in patients with CHF, with or without an introductory period in a hospital setting, can be used for initial improvement and retention of walking distance and health‐related quality of life.

Effect of home-based rehabilitation on activities of daily living and gait in older adults with heart failure at risk for falling: A retrospective cohort study

PURPOSE

The purpose of this study is to describe improvement in activities of daily living (ADL) and gait speed, and associated factors in subjects receiving home-based rehabilitation after hospital admission for heart failure.

METHODS

A total of 1,055 patients (mean age 82 ± 8 years SD) receiving post-admission home care services for heart failure. Subjects were included if they were referred for home-care rehabilitation after inpatient admission with ICD-9 code indicating heart failure at inpatient discharge, primary home care, or co-morbid diagnosis on admission Outcome and Assessment Information Set version-C (OASIS-C). Change in total ADL score was described and adjusted for significant baseline factors/covariates using a generalized linear model. Factors predictive of exceeding the ADL score Minimal Detectable Change (MDC) were identified with multiple variable logistic regression.

RESULTS

Mean change in total ADL score from admission to discharge was 1.6 ± 1.2, the mean change for gait speed was 0.17 ± 0.21 m/s, and the minimum detectable change (MDC) (1.3) was exceeded by 57% of subjects. Improvement in mean ADL score was significantly predicted by age, baseline total ADL score, baseline gait speed score, cognitive-behavioral status, and living situation (R² = 42%).

CONCLUSIONS

Patients with heart failure receiving home-based rehabilitation services make significant improvements in ADL function and gait performance. Greater ADL improvements are associated with younger age, faster gait speed at baseline, and greater impairment of baseline ADL scores. Age, baseline gait speed, and ADL composite score are significantly related to making a change beyond measurement error in ADL change score.

Exercise therapy for functional capacity in chronic diseases: an overview of meta-analyses of randomised controlled trials

OBJECTIVE

To summarise all meta-analyses of randomised controlled trials that have evaluated the effects of exercise therapy on functional capacity in patients with chronic diseases.

DESIGN

Umbrella review of meta-analyses of randomised controlled trials.

DATA SOURCES

We systematically searched the CENTRAL, CINAHL, DARE, Medline, OTSeeker, PEDro, SPORTDiscus, ProQuest Nursing & Allied Health Database, Web of Science, Scopus, OpenGrey and BMC Proceedings from database inception to 1 September 2016.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included meta-analyses that compared the effects of exercise therapy with no treatment or usual care in adults with non-communicable chronic diseases and included outcomes related to functional capacity. We excluded meta-analyses with less than 100 patients.

RESULTS

Eighty-five meta-analyses with 22 different chronic diseases were included. The exercise interventions resulted in statistically significant (p<0.05) improvements for 126 of 146 (86%) functional capacity outcomes, compared with the control group. The standardised mean differences were small in 64 (44%), moderate in 54 (37%) and large in 28 (19%) of the 146 functional capacity outcomes. The results were similar for aerobic exercise, resistance training, and aerobic and resistance training combined. There were no significant differences in serious adverse effects between the intervention and control groups in any of the meta-analyses.

CONCLUSION

Exercise therapy appears to be a safe way to improve functional capacity and reduce disability in individuals with chronic disease.

Exercise as medicine - evidence for prescribing exercise as therapy in 26 different chronic diseases

This review provides the reader with the up-to-date evidence-based basis for prescribing exercise as medicine in the treatment of 26 different diseases: psychiatric diseases (depression, anxiety, stress, schizophrenia); neurological diseases (dementia, Parkinson's disease, multiple sclerosis); metabolic diseases (obesity, hyperlipidemia, metabolic syndrome, polycystic ovarian syndrome, type 2 diabetes, type 1 diabetes); cardiovascular diseases (hypertension, coronary heart disease, heart failure, cerebral apoplexy, and claudication intermittent); pulmonary diseases (chronic obstructive pulmonary disease, asthma, cystic fibrosis); musculo-skeletal disorders (osteoarthritis, osteoporosis, back pain, rheumatoid arthritis); and cancer. The effect of exercise therapy on disease pathogenesis and symptoms are given and the possible mechanisms of action are discussed. We have interpreted the scientific literature and for each disease, we provide the reader with our best advice regarding the optimal type and dose for prescription of exercise.

Impact of Exercise Programs on Hospital Readmission Following Hospitalization for Heart Failure: A Systematic Review

Given persistently high 30-day readmission rates among patients hospitalized for heart failure, there is an ongoing need to identify new interventions to reduce readmissions. Although exercise programs can improve outcomes among ambulatory heart failure patients, it is not clear whether this benefit extends to reducing readmissions following heart failure hospitalization. We therefore conducted a systematic review of the literature to identify randomized controlled trials examining the impact of exercise programs on hospital readmissions among patients recently hospitalized for heart failure. We searched Ovid MEDLINE, EMBASE, and the Wiley Cochrane Library for studies that fulfilled pre-defined criteria, including that the exercise program pre-specify activity type and exercise frequency, duration, and intensity. Exercise interventions could occur at any location including within the hospital, at an outpatient facility, or at home. Among 1213 unique publications identified, only one study fulfilled inclusion criteria. This study was a single-site randomized controlled trial that consisted of a 12-week exercise program in a cohort of 105 patients with a principal diagnosis of HF at a metropolitan hospital in Australia. This study revealed a reduction in 12-month all-cause and cardiovascular-related hospitalization rates. However, inferences were limited by its single-site study design, small sample size, premature termination, and high risk for selection, performance, and detection bias. As no studies have built upon the findings of this study, it remains unknown whether exercise programs can improve readmission rates among patients recently hospitalized for heart failure, a significant gap in the literature.

Home-based cardiac rehabilitation for people with heart failure: A systematic review and meta-analysis

AIMS

To assess the effectiveness of home-based cardiac rehabilitation (CR) for heart failure compared to either usual medical care (i.e. no CR) or centre-based CR on mortality, morbidity, exercise capacity, health-related quality of life, drop out, adherence rates, and costs.

METHODS

Randomised controlled trials were initially identified from previous systematic reviews of CR. We undertook updated literature searches of MEDLINE, EMBASE, CINAHL, PsycINFO and Cochrane Library to December 2015. A total of 19 trials with median follow up of 3months were included - 17 comparisons of home-based CR to usual care (995 patients) and four comparing home and centre-based CR (295 patients).

RESULTS

Compared to usual care, home-based CR improved VO2max (mean difference: 1.6ml/kg/min, 0.8 to 2.4) and total Minnesota Living with Quality of Life score (-3.3, -7.5 to 1.0), with no difference in mortality, hospitalisation or study drop out. Outcomes and costs were similar between home-based and centre-based CR with the exception of higher levels of trial completion in the home-based group (relative risk: 1.2, 1.0 to 1.3).

CONCLUSIONS

Home-based CR results in short-term improvements in exercise capacity and health-related quality of life of heart failure patients compared to usual care. The magnitude of outcome improvement is similar to centre-based CR. Home-based CR appears to be safe with no evidence of increased risk of hospitalisation or death. These findings support the provision of home-based CR for heart failure as an evidence-based alternative to the traditional centre-based model of provision.

Characterizing patient-oriented tools that could be packaged with guidelines to promote self-management and guideline adoption: a meta-review

BACKGROUND

Self-management is an important component of care for patients or consumers (henceforth termed patients) with chronic conditions. Research shows that patients view guidelines as potential sources of self-management support. However, few guidelines provide such support. The primary purpose of this study was to characterize effective types of self-management interventions that could be packaged as resources in (i.e., appendices) or with guidelines (i.e., accompanying products).

METHODS

We conducted a meta-review of systematic reviews that evaluated self-management interventions. MEDLINE, EMBASE, and the Cochrane Library were searched from 2005 to 2014 for English language systematic reviews. Data were extracted on study characteristics, intervention (content, delivery, duration, personnel, single or multifaceted), and outcomes. Interventions were characterized by the type of component for different domains (inform, activate, collaborate). Summary statistics were used to report the characteristics, frequency, and impact of the types of self-management components. A Measurement Tool to Assess Systematic Reviews (AMSTAR) was used to assess the methodological quality of included reviews.

RESULTS

Seventy-seven studies were included (14 low, 44 moderate, 18 high risk of bias). Reviews addressed numerous clinical topics, most frequently diabetes (23, 30 %). Fifty-four focused on single (38 educational, 16 self-directed) and 21 on multifaceted interventions. Support for collaboration with providers was the least frequently used form of self-management. Most conditions featured multiple types of self-management components. The most frequently occurring type of self-management component across all studies was lifestyle advice (72 %), followed by psychological strategies (69 %), and information about the condition (49 %). In most reviews, the intervention both informed and activated patients (57, 76 %). Among the reviews that achieved positive results, 83 % of interventions involved activation alone, 94 % in combination with information, and 95 % in combination with information and collaboration. No trends in the characteristics and impact of self-management by condition were observed.

CONCLUSIONS

This study revealed numerous opportunities for enhancing guidelines with resources for both patients and providers to support self-management. This includes single resources that provide information and/or prompt activation. Further research is needed to more firmly establish the statistical association between the characteristics of self-management support and outcomes; and to and optimize the design of self-management resources that are included in or with guidelines, in particular, resources that prompt collaboration with providers.

Effects of Exercise Training on Exercise Capacity in Pulmonary Arterial Hypertension: A Systematic Review of Clinical Trials

BACKGROUND

Pulmonary arterial hypertension (PAH) causes profound functional limitations and poor quality of life. Yet, there is only a limited literature available on the role of exercise training. This paper systematically reviews the effects of exercise training on exercise capacity in PAH.

METHODS

A systematic search of databases (PubMed, CINAHL, CENTRAL, Web of Science and PEDRo) was undertaken for English language articles published between 1(st) January 1980 and 31(st) March 2015. Quality rating for all articles was done using the Downs and Black scoring system.

RESULTS

Fifteen articles of good (n=4), moderate (n=6) and poor (n=5) quality were included in the review. Exercise interventions included aerobic, resistance, inspiratory muscle training or a combination, for 6-18 weeks. Improvements were seen in exercise capacity (six minute walk distance (6MWD) and peak VO2) by 17-96m and 1.1-2.1ml/Kg/min, functional class by one class and quality of life, with minimal adverse events.

CONCLUSIONS

There is evidence to recommend the use of exercise training as an adjunct to medical treatment in PAH. More clinical trials and research are required to assess the effects of different types of exercise programs in patients with PAH, while focussing on strong exercise endpoints to quantify the improvements seen with exercise training.

Predictors of exercise capacity following exercise-based rehabilitation in patients with coronary heart disease and heart failure: A meta-regression analysis

BACKGROUND

The aim of this study was to undertake a comprehensive assessment of the patient, intervention and trial-level factors that may predict exercise capacity following exercise-based rehabilitation in patients with coronary heart disease and heart failure.

DESIGN

Meta-analysis and meta-regression analysis.

METHODS

Randomized controlled trials of exercise-based rehabilitation were identified from three published systematic reviews. Exercise capacity was pooled across trials using random effects meta-analysis, and meta-regression used to examine the association between exercise capacity and a range of patient (e.g. age), intervention (e.g. exercise frequency) and trial (e.g. risk of bias) factors.

RESULTS

55 trials (61 exercise-control comparisons, 7553 patients) were included. Following exercise-based rehabilitation compared to control, overall exercise capacity was on average 0.95 (95% CI: 0.76-1.41) standard deviation units higher, and in trials reporting maximum oxygen uptake (VO2max) was 3.3 ml/kg.min(-1) (95% CI: 2.6-4.0) higher. There was evidence of a high level of statistical heterogeneity across trials (I(2) statistic > 50%). In multivariable meta-regression analysis, only exercise intervention intensity was found to be significantly associated with VO2max (P = 0.04); those trials with the highest average exercise intensity had the largest mean post-rehabilitation VO2max compared to control.

CONCLUSIONS

We found considerable heterogeneity across randomized controlled trials in the magnitude of improvement in exercise capacity following exercise-based rehabilitation compared to control among patients with coronary heart disease or heart failure. Whilst higher exercise intensities were associated with a greater level of post-rehabilitation exercise capacity, there was no strong evidence to support other intervention, patient or trial factors to be predictive.

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.

Exercise-based cardiac rehabilitation in patients with coronary heart disease: meta-analysis outcomes revisited

Cardiac rehabilitation that includes either exercise training alone or exercise training in addition to psychosocial, risk factor management and/or educational interventions is considered a Class I indication [i.e., useful and effective] for patients with coronary heart disease. This overview of six independent cardiac rehabilitation meta-analyses published since 2000 includes a total of 71 randomized clinical trials (n = 13,824 patients) and clearly demonstrates significant clinical outcomes (reduced all-cause and cardiac mortality, nonfatal reinfarction and reduced hospitalization rates) and significant positive changes in modifiable risk factors (total cholesterol, triglycerides and systolic blood pressure). Despite the observation that the elderly, females, minority ethnic groups, low socioeconomic status patients and patients with comorbidities have not been well represented in the randomized clinical trials. Recent guidelines in the UK and USA have concluded with the recommendation that cardiac rehabilitation is reasonable and necessary and should be promoted by healthcare professionals, including senior medical staff.

Exercise prescription for hospitalized people with chronic obstructive pulmonary disease and comorbidities: a synthesis of systematic reviews

INTRODUCTION

The prescription of physical activity for hospitalized patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) can be complicated by the presence of comorbidities. The current research aimed to synthesize the relevant literature on the benefits of exercise for people with multimorbidities who experience an AECOPD, and ask: What are the parameters and outcomes of exercise in AECOPD and in conditions that are common comorbidities as reported by systematic reviews (SRs)?

METHODS

An SR was performed using the Cochrane Collaboration protocol. Nine electronic databases were searched up to July 2011. Articles were included if they (1) described participants with AECOPD, chronic obstructive pulmonary disease (COPD), or one of eleven common comorbidities, (2) were an SR, (3) examined aerobic training (AT), resistance training (RT), balance training (BT), or a combination thereof, (4) included at least one outcome of fitness, and (5) compared exercise training versus control/sham.

RESULTS

This synthesis examined 58 SRs of exercise training in people with AECOPD, COPD, or eleven chronic conditions commonly associated with COPD. Meta-analyses of endurance (aerobic or exercise capacity, 6-minute walk distance--6MWD) were shown to significantly improve in most conditions (except osteoarthritis, osteoporosis, and depression), whereas strength was shown to improve in five of the 13 conditions searched: COPD, older adults, heart failure, ischemic heart disease, and diabetes. Several studies of different conditions also reported improvements in quality of life, function, and control or prevention outcomes. Meta-analyses also demonstrate that exercise training decreases the risk of mortality in older adults, and those with COPD or ischemic heart disease. The most common types of training were AT and RT. BT and functional training were commonly applied in older adults. The quality of the SRs for most conditions was moderate to excellent (>65%) as evaluated by AMSTAR scores.

CONCLUSION

In summary, this synthesis showed evidence of significant benefits from exercise training in AECOPD, COPD, and conditions that are common comorbidities. A broader approach to exercise and activity prescription in pulmonary rehabilitation may induce therapeutic benefits to ameliorate clinical sequelae associated with AECOPD and comorbidities such as the inclusion of BT and functional training.

Self-efficacy: a useful construct to promote physical activity in people with stable chronic heart failure

AIM

To explore the conceptual underpinnings of self-efficacy to address the barriers to participating in physical activity and propose a model of intervention.

BACKGROUND

The benefits of physical activity in reducing cardiovascular risk have led to evidence-based recommendations for patients with heart disease, including those with chronic heart failure. However, adherence to best practice recommendations is often suboptimal, particularly in those individuals who experience high symptom burden and feel less confident to undertake physical activity. Self-efficacy is the degree of confidence an individual has in his/her ability to perform behaviour under several specific circumstances. Four factors influence an individual's level of self-efficacy: (1) past performance, (2) vicarious experience, (3) verbal persuasion and (4) physiological arousal.

DESIGN

Discursive.

METHODS

Using the method of a discursive paper, this article seeks to explore the conceptual underpinnings of self-efficacy to address the barriers to participating in physical activity and proposes a model of intervention, the Home-Heart-Walk, to promote physical activity and monitor functional status.

CONCLUSIONS

Implementing effective interventions to promote physical activities require appreciation of factors impacting on behaviour change. Addressing concepts relating to self-efficacy in physical activity interventions may promote participation and adherence in the longer term.

RELEVANCE TO CLINICAL PRACTICE

The increasing burden of chronic disease and the emphasis on self-management strategies underscore the importance of promoting adherence to recommendations, such as physical activity.

Effective home programme intervention for adults: a systematic review

Objective: To summarize evidence on effective home programme intervention for adults and describe characteristics of successful home programmes.

Data sources: A search was conducted of MEDLINE, CINAHL, PsycINFO, EMBASE, DARE, The Physiotherapy Evidence Database, Cochrane Database of Systematic Reviews, OTSeeker and Google Scholar and references in manuscripts retrieved.

Review methods: Two independent reviewers determined whether retrieved study abstracts met inclusion criteria: human subjects; adults; home programme intervention; systematic reviews, randomized controlled trials or controlled trials. Included papers were appraised for study design, participants, type and intensity of intervention, and outcomes. Methodological quality of trials was rated using the PEDro scale (1–10 highest).

Results: Thirty-two papers were retrieved (6 systematic reviews, 26 trials). The 23 randomized controlled trials and 3 controlled trials were appraised. All the retrieved papers were level 1a, 1b or 2b evidence. Major findings were: (a) home programme intervention was more effective than no intervention at all; (b) home programme intervention was equally effective to expert-provided therapy, except when therapeutic modalities were used; and (c) different instruction formats produced similar outcomes. Home programmes with favourable outcomes were more likely to: involve the patients in establishing the programme; intervene on the person, task and environment; and provide feedback about progress. Dose did not appear to be related to outcome.

Conclusion: There is grade 1A evidence supporting the effectiveness of home programmes for adults. Home programmes are as effective as expert-provided therapy.

Exercise in elderly patients with chronic heart failure in primary care: effects on physical capacity and health-related quality of life

INTRODUCTION

Chronic heart failure (CHF) limits exercise capacity which influences physical fitness and health-related quality of life (HRQoL).

AIM

The aim was to determine the effects on physical capacity and HRQoL of an exercise programme in elderly patients with CHF in primary care.

METHODS

An exercise intervention was conducted as a prospective, longitudinal and controlled clinical study in primary care in elderly patients with CHF. Endurance exercise and resistance training were conducted as group-training at the primary care centre and as home training. Follow-up on physical capacity and HRQoL was done at 3, 6 and 12months.

RESULTS

Exercise significantly improved muscle endurance in the intervention group (n=29, mean age 76.2years) compared to the control group (n=31, mean age 74.4years) at all follow-ups except for shoulder flexion right at 12months (shoulder abduction p=0.006, p=0.048, p=0.029; shoulder flexion right p=0.002, p=0.032, p=0.585; shoulder flexion left p=0.000, p=0.046, p=0.004). Six minute walk test improved in the intervention group at 3months (p=0.013) compared to the control group. HRQoL measured by EQ5D-VAS significantly improved in the intervention group at 3 and 12months (p=0.016 and p=0.034) and SF-36, general health (p=0.048) and physical component scale (p=0.026) significantly improved at 3months compared to the control group.

CONCLUSION

This study shows that exercise conducted in groups in primary care and in the patients' homes could be used in elderly patients with CHF. The combination of endurance exercise and resistance training has positive effects on physical capacity. However, the minor effects in HRQoL need further verification in a study with a larger study population.

A comparison of home and hospital-based exercise training in heart failure: immediate and long-term effects upon physical activity level

BACKGROUND

In heart failure, reduced physical activity level can adversely affect physical and psychosocial functioning. No previous heart failure research has compared effects of home and hospital-based exercise training upon physical activity level, or has objectively assessed their long-term effects upon physical activity. This study used an activPAL™ monitor to examine immediate and long-term effects of home and hospital-based aerobic exercise training upon physical activity level.

DESIGN

Randomized controlled trial.

METHODS

Sixty patients with heart failure (mean age 66 years; NYHA class II/III; 51 male/9 female) were randomized to home training, hospital training or control. Both programmes consisted of aerobic circuit training, undertaken twice a week for one hour, for eight weeks. All participants wore the activPAL™ at baseline, and after eight weeks, for one week. Six months after cessation of training, a subgroup of participants from the home and hospital training groups (n = 10 from each group) wore the activPAL™ for a further week.

RESULTS

Hospital-based training significantly increased steps taken per day during 'extra long' (P = 0.04) and 'long' (P = 0.01) walks. Neither programme had any immediate effect upon physical activity level otherwise. Though daily upright duration for the home group significantly improved six months after cessation of training (P = 0.02), generally physical activity level was maintained in the long term for both training groups.

CONCLUSIONS

Hospital-based training enabled participants to walk for longer periods. It is clinically important that both training groups maintained physical activity level in the long term, given the potential for heart failure to worsen over this time period.

Exercise Training for Heart Failure Patients with and without Systolic Dysfunction: An Evidence-Based Analysis of How Patients Benefit

Significant benefits can be derived by heart failure patients from exercise training. This paper provides an evidence-based assessment of expected clinical benefits of exercise training for heart failure patients. Meta-analyses and randomized, controlled trials of exercise training in heart failure patients were reviewed from a search of PubMed, Cochrane Controlled Trial Registry (CCTR), CINAHL, and EMBASE. Exercise training improves functional capacity, quality of life, hospitalization, and systolic and diastolic function in heart failure patients. Heart failure patients with preserved systolic function (HFnEF) participating in exercise training studies are more likely to be women and are 5–7 years older than their systolic heart failure (CHF) counterparts. All patients exhibit low functional capacities, although in HFnEF patients this may be age related, therefore subtle differences in exercise prescriptions are required. Published works report that exercise training is beneficial for heart failure patients with and without systolic dysfunction.