A Randomized Controlled Trial of an Exercise Maintenance Intervention in Men and Women After Cardiac Rehabilitation (ECO-PCR Trial)

Exploring maintenance rehabilitation in adults with chronic conditions: a scoping review of the literature

OBJECTIVE

Individuals with chronic conditions have long-term needs which can be addressed by maintenance rehabilitation. The 2013 Jimmo v Sebelius settlement in the United States (US) clarified the Medicare coverage of maintenance rehabilitation as a skilled service, even when no improvement is expected. A scoping review was conducted to describe maintenance rehabilitation.

MATERIALS AND METHODS

A systematic search was performed across 9 databases. Maintenance rehabilitation was defined as services (e.g. occupational, physical, or speech language therapies), intended to maintain a person's condition and prevent decline. Studies focused on medical, or non-rehabilitative, interventions (e.g. opioid cessation or chemotherapy) were excluded. Of the 734 abstracts reviewed, 90 met inclusion criteria. Two reviewers extracted data and used descriptive statistics. An exploratory thematic analysis in a convenience sample contextualized the works.

RESULTS

Most works (90%) were peer-reviewed publications. The works represented 12,638 individuals, with predominant populations being cardiac (4,122 individuals) and pulmonary (2,324 individuals). Physical activity interventions were identified most frequently (87%). Outcome measures primarily focused on activities (49%) or body systems (42%). Thematic analysis suggests maintenance rehabilitation may support domains contributing to quality of life.

CONCLUSIONS

While evidence exists for maintenance therapy, future research on intervention design will guide implementation by health systems.

Device-based 24-hour movement behaviours in adult phase III cardiac rehabilitation service-users during the COVID-19 pandemic: a mixed-methods prospective observational study

PURPOSE

To examine changes in device-based 24-hour movement behaviours (MB), and facilitators and barriers to physical activity (PA) and exercise, during remotely-delivered cardiac rehabilitation (RDCR).

MATERIALS AND METHODS

This prospective observational study used wrist-worn GENEActiv accelerometers to assess MB of 10 service-users (63 ± 10 years) at the start, middle, and end of three-months of RDCR. Barriers and facilitators to PA and exercise were explored through self-report diaries and analysed using content analysis.

RESULTS

At start, service-users were sedentary for 12.6 ± 0.7 h · day-1 and accumulated most PA at a light-intensity (133.52 ± 28.57 min · day-1) - neither changed significantly during RDCR. Sleep efficiency significantly reduced from start (88.80 ± 4.2%) to the end (86.1 ± 4.76%) of CR, with values meeting health-based recommendations (≥85%). Barriers to RDCR exercise included exertional discomfort and cardiac symptoms, and reduced confidence when exercising alone. Setting meaningful PA goals, self-monitoring health targets, and having social support, facilitated PA and exercise during RDCR.

CONCLUSIONS

Our RDCR programme failed to elicit significant changes in MB or sleep. To increase the likelihood of successful RDCR, it is important to promote a variety of exercise and PA options, target sedentary time, and apply theory to RDCR design, delivery, and support strategies.

mHealth intervention including text messaging and behaviour change techniques to support maintenance of physical activity after cardiac rehabilitation: A single-arm feasibility study

Objective

To evaluate the feasibility of a mobile health-supported intervention in patients with cardiovascular diseases after completion of a cardiac rehabilitation programme.

Methods

The feasibility study was performed in two hospitals and one municipality in Region Zealand, Denmark. Eligible participants were ≥18 years old, participated in a supervised cardiac rehabilitation programme, had access to a mobile phone, and could walk 3 m independently. Participants received a 12-week intervention utilizing behaviour change techniques, consisting of action planning, text messages, and phone support. Feasibility was assessed using pre-defined progression criteria, which included recruitment (≥75%), retention (≥80%), accelerometer data completeness (≥80%), coordinator (phone support) time (≤30 min), the response rate on patient-reported outcomes (≥90%), adherence (≥75% respond to ≥75% of messages), and acceptability (≥75%). The secondary outcome of objective physical activity was assessed with accelerometers.

Results

Ten women and 30 men with cardiovascular diseases aged 63.5 (±9.8 SD) participated. The progression criteria for retention (90%), accelerometer data completeness (83%), coordinator time (9.9 min), adherence (83%), and acceptability (82%) were at acceptable levels, exceptions were progression criteria for recruitment (35%) being below acceptable levels for recruitment, and response rate on patient-reported outcomes (75%). High satisfaction (92.6%) with the intervention was found. All objectively measured physical activity levels remained unchanged from baseline to follow-up. No serious adverse events related to the intervention were reported.

Conclusion

Mobile health-supported maintenance of physical activity after cardiac rehabilitation completion was feasible, safe, and acceptable. Yet, changes to improve recruitment and response rate are needed before conducting a large-scale effect evaluation.

The effectiveness of digital health interventions for the maintenance of physical activity following cardiac rehabilitation: A systematic review and meta-analysis

Objective

To summarise the effectiveness of digital health maintenance interventions for subjectively and objectively measured physical activity level (PA) and physical function, fitness and health-related quality of life (HRQoL) after completion of phase II cardiac rehabilitation (CR).

Methods

We conducted a search for studies in MEDLINE, Embase, CENTRAL, and CINAHL (inception to May 2024). Independent reviewers selected and included randomised controlled trials (RCTs) using digital health interventions to maintain PA in patients with cardiovascular disease after phase II CR. Independent reviewers conducted data extraction, assessed the risk of bias using the Cochrane Risk of Bias 2 tool and rated the certainty of evidence using Grading of Recommendations Assessment, Development and Evaluation - registered at PROSPERO: CRD42023396629.

Results

From 17,455 hits, 20 RCTs with 1801 participants were included. Risk of bias for most studies reporting on PA outcomes was rated as 'some concerns'. Comparing digital health intervention with minimal intervention/usual care showed no effect of objective PA (standardised mean difference (SMD) 0.85, 95% CI: -0.07 to 1.77) and a small effect of subjective PA (SMD 0.37, 95% CI: 0.05 to 0.69) at the end of intervention both graded as very low certainty of evidence. We found very low certainty of evidence for moderate effects on physical function (SMD 0.63, 95% CI: 0.03 to 1.24), and low certainty of evidence for no effect on physical fitness (SMD 0.19, 95% CI: 0.05 to 0.34) and HRQoL (SMD 0.13, 95% CI: -0.02 to 0.28), I 2= 0.00%) at the end of intervention.

Conclusion

Digital health interventions showed a small effect on subjectively measured PA, and no effect on objective PA, physical fitness and HRQoL, but may increase physical function after CR completion. Yet, the certainty of evidence is low and higher quality studies with longer follow-up duration are needed to guide this area further.

Understanding Exercise Capacity: From Elite Athlete to HFpEF

Exercise capacity is a spectrum that reflects an individual's functional capacity and the dynamic nature of cardiac remodelling along with respiratory and skeletal muscle systems. The relationship of increasing physical activity, increased cardiac mass and volumes, and improved cardiorespiratory fitness (CRF) is well established in the endurance athlete. However, less emphasis has been placed on the other end of the spectrum, which includes individuals with a more sedentary lifestyle and small hearts who are at increased risk of functional disability and poor clinical outcomes. Reduced CRF is an independent predictor of all-cause mortality and cardiovascular events determined by multiple inter-related exogenous and endogenous factors. In this review, we explore the relationship of physical activity, cardiac remodelling, and CRF across the exercise spectrum, emphasising the critical role of cardiac size in determining exercise capacity. In contrast to the large compliant left ventricle of the endurance athlete, an individual with a lifetime of physical inactivity is likely to have a small, stiff heart with reduced cardiac reserve. We propose that this might contribute to the development of heart failure with preserved ejection fraction in certain individuals, and is key to understanding the link between low CRF and increased risk of heart failure.

Women-Focused Cardiovascular Rehabilitation: An International Council of Cardiovascular Prevention and Rehabilitation Clinical Practice Guideline

Women-focused cardiovascular rehabilitation (CR; phase II) aims to better engage women, and might result in better quality of life than traditional programs. This first clinical practice guideline by the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) provides guidance on how to deliver women-focused programming. The writing panel comprised experts with diverse geographic representation, including multidisciplinary health care providers, a policy-maker, and patient partners. The guideline was developed in accordance with Appraisal of Guidelines for Research and Evaluation (AGREE) II and the Reporting Items for practice Guidelines in HealTh care (RIGHT). Initial recommendations were on the basis of a meta-analysis. These were circulated to a Delphi panel (comprised of corresponding authors from review articles and of programs delivering women-focused CR identified through ICCPR's audit; N = 76), who were asked to rate each on a 7-point Likert scale in terms of impact and implementability (higher scores positive). A Web call was convened to achieve consensus; 15 panelists confirmed strength of revised recommendations (Grading of Recommendations Assessment, Development, and Evaluation [GRADE]). The draft underwent external review from CR societies internationally and was posted for public comment. The 14 drafted recommendations related to referral (systematic, encouragement), setting (model choice, privacy, staffing), and delivery (exercise mode, psychosocial, education, self-management empowerment). Nineteen (25.0%) survey responses were received. For all but 1 recommendation, ≥ 75% voted to include; implementability ratings were < 5/7 for 4 recommendations, but only 1 for effect. Ultimately 1 recommendation was excluded, 1 separated into 2 and all revised (2 substantively); 1 recommendation was added. Overall, certainty of evidence for the final recommendations was low to moderate, and strength mostly strong. These recommendations and associated tools can support all programs to feasibly offer some women-focused programming.

The effectiveness of eHealth interventions on moderate-to-vigorous intensity physical activity among cardiac rehabilitation participants: a systematic review and meta-analysis (Preprint)

BACKGROUND

Cardiac rehabilitation is a class IA recommendation for patients with cardiovascular diseases. Physical activity is the core component and core competency of a cardiac rehabilitation program. However, many patients with cardiovascular diseases are failing to meet cardiac rehabilitation guidelines that recommend moderate-to-vigorous intensity physical activity.

OBJECTIVE

The major objective of this study was to review the evidence of the effectiveness of eHealth interventions in increasing moderate-to-vigorous intensity physical activity among patients in cardiac rehabilitation. The secondary objective was to examine the effectiveness of eHealth interventions in improving cardiovascular-related outcomes, that is, cardiorespiratory fitness, waist circumference, and systolic blood pressure.

METHODS

A comprehensive search strategy was developed, and a systematic search of 4 electronic databases (PubMed, Web of Science, Embase, and Cochrane Library) was conducted for papers published from the start of the creation of the database until November 27, 2022. Experimental studies reporting on eHealth interventions designed to increase moderate-to-vigorous intensity physical activity among patients in cardiac rehabilitation were included. Multiple unblinded reviewers determined the study eligibility and extracted data. Risk of bias was evaluated using the Cochrane Collaboration Tool for randomized controlled trials and the Cochrane Effective Practice and Organization of Care group methods for nonrandomized controlled trials. A random-effect model was used to provide the summary measures of effect (ie, standardized mean difference and 95% CI). All statistical analyses were performed using Stata 17.

RESULTS

We screened 3636 studies, but only 29 studies were included in the final review, of which 18 were included in the meta-analysis. The meta-analysis demonstrated that eHealth interventions improved moderate-to-vigorous intensity physical activity (standardized mean difference=0.18, 95% CI 0.07-0.28; P=.001) and vigorous-intensity physical activity (standardized mean difference=0.2, 95% CI 0.00-0.39; P=.048) but did not improve moderate-intensity physical activity (standardized mean difference=0.19, 95% CI -0.12 to 0.51; P=.23). No changes were observed in the cardiovascular-related outcomes. Post hoc subgroup analyses identified that wearable-based, web-based, and communication-based eHealth intervention delivery methods were effective.

CONCLUSIONS

eHealth interventions are effective at increasing minutes per week of moderate-to-vigorous intensity physical activity among patients in cardiac rehabilitation. There was no difference in the effectiveness of the major eHealth intervention delivery methods, thereby providing evidence that in the future, health care professionals and researchers can personalize convenient and affordable interventions tailored to patient characteristics and needs to eliminate the inconvenience of visiting center-based cardiac rehabilitation programs during the COVID-19 pandemic and to provide better support for home-based maintenance of cardiac rehabilitation.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42021278029; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=278029.

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.