Effect of Treadmill Testing and Exercise Training on Self-Efficacy in Patients with Heart Failure

Combined aerobic and strength training for fitness outcomes in heart failure: meta-analysis and meta-regression

PURPOSE

To compare the effects of combined training (CT) versus aerobic training (AT) or versus control on VO₂ peak and quadriceps muscle strength in patients with heart failure (HF).

MATERIALS AND METHODS

Major electronic databases were searched, from inception to November 2020, for randomized clinical trials comparing the effects of CT against AT or control on VO₂ peak and/or quadriceps muscle strength in patients with HF. Random effects meta-analyses were conducted, calculating the standardized mean difference (SMD).

RESULTS

Twenty-eight articles were included. An increase on VO₂ peak (SMD = 0.77, 95%CI 0.39-1.14, I²=80.1%) and quadriceps muscle strength (SMD = 0.67, 95%CI 0.18-1.16, I²=0%) was found in CT compared to control. CT increased quadriceps muscle strength, versus AT (SMD = 0.44, 95%CI 0.15-0.74, I²=0%). There were no differences between CT and AT on VO₂ peak (SMD=-0.01, 95%CI -0.36 to 0.34, I²=65%). Time of session and training duration moderate the effects of CT over control on VO₂ peak.

CONCLUSIONS

CT promotes increases on quadriceps muscle strength and aerobic capacity over control and provides additional gains on quadriceps muscle strength, having the same effects on VO₂ peak compared to AT. A longer time of session is associated with greater benefits to aerobic capacity.Implications for rehabilitationCombining aerobic and strength training increases the functional capacity and quadriceps muscle strength in heart failure patients.Using longer sessions of training has a greater impact on aerobic capacity.

Confirming a beneficial effect of the six-minute walk test on exercise confidence in patients with heart failure

Background:

Low confidence to exercise is a barrier to engaging in exercise in heart failure patients. Participating in low to moderate intensity exercise, such as the six-minute walk test, may increase exercise confidence.

Aim:

To compare the effects of a six-minute walk test with an educational control condition on exercise confidence in heart failure patients.

Methods:

This was a prospective, quasi-experimental design whereby consecutive adult patients attending an out-patient heart failure clinic completed the Exercise Confidence Scale prior to and following involvement in the six-minute walk test or an educational control condition.

Results:

Using a matched pairs, mixed model design ( n=60; 87% male; Mage=58.87±13.16), we identified a significantly greater improvement in Total exercise confidence ( F(1,54)=4.63, p=0.036, partial η2=0.079) and Running confidence ( F(1,57)=4.21, p=0. 045, partial η2=0.069) following the six-minute walk test compared to the educational control condition. These benefits were also observed after adjustment for age, gender, functional class and depression.

Conclusion:

Heart failure patients who completed a six-minute walk test reported greater improvement in exercise confidence than those who read an educational booklet for 10 min. The findings suggest that the six-minute walk test may be used as a clinical tool to improve exercise confidence. Future research should test these results under randomized conditions and examine whether improvements in exercise confidence translate to greater engagement in exercise behavior.

Diabetes-Related Behavior Change Knowledge Transfer to Primary Care Practitioners and Patients: Implementation and Evaluation of a Digital Health Platform

BACKGROUND

Behavioral science is now being integrated into diabetes self-management interventions. However, the challenge that presents itself is how to translate these knowledge resources during care so that primary care practitioners can use them to offer evidence-informed behavior change support and diabetes management recommendations to patients with diabetes.

OBJECTIVE

The aim of this study was to develop and evaluate a computerized decision support platform called "Diabetes Web-Centric Information and Support Environment" (DWISE) that assists primary care practitioners in applying standardized behavior change strategies and clinical practice guidelines-based recommendations to an individual patient and empower the patient with the skills and knowledge required to self-manage their diabetes through planned, personalized, and pervasive behavior change strategies.

METHODS

A health care knowledge management approach is used to implement DWISE so that it features the following functionalities: (1) assessment of primary care practitioners' readiness to administer validated behavior change interventions to patients with diabetes; (2) educational support for primary care practitioners to help them offer behavior change interventions to patients; (3) access to evidence-based material, such as the Canadian Diabetes Association's (CDA) clinical practice guidelines, to primary care practitioners; (4) development of personalized patient self-management programs to help patients with diabetes achieve healthy behaviors to meet CDA targets for managing type 2 diabetes; (5) educational support for patients to help them achieve behavior change; and (6) monitoring of the patients' progress to assess their adherence to the behavior change program and motivating them to ensure compliance with their program. DWISE offers these functionalities through an interactive Web-based interface to primary care practitioners, whereas the patient's self-management program and associated behavior interventions are delivered through a mobile patient diary via mobile phones and tablets. DWISE has been tested for its usability, functionality, usefulness, and acceptance through a series of qualitative studies.

RESULTS

For the primary care practitioner tool, most usability problems were associated with the navigation of the tool and the presentation, formatting, understandability, and suitability of the content. For the patient tool, most issues were related to the tool's screen layout, design features, understandability of the content, clarity of the labels used, and navigation across the tool. Facilitators and barriers to DWISE use in a shared decision-making environment have also been identified.

CONCLUSIONS

This work has provided a unique electronic health solution to translate complex health care knowledge in terms of easy-to-use, evidence-informed, point-of-care decision aids for primary care practitioners. Patients' feedback is now being used to make necessary modification to DWISE.

Multimedia Exercise Training Program Improves Distance Walked, Heart Rate Recovery, and Self-efficacy in Cardiac Surgery Patients

BACKGROUND

Patient education has been shown to be more effective when delivered using multimedia than written materials. However, the effects of using multimedia to assist patients in cardiac rehabilitation have not been investigated.

OBJECTIVE

The purpose of this study is to examine the effect of an inpatient multimedia exercise training program on distance walked in the 6-minute walking test (6MWT), heart rate recovery, and walking self-efficacy of patients who had undergone heart surgery.

METHODS

For this longitudinal quasi-experimental study, 60 consecutive patients were assigned to an experimental (n = 20; inpatient multimedia exercise training program) or control (n = 40; routine care) group. Data were collected at 3 times (before surgery, 1 to 2 days before hospital discharge, and 1 month after hospital discharge) and analyzed with the generalized estimating equation approach.

RESULTS

Most subjects were men (66.7%), had a mean age of 61.32 ± 13.4 years and left ventricular ejection fraction of 56.96% ± 13.28%, and underwent coronary artery bypass graft surgery (n = 34, 56.7%). Subjects receiving the exercise training program showed significantly greater improvement than those in the control group in the 6MWT walking distance (P < .001), heart rate recovery (P = .04), and self-efficacy (P = .002) at hospital discharge. Furthermore, the intervention effects on 6MWT distance (P < .001) and self-efficacy (P < .001) were sustained at 1 month after hospital discharge.

CONCLUSION

Our inpatient multimedia exercise training program safely improved distance walked in the 6MWT, heart rate recovery, and self-efficacy at hospital discharge in patients after heart surgery and maintained their improvement in 6MWT and self-efficacy 1 month later.

Adherence to recommended exercise guidelines in patients with heart failure

Exercise training has been shown to be beneficial in patients with heart failure, and its effectiveness is connected to adherence to the exercise program. Nonetheless, adherence to exercise in these patients remains a concern. Heart failure patients can be considered adherent to an exercise program if they meet 80 % of the recommended dose. We summarize exercise recommendations for patients with heart failure, identify exercise prescription methodologies used in studies that have reported exercise adherence, identify strategies and tools used to improve adherence and examine whether these strategies were developed using a theoretical platform with the primary aim to change behavior and improve adherence to exercise. Factors which may also impact adherence such as exercise setting, intensity and length of participation, gender, race, New York Heart Association functional class and heart failure with preserved and reduced ejection fraction were also investigated. Finally, recommendations for future studies for improving adherence to exercise in patients with heart failure are provided.

A model to increase rehabilitation adherence to home exercise programmes in patients with varying levels of self-efficacy

Patient adherence to rehabilitation programmes is frequently low - particularly adherence to home exercise programmes. Home exercise programmes have been identified as complementary to clinic-based physical therapy in an orthopaedic setting. Barriers to patient adherence have previously been identified within the literature. Low self-efficacy is a barrier to adherence that clinicians have the ability to have an impact on and improve. The theory of self-efficacy is defined as a person's confidence in their ability to perform a task. This theory examines the ability of a person to change through exerting control over inner processes of goal setting, self-monitoring, feedback, problem solving and self-evaluation. If clinicians are able to identify patients with low self-efficacy prior to the prescription of a home exercise programme, adjustments to individualized care can be implemented. Individualized care based on improving self-efficacy for home exercise programmes may improve patient adherence to these programmes. The purpose of this article was to use the theory of self-efficacy to direct clinicians in providing individualized programmes to patients with varying levels of self-efficacy.

Heart Failure and Exercise: A Narrative Review of the Role of Self-Efficacy

Chronic heart failure (CHF) is a common, debilitating condition associated with significant health and economic burden. CHF management is multidisciplinary, however, achieving better health relies on a collaborative effort and patient engagement in self-care. Despite the importance of self-care in CHF, many patients have poor adherence to their medical and lifestyle regimens, in particular with regards to engaging in physical exercise. The patient's confidence in their ability, otherwise known as self-efficacy, is an important determinant of CHF health outcomes, most likely due to its effect on the uptake of CHF self-care activities especially exercise initiation and maintenance. Self-efficacy is responsive to experience such as exercise training, however the critical components of exercise interventions to improve self-efficacy have yet to be determined. This narrative review provides an overview of the role of self-efficacy in exercise adherence in CHF.

The home physical environment and its relationship with physical activity and sedentary behavior: a systematic review

Reviews of neighborhood (macro) environment characteristics such as the presence of sidewalks and esthetics have shown significant correlations with resident physical activity (PA) and sedentary (SD) behavior. Currently, no comprehensive review has appraised and collected available evidence on the home (micro) physical environment. The purpose of this review was to examine how the home physical environment relates to adult and child PA and SD behaviors. Articles were searched during May 2014 using Medline, PsycINFO, PubMed, Scopus, and SPORTDiscus databases which yielded 3265 potential studies. Papers were considered eligible if they investigated the presence of PA (ie. exercise equipment, exergaming devices) or SD (ie. television, videogames) equipment and PA or SD behavior. After, screening and manual cross-referencing, 49 studies (20 experimental and 29 observational designs) were found to meet the eligibility criteria. Interventions that reduced sedentary time by using TV limiting devices were shown to be effective for children but the results were limited for adults. Overall, large exercise equipment (ie. treadmills), and prominent exergaming materials (exergaming bike, dance mats) were found to be more effective than smaller devices. Observational studies revealed that location and quantity of televisions correlated with SD behavior with the latter having a greater effect on girls. This was similarly found for the quantity of PA equipment which also correlated with behavior in females. Given the large market for exercise equipment, videos and exergaming, the limited work performed on its effectiveness in homes is alarming. Future research should focus on developing stronger randomized controlled trials, investigate the location of PA equipment, and examine mediators of the gender discrepancy found in contemporary studies.

An integrative review: application of self-efficacy instruments for walking in populations with peripheral arterial disease

OBJECTIVE

The study objective was to identify which self-efficacy measurement instruments are being used for walking in patients with peripheral arterial disease (PAD), the psychometrics of these instruments, and recommendations for use in research on patients with PAD.

BACKGROUND

PAD is a common problem for individuals with similar risk factors as cardiovascular disease (CVD). Experts recommend a supervised walking program with incremental increases in speed and distance as an initial treatment for patients with intermittent claudication. Because patients may experience pain while walking, there is a tendency to be nonadherent with exercise therapy, and many limit or avoid walking all together, resulting in a sedentary lifestyle. Self-efficacy plays a role in determining a person's confidence in his or her ability to participate in an exercise program. Data sources for this study were PubMed, Cumulative Index of Nursing and Allied Health Literature, PsycINFO, and the Cochrane database.

METHODS

The integrative review method described by Wittemore and Knafl was used for this review (Wittemore R, Knafl K. The integrative review: updated methodology. J Adv Nurs 2005;52:546-53.). Publications were retrieved electronically and reviewed for inclusion on the basis of studies that measured self-efficacy for walking in populations with PAD, peripheral vascular disease, and CVD. The analysis consisted of 9 publications.

RESULTS

Only 2 studies were specific to the population with PAD. The remaining studies addressed self-efficacy issues in CVD or congestive heart failure. The analysis identified 4 instruments based on Bandura's Social Cognitive Theory that were used to assess self-efficacy: (1) the Self-Efficacy Expectation Scale, (2) the Self-Efficacy for Managing Chronic Disease Scale, (3) the Performance-Based Efficacy Scale, and (4) the Barriers Self-Efficacy Scale. The Self-Efficacy Expectation Scale was most frequently used in these studies.

CONCLUSIONS

The use of the Self-Efficacy Expectation Scale instruments for walking in patients with PAD is limited because reliability and validity have been demonstrated in an older, mostly white population with CVD and congestive heart failure. Instruments that encompass the key constructs of self-efficacy, including physical, personal, and environmental aspects, would allow full evaluation with identification of potential explanations for success or failure for the chosen outcome. This should be taken into consideration in future studies when using instruments of self-efficacy.

Functional status, anxiety, cardiac self-efficacy, and health beliefs of patients with coronary heart disease

BACKGROUND

Beliefs and emotions could effect on functional status, quality of life, and mortality amongst patients who are suffering coronary heart disease (CHD). Current study examined the role of anxiety: trait/ state, self-efficacy, health beliefs, and functional status among patient with history of CHD.

METHOD

In this correlational study, 105 hospitalized and outpatients patients suffering CHD in Tehran Heart Center Hospital participated by using convenience sampling method in 2012. Cardiac self-efficacy, Seattle Angina, and research-designed health beliefs questionnaires were used to gather data.

RESULTS

The functional status in CHD patients showed significant relationships with gender, job, and type of medical insurance of the participants (All ps<0.05). In addition , perceived vulnerability to face again cardiac attack in the future, per-ceived severity of next cardiac attack, anxiety, state anxiety and trait anxiety (All ps<0.05) had significant and negative relationships with functional status. Con-versely, the cardiac self-efficacy had a positive and significant relationship (P<0.001) with functional status.

CONCLUSION

Psychological factors have important role in functional status and quality of life of patients who suffering CHD. Therefore, it is necessary to emphasize on supportive and complementary programs to promote Cardiac Reha-bilita-tion Programs.

Benefits of wellness interventions for persons with chronic and disabling conditions: a review of the evidence

BACKGROUND

Persons living with the effects of chronic and disabling conditions are often at increased risk for the development of secondary conditions and disabilities that can lead to further decline in health status, independence, functional status, life satisfaction, and overall quality of life.

OBJECTIVE

The purpose of this study was to review the evidence for the benefits of wellness/health promotion interventions for persons with chronic and disabling conditions.

METHODS

The authors conducted a Medline search (1990-2007) using terms related to wellness and health promotion cross-referenced with general terms for chronic and disabling conditions, as well as 15 specific chronic and/or disabling conditions (e.g., multiple sclerosis, spinal cord injury). Selection of studies was limited to those published in English that reported randomized controlled trails or prospective studies that involved adult human subjects with a chronic and/or disabling condition. All selected studies focused on some aspect of a wellness or health promotion intervention and involved a comparison or control group. Of the 5,847 studies initially identified in the search using medical subject heading terms, 190 met the criteria for full review. Data were extracted from these publications and summarized using descriptive statistics.

RESULTS

Almost all studies (95%) explored the effects of wellness intervention in a sample diagnosed with a single condition (e.g., cancer, stroke, arthritis). Although the mean sample size was 100, the range in sample size varied widely (6-688); 25% of the studies had sample of 30 or fewer. Almost all studies (89.5%) reported positive effects of the wellness intervention, although the delivery and content of interventions as well as the measurement of outcomes, varied greatly.

CONCLUSIONS

Our findings support an immediate post-intervention positive impact of wellness interventions across persons with a wide variety of chronic and disabling conditions. Future research that clearly specifies primary study outcomes and follows the CONSORT guidelines will strengthen future reviews of the evidence and facilitate application of the evidence of practice.

Limitations to high intensity exercise prescription in chronic heart failure patients

BACKGROUND

Interval training is recommended for chronic heart failure patients (CHF), but specific guidelines on setting appropriate workloads have not been fully established. The aim of this study was to compare a traditional method of interval training prescription with a protocol specifically designed for CHF.

METHODS

Ten CHF and 7 healthy controls performed 2 maximal incremental cycle tests to determine interval training workload; a standard test (10Wmin(-)(1)) and a steep test (25W.10(-)(s)). Peak work rate and oxygen uptake (VO(2 peak)) were determined. Training workloads were defined as 100% standard test and 50% steep test peak work rate.

RESULTS

Training workload determined from the standard test was higher than from the steep test in healthy controls (151 ± 17W vs 118 ± 13W; P<0.01), whereas in CHF there was no significant difference between methods (88 ± 10W vs 96 ± 9W; P>0.05). Steep test VO(2peak) reached 91 ± 5% of standard test VO(2 peak) in controls, and 99 ± 4% in CHF, with no significant differences between tests in either group.

CONCLUSION

Prescribing interval training from a standard test results in higher workloads than from a steep test in healthy individuals, but in CHF both methods prescribe similar workloads. However it should not be assumed that the two tests can be used interchangeably for CHF. This small-sized study raises issues about interval training prescription that may be hypothesis-generating for future larger-scale studies.

Self-efficacy as a marker of cardiac function and predictor of heart failure hospitalization and mortality in patients with stable coronary heart disease: findings from the Heart and Soul Study

OBJECTIVE

The authors sought to evaluate the association of self-efficacy with objective measures of cardiac function, subsequent hospitalization for heart failure (HF), and all-cause mortality.

DESIGN

Observational cohort of ambulatory patients with stable CHD. The authors measured self-efficacy using a published, validated, 5-item summative scale, the Sullivan Self-Efficacy to Maintain Function Scale. The authors also performed a cardiac assessment, including an exercise treadmill test with stress echocardiography.

MAIN OUTCOME MEASURES

Hospitalizations for HF, as determined by blinded review of medical records, and all-cause mortality, with adjustment for demographics, medical history, medication use, depressive symptoms, and social support.

RESULTS

Of the 1,024 predominately male, older CHD patients, 1013 (99%) were available for follow-up, 124 (12%) were hospitalized for HF, and 235 (23%) died during 4.3 years of follow-up. Mean cardiac self-efficacy score was 9.7 (SD 4.5, range 0-20), corresponding to responses between "not at all confident" and "somewhat confident" for ability to maintain function. Lower self-efficacy predicted subsequent HF hospitalization (OR per SD decrease = 1.4, p = .0006), and all-cause mortality (OR per SD decrease = 1.4, p < .0001). After adjustment, the association of cardiac self-efficacy with both HF hospitalization and mortality was explained by worse baseline cardiac function.

CONCLUSION

Among patients with CHD, self-efficacy was a reasonable proxy for predicting HF hospitalizations. The increased risk of HF associated with lower baseline self-efficacy was explained by worse cardiac function. These findings indicate that measuring cardiac self-efficacy provides a rapid and potentially useful assessment of cardiac function among outpatients with CHD.

Chronic heart failure: promoting quality of life

There are growing numbers of people with heart failure, which is disabling for the individuals and costly for the health services. Heart failure is often associated with anxiety and depression. Nurses can improve patients' well-being by promoting regular exercise and self-care. Palliative care, which includes specialist heart failure services improves end-of-life experiences. This article reports the findings of a literature review derived from a search of 5 electronic databases to identify studies relating to the promotion of quality of life in chronic heart failure.

Reliability and validity of the self-efficacy expectations and outcome expectations after implantable cardioverter defibrillator implantation scales

The purpose of this study was to assess the reliability and validity characteristics of two new scales that measure self-efficacy expectations (Self-Efficacy Expectations After Implantable Cardioverter Defibrillator Implantation Scale [SE-ICD]) and outcome expectations (Outcome Expectations After ICD Implantation Scale [OE-ICD]) in survivors (N = 168) of sudden cardiac arrest, all of whom received an ICD. Cronbach's alpha reliability demonstrated good internal consistency (SE-ICD alpha = .93 and OE-ICD alpha = .81). Correlations with other self-efficacy instruments (general self-efficacy and social self-efficacy) were consistently high. The instruments were responsive to change across time with effect sizes of .46 for SE-ICD and .26 for OE-ICD. These reliable, valid, and responsive instruments for measurement of self-efficacy expectations and outcome expectations after an ICD can be used in research and clinical settings.

Self-efficacy and health status in patients with coronary heart disease: findings from the heart and soul study

OBJECTIVE

To examine the relationship between cardiac self-efficacy and health status, including symptom burden, physical limitation, quality of life, and overall health among outpatients with stable coronary heart disease (CHD). We hypothesized that lower self-efficacy would predict worse health status, independent of CHD severity and depression.

METHODS

We performed a cross-sectional study of 1024 outpatients with CHD, who were recruited between 2000 and 2002 for the Heart and Soul Study. We administered a validated measure of cardiac self-efficacy, assessed cardiac function using exercise treadmill testing with stress echocardiography, and measured depressive symptoms using the Patient Health Questionnaire. Health status outcomes (symptom burden, physical limitation, and quality of life) were assessed using the Seattle Angina Questionnaire, and overall health was measured as fair or poor (versus good, very good, or excellent).

RESULTS

After adjustment for CHD severity and depressive symptoms, each standard deviation (4.5-point) decrease in self-efficacy score was independently associated with greater symptom burden (adjusted odds ratio (OR) = 2.1, p = .001), greater physical limitation (OR = 1.8, p < .0001), worse quality of life (OR = 1.6, p < .0001), and worse overall health (OR = 1.9, p < .0001). Depressive symptoms and poor treadmill exercise capacity were also associated with poor health status, but left ventricular ejection fraction and ischemia were not.

CONCLUSIONS

Among patients with CHD, low cardiac self-efficacy is associated with poor health status, independent of CHD severity and depressive symptoms. Further study should examine if self-efficacy constitutes a useful target for cardiovascular disease management interventions.