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Marzolini S, Brunne A, Hébert AA, Mayo AL, MacKay C. Barriers and Facilitators to Cardiovascular Rehabilitation Programmes for People with Lower Limb Amputation: A Survey of Clinical Practice in Canada. Physiother Can 2024; 76:199-208. [PMID: 38725599 PMCID: PMC11078241 DOI: 10.3138/ptc-2022-0043] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 07/29/2022] [Accepted: 08/30/2022] [Indexed: 05/12/2024]
Abstract
Purpose This study determines barriers and facilitators to including people with lower limb amputation (LLA) in cardiovascular rehabilitation programmes (CRPs). Method Canadian CRP managers and exercise therapists were invited to complete a questionnaire. Results There were 87 respondents. Of the 32 CRP managers, 65.6% reported that people with LLA were eligible for referral, but of these, 61.9% only accepted people with LLA and cardiac disease, and 38.1% only accepted them with ≥ 1 cardiovascular risk factor. CRP eligibility progressively decreased as mobility severity increased, with 94% of programmes accepting those with mild mobility deficits but only 48% accepting those with severe deficits. Among therapists in CRPs that accepted LLAs, 54.3% reported not having an LLA participant within the past three years. Among all responding therapists and managers who were also therapists (n = 58), 43% lacked confidence in managing safety concerns, and 45%, 16%, and 7% lacked confidence in prescribing aerobic exercise to LLA with severe, moderate, and no mobility deficits respectively. There was a similar finding with prescribing resistance training. LLA-specific education had not been provided to any respondent within the past three years. The top barriers were lack of referrals (52.6%; 30) and lack of knowledge of the contraindications to exercise specific for LLA (43.1%; 31). Facilitators included the provision of a resistance-training tool kit (63.4%; 45), education on exercise safety (63.4%; 45), and indications for physician intervention/inspection (63.6%; 42). Conclusion Most of the CRPs surveyed only accept people with LLA if they have co-existing cardiac disease or cardiovascular risk factors. Few people with LLA participate. Education on CRP delivery for LLAs is needed to improve therapists' confidence and exercise safety.
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Affiliation(s)
- Susan Marzolini
- From the:
KITE Research Institute, Toronto Rehabilitation Institute – University Health Network, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Amanda Brunne
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | | | - Amanda L. Mayo
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Crystal MacKay
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
- West Park Healthcare Centre, Toronto, Ontario, Canada
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Nguyen CH, Marzolini S. Pre-participation Withdrawal and Noncompletion of Cardiac Rehabilitation in Peripheral Artery Disease: MATCHED COMPARISONS TO CORONARY ARTERY DISEASE. J Cardiopulm Rehabil Prev 2024; 44:55-63. [PMID: 37624048 DOI: 10.1097/hcr.0000000000000818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
PURPOSE Despite the mortality benefit of cardiac rehabilitation (CR) participation, as well as its cost-effectiveness for people with peripheral artery disease (PAD), there are limited data on adherence and completion of CR in those with and without concomitant coronary artery disease (CAD). The objective of this study was to compare CR pre-participation withdrawal and noncompletion between patients with PAD and concomitant PAD and CAD (PAD/CAD) versus matched and unmatched patients with CAD (uCAD). METHODS Consecutively referred patients between 2006-2017 with PAD (n = 271) and PAD/CAD (n = 610) were matched to CAD by age, sex, diabetes, smoking status, and referral year. The uCAD (n = 14 487) group was included for comparison. Reasons for withdrawal were ascertained by interview. RESULTS There were no significant differences in pre-participation withdrawal between PAD and matched CAD (46 vs 43%, P = .49), nor in noncompletion (22 vs 18%, P = .28). Results were similar for PAD/CAD and matched CAD (withdrawal: 36 vs 34%, P = .37) and (noncompletion: 25 vs 23%, P = .46). A smaller proportion of patients with uCAD withdrew (28%) than patients with PAD ( P < .001) and PAD/CAD ( P < .001), with no difference in noncompletion ( P > .40, both). There were no differences between PAD and PAD/CAD and their matched counterparts for medical and nonmedical reasons for withdrawal and noncompletion ( P ≥ .25, all). CONCLUSION Pre-participation withdrawal rates were similar between patients with PAD, PAD/CAD, and their matched cohorts but greater than patients with uCAD. Once patients started CR, there were similar completion rates among all groups. Reports that patients with PAD are less likely to start CR may be related to their complex medical profile rather than PAD alone. Strategies to improve participation among patients with PAD should focus on the immediate post-referral period.
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Affiliation(s)
- Cindy H Nguyen
- Michael DeGroote School of Medicine, McMaster University-Niagara Regional Campus, St Catharines, Ontario, Canada (Dr Nguyen); KITE Research Institute, Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada (Drs Nguyen and Marzolini); Department of Exercise Sciences, Faculty of Kinesiology and Physical Education (Dr Marzolini), and Rehabilitation Sciences Institute, Temerty Faculty of Medicine (Dr Marzolini), University of Toronto, Toronto, Ontario, Canada; and Healthy Living for Pandemic Event Protection (HL-PIVOT) Network, Toronto, Ontario, Canada (Dr Marzolini)
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Marzolini S, Nguyen CH. Determining the Optimal Type of Exercise for People With Symptomatic Lower Extremity Peripheral Artery Disease: Is There a One-Size-Fits-All Approach? J Cardiopulm Rehabil Prev 2023; 43:315-317. [PMID: 37615670 DOI: 10.1097/hcr.0000000000000814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Affiliation(s)
- Susan Marzolini
- KITE Research Institute, Toronto Rehabilitation Institute-University Health Network, Toronto, Canada (Drs Marzolini and Nguyen); Department of Exercise Sciences, Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Canada, and Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada (Dr Marzolini); and Department of Physical Medicine and Rehabilitation, School of Medicine, Queen's University, Kingston, Canada (Dr Nguyen)
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Clinical Determinants and Barriers to Cardiac Rehabilitation Enrollment of Patients with Heart Failure with Reduced Ejection Fraction: A Single-Center Study in Portugal. J Cardiovasc Dev Dis 2022; 9:jcdd9100344. [PMID: 36286296 PMCID: PMC9604186 DOI: 10.3390/jcdd9100344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 09/28/2022] [Accepted: 10/07/2022] [Indexed: 11/07/2022] Open
Abstract
Despite cardiac rehabilitation (CR) being a recommended treatment for patients with heart failure with reduced ejection fraction (HFrEF), it is still underused. This study investigated the clinical determinants and barriers to enrollment in a CR program for HFrEF patients. We conducted a cohort study using the Cardiac Rehabilitation Barriers Scale (CRBS) to assess the reason for non-enrollment. Of 214 HFrEF patients, 65% had not been enrolled in CR. Patients not enrolled in CR programs were older (63 vs. 58 years; p < 0.01) and were more likely to have chronic obstructive pulmonary disease (COPD) (20% vs. 5%; p < 0.01). Patients enrolled in CR were more likely to be treated with sacubitril/valsartan (34% vs. 19%; p = 0.01), mineralocorticoid receptor antagonists (84% vs. 72%; p = 0.04), an implantable cardioverter defibrillator (ICD) (41% vs. 20%; p < 0.01), and cardiac resynchronization therapy (21% vs. 10%; p = 0.03). Multivariate analysis revealed that age (adjusted OR 1.04; 95% CI 1.01−1.07), higher education level (adjusted OR 3.31; 95% CI 1.63−6.70), stroke (adjusted OR 3.29; 95% CI 1.06−10.27), COPD (adjusted OR 4.82; 95% CI 1.53−15.16), and no ICD status (adjusted OR 2.68; 95% CI 1.36−5.26) were independently associated with CR non-enrollment. The main reasons for not being enrolled in CR were no medical referral (31%), concomitant medical problems (28%), patient refusal (11%), and geographical distance to the hospital (9%). Despite the relatively high proportion (35%) of HFrEF patients who underwent CR, the enrollment rate can be further improved. Innovative multi-level strategies addressing physicians’ awareness, patients’ comorbidities, and geographical issues should be pursued.
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Post pandemic research priorities: A consensus statement from the HL-PIVOT. Prog Cardiovasc Dis 2022; 73:2-16. [PMID: 35842068 PMCID: PMC9278010 DOI: 10.1016/j.pcad.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 07/09/2022] [Indexed: 11/20/2022]
Abstract
We have been amid unhealthy living and related chronic disease pandemics for several decades. These longstanding crises have troublingly synergized with the coronavirus disease 2019 (COVID-19) pandemic. The need to establish research priorities in response to COVID-19 can be used to address broad health and wellbeing, social and economic impacts for the future is emerging. Accordingly, this paper sets out a series of research priorities that could inform interdisciplinary collaboration between clinical sciences, public health, business, technology, economics, healthcare providers, and the exercise science/sports medicine communities, among others. A five-step methodology was used to generate and evaluate the research priorities with a focus on broad health and well-being impacts. The methodology was deployed by an international and interdisciplinary team from the Healthy Living for Pandemic Event Protection (HL- PIVOT) network. This team were all engaged in responding to the Pandemic either on the 'front-line' and/or in leadership positions ensuring the currency and authenticity of the process. Eight research priorities were identified clustered into two groups: i) Societal & Environmental, and ii) Clinical. Our eight research priorities are presented with insight from previously published research priorities from other groups.
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Building your Peripheral Artery Disease Tool Kit: Medical Management of PAD in 2022. Can J Cardiol 2022; 38:634-644. [DOI: 10.1016/j.cjca.2022.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/24/2022] [Accepted: 02/05/2022] [Indexed: 12/24/2022] Open
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Peterman JE, Arena R, Myers J, Marzolini S, Ades PA, Savage PD, Lavie CJ, Kaminsky LA. Reference Standards for Cardiorespiratory Fitness by Cardiovascular Disease Category and Testing Modality: Data From FRIEND. J Am Heart Assoc 2021; 10:e022336. [PMID: 34747182 PMCID: PMC8751972 DOI: 10.1161/jaha.121.022336] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The importance of cardiorespiratory fitness for stratifying risk and guiding clinical decisions in patients with cardiovascular disease is well‐established. To optimize the clinical value of cardiorespiratory fitness, normative reference standards are essential. The purpose of this report is to extend previous cardiorespiratory fitness normative standards by providing updated cardiorespiratory fitness reference standards according to cardiovascular disease category and testing modality. Methods and Results The analysis included 15 045 tests (8079 treadmill, 6966 cycle) from FRIEND (Fitness Registry and the Importance of Exercise National Database). Using data from tests conducted January 1, 1974, through March 1, 2021, percentiles of directly measured peak oxygen consumption (VO2peak) were determined for each decade from 30 through 89 years of age for men and women with a diagnosis of coronary artery bypass surgery, myocardial infarction, percutaneous coronary intervention, or heart failure. There were significant differences between sex and age groups for VO2peak (P<0.001). The mean VO2peak was 23% higher for men compared with women and VO2peak decreased by a mean of 7% per decade for both sexes. Among each decade, the mean VO2peak from treadmill tests was 21% higher than the VO2peak from cycle tests. Differences in VO2peak were observed among the age groups in both sexes according to cardiovascular disease category. Conclusions This report provides normative reference standards by cardiovascular disease category for both men and women performing cardiopulmonary exercise testing on a treadmill or cycle ergometer. These updated and enhanced reference standards can assist with patient risk stratification and guide clinical care.
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Affiliation(s)
- James E Peterman
- Fisher Institute of Health and Well-BeingCollege of HealthBall State University Muncie IN.,Healthy Living for Pandemic Event Protection (HL-PIVOT) Network Chicago IL
| | - Ross Arena
- Healthy Living for Pandemic Event Protection (HL-PIVOT) Network Chicago IL.,Department of Physical Therapy College of Applied Science University of Illinois at Chicago Chicago IL
| | - Jonathan Myers
- Healthy Living for Pandemic Event Protection (HL-PIVOT) Network Chicago IL.,Division of Cardiology Veterans Affairs Palo Alto Healthcare System and Stanford University Palo Alto CA
| | - Susan Marzolini
- Healthy Living for Pandemic Event Protection (HL-PIVOT) Network Chicago IL.,KITEToronto Rehabilitation InstituteUniversity Health Network Toronto Ontario Canada
| | - Philip A Ades
- Division of Cardiology University of Vermont College of Medicine Burlington VT
| | - Patrick D Savage
- Healthy Living for Pandemic Event Protection (HL-PIVOT) Network Chicago IL.,Division of Cardiology University of Vermont College of Medicine Burlington VT
| | - Carl J Lavie
- Healthy Living for Pandemic Event Protection (HL-PIVOT) Network Chicago IL.,John Ochsner Heart and Vascular InstituteOchsner Clinical SchoolThe University of Queensland School of Medicine New Orleans LA
| | - Leonard A Kaminsky
- Fisher Institute of Health and Well-BeingCollege of HealthBall State University Muncie IN.,Healthy Living for Pandemic Event Protection (HL-PIVOT) Network Chicago IL
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Marzolini S, Banks L, Oh PI. Sex Differences in Predictors of Completion of a 6-month Adapted Cardiac Rehabilitation Program for People with Type 2 Diabetes and No Known Cardiac Disease. Can J Diabetes 2021; 46:277-286.e1. [DOI: 10.1016/j.jcjd.2021.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 10/19/2021] [Accepted: 11/01/2021] [Indexed: 11/16/2022]
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Harwood AE, Pymer S, Ibeggazene S, Ingle L, Caldow E, Birkett ST. Provision of exercise services in patients with peripheral artery disease in the United Kingdom. Vascular 2021; 30:874-881. [PMID: 34348503 PMCID: PMC9485155 DOI: 10.1177/17085381211035259] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Objectives Supervised exercise programmes (SEPs) are a vital treatment for people with intermittent claudication, leading improvements in walking distance and quality of life and are recommended in multiple national and international guidelines. We aimed to evaluate the use and structure of SEPs in the United Kingdom (UK). Design We conducted an anonymous online survey using the Jisc platform comprising of 40 questions. The survey was designed to address key areas such as access, provision, uptake and delivery of SEPs in the United Kingdom. Ethical approval was obtained from Coventry University (P108729). Methods The list of trusts providing vascular services was obtained from the National Vascular Registry (NVR) report. The survey was disseminated via social media, The Vascular Society of Great Britain and Ireland and the Society for Vascular Technology. Data were exported to a Microsoft Excel document and analysed using simple descriptive statistics. Results Of 93 vascular units identified, we received response from 48. Of these, 23 had access to an exercise programme (48%). The majority of SEPs were exclusively for PAD patients (77%), with 21% using integrated services. 67% of respondents were providing a circuit-based programme, and 5 out of 23 were meeting the dose recommendations in the UK National Institute for Health and Care Excellence (NICE) guidelines. Respondents felt that programmes were moderately to extremely important to patients, slightly to very important to clinicians and not at all important to slightly important to commissioning/funding bodies. Conclusion SEPs are a well-established first-line treatment for patients with IC and they are recommended by NICE guidelines. Despite this, many patients still do not have access to an exercise programme, and clinicians do not feel that they have support from commissioning/funding bodies to develop them. There is an urgent need for funding, development and delivery of SEPs in the United Kingdom.
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Affiliation(s)
- Amy E Harwood
- Centre for Sport, Exercise and Life Sciences, Faculty of Health and Life Sciences, Science and Health Building, Whitefriars Street, RinggoldID:120958Coventry University, Coventry, UK
| | - Sean Pymer
- Academic Vascular Surgical Unit, 12195Hull York Medical School, Hull, UK
| | - Said Ibeggazene
- College of Health, Wellbeing and Life Sciences, 7314Sheffield Hallam University, Sheffield, UK
| | - Lee Ingle
- Department of Sport, Health and Exercise Sciences, Faculty of Health Sciences, 4019University of Hull, Hull, UK
| | - Eddie Caldow
- School of Health and Society, 7046University of Salford, Salford, UK
| | - Stefan T Birkett
- School of Sport and Health Sciences, 6723University of Central Lancashire, Preston, UK
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Barraclough JY, Harmer JA, Yu J, Figtree GA, Arnott C. Why Are We Forgetting Patients With Peripheral Arterial Disease? Heart Lung Circ 2021; 30:939-942. [PMID: 33965306 DOI: 10.1016/j.hlc.2021.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
| | - Jason A Harmer
- The George Institute for Global Health, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Jie Yu
- The George Institute for Global Health, Sydney, NSW, Australia
| | - Gemma A Figtree
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia; The Kolling Institute, University of Sydney, Sydney, NSW, Australia
| | - Clare Arnott
- The George Institute for Global Health, Sydney, NSW, Australia; Royal Prince Alfred Hospital, Sydney, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
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