Individualized vs. group exercise in improving quality of life and physical activity in patients with cardiac disease and low exercise capacity: results from the DOPPELHERZ trial

Impact of reduced group size on patient adherence and functional outcomes in cardiac rehabilitation: insights from a COVID-19 pandemic natural experiment

Introduction

Cardiac rehabilitation (CR) adherence and functional outcomes were measured after COVID-19 regulations reduced group sizes to one-on-one, modeling a natural experiment.

Methods

A retrospective analysis using a natural experiment model measured participants in 12 weeks of CR during the 17 months before and after a COVID-19-related closure was conducted. The age, sex, race, ethnicity, and referral diagnoses of the pre-COVID-19 closure and post-COVID-19 closure groups were analyzed using a student's unpaired T-test. Adherence (completion rate of CR) and functional outcomes [change in six-minute walk test (6MWT)] were assessed between the two groups using unpaired two-tailed student T tests in GraphPad Prism and confidence intervals were calculated with the Baptista-Pike method.

Results

There were 204 patients in the pre-COVID-19 group and 51 patients in the post-COVID-19 group, due to the smaller group sizes in the post-COVID-19 group, with no significant differences in baseline characteristics between the groups. The pre-COVID-19 group had a higher patient-to-provider ratio [2.8 patients/provider (SD 0.74)] relative to the post-COVID-19 group [0.4 patients/provider (SD 0.12); p < 0.0001]. The post-COVID-19 group had a higher completion rate than pre-COVID-19 group [75% vs. 21%; OR 10.9 (95% CI, 5.3-21.3, p < 0.0001)]. Among those that completed CR, there was no significant difference between groups in 6MWT improvement [+377.9 ft. (n = 47; SD 275.67 ft.) vs. +346.9 ft. (n = 38; SD 196.27 ft.); p = 0.59].

Discussion

The reduction in group size to one-on-one was associated with 10 times higher odds of CR completion. Among those that completed CR, functional outcomes were not influenced by group size. Thus, pursuit of one-on-one sessions may improve CR adherence.

Effects of a physical therapist-driven individualized hybrid model of the exercise component of cardiac rehabilitation on patient outcomes: a prospective single group, time-series design

PURPOSE

The aim of this prospective single group, time-series study was to determine the feasibility, adherence, and effectiveness of an individualized physical therapist (PT)-driven hybrid model of the exercise component of cardiac rehabilitation (CR) that uses a novel intensity-recovery progression protocol (IRPP) and cardiac testing template (CTT) to assess achieved heart rate (HR) intensity, HR recovery, and intensity-recovery total to guide treatment.

METHODS

Assessment of a questionnaire, treadmill 6-min walk (6MW), 1-min sit-to-stand (1STS), 1-min step, and 1-min agility square tests were assessed on 100 participants. Compared to traditional CR the 36-visit 1:1 hybrid model was individualized using the IRPP program and CTT.

RESULTS

Adherence was 35% (timely) and 44% (overall) completion. The per-protocol analysis (PPA) and intent-to-treat (ITT) analysis suggest significant improvement in objective assessments baseline to visit 15 (PPA = 11 of 14) (ITT = 13 of 14), baseline to visit 30 (PPA = 12 of 14) (ITT = 12 of 14) and visit 15 to visit 30 (PPA = 9 of 14) (ITT = 10 of 14). Improvement beyond the minimal clinically important difference (MCID) was 94.3% in the 6MW and 91.4% in the 1STS.

CONCLUSIONS

The PT-driven IRPP program was feasible in terms of adherence and safety, showing significant improvement in a majority of assessments. Analysis of HR using the CTT may help clinical decision making for progression in CR.Implications for rehabilitationCardiac rehabilitation (CR) is an underutilized means of improving health for people recovering from cardiac surgery.People recovering from cardiac surgery have complex reasons for why they choose to enroll in, drop out from, or complete a CR program.Reporting of outcomes in CR and progression in intensity is not often individualized.An individualized physical therapist driven CR program using both subjective and objective assessments may be successful at improving adherence and effectiveness in this cohort.

Participant Engagement in Supported Employment: A Systematic Scoping Review

Purpose This study aimed to synthesise the available knowledge on how participant engagement in supported employment (SE) interventions is presented, defined, and conceptualised. We also aimed to develop a working definition of participant engagement in SE based on the results of our study. Methods This systematic scoping review was conducted following the PRISMA extension for scoping reviews. The following databases were systematically searched: EBSCO, SCOPUS, Social Care Online, and JSTOR. We included peer-reviewed publications in English based on empirical studies. Results Sixteen articles met the inclusion criteria and were included in the final analysis. Thematic framework analysis resulted in three themes conveying the concept of participant engagement: self-determined choice, empowerment, and collaboration/working alliance. We suggest that participant engagement in SE is an active multifaceted process that involves the empowerment of participants, participants' exercise of self-determined informed choice, and their collaboration with SE practitioners in a working alliance. Conclusions Participant empowerment, self-determined choice, and collaboration are important aspects of participant engagement in SE. The study results will appeal to SE practitioners and make significant contributions to the broader field of other vocational services supporting people in (re-)entering the competitive labour market.

Long-term Cardiac Maintenance Programming: A SINGLE-SITE ANALYSIS OF MORE THAN 200 PARTICIPANTS

PURPOSE

Greater than 65% of all cardiac mortality is related to coronary artery disease (CAD). Cardiac rehabilitation (CR) aims to reduce cardiovascular risk and number of hospital readmissions. Cardiac maintenance programs (CMPs) are designed to sustain or improve health after completing early CR. Although CMPs are supported by most national health guidelines, few long-term studies on these diverse programs have been performed.

METHODS

This was a retrospective repeated-measures analysis with case-controlled subanalysis. Within-subject differences for CMP participants were examined between enrollment and last clinical visit. Assessments included medical history, anthropometry, blood analysis, and cardiopulmonary exercise testing. A subset of 20 CMP participants were compared with 20 patients with CAD who chose not to participate in CMP, matched for age, sex, and follow-up duration.

RESULTS

A total of 207 patients (60 ± 9 yr, 16% female) were included for the primary analyses. Average follow-up was 6.3 ± 4.8 yr (range 4-20 yr). CMP participants reduced peak workload (1.76 ± 0.56 to 1.60 ± 0.58 W/kg; P < .001) and aerobic capacity (26.1 ± 6.2 to 24.6 ± 7.1 mL/kg/min; P = .003). High-density lipoprotein-cholesterol increased significantly (48 ± 12 to 51 ± 14 mg/dL; P < .001), whereas all other metabolic risk factors remained unaffected. Matched controls had higher functional capacity (2.35 ± 0.81 vs 1.56 ± 0.52 W/kg; P < .001) and lower body mass index (25.3 ± 3.6 vs 28.6 ± 3.9 kg/m2) at baseline, but no significant differences with respect to long-term efficacy were observed.

CONCLUSIONS

Long-term participation in CMP did not result in maintaining functional capacity or cardiovascular risk profile in patients with CAD. However, compared with matched nonparticipants, CMP participants (are more deconditioned at baseline) but do not seem to deteriorate as quickly.

Mobile Health Monitoring of Cardiac Status

Cardiovascular diseases (CVDs) are responsible for more deaths than any other cause, with coronary heart disease and stroke accounting for two-thirds of those deaths. Morbidity and mortality due to CVD are largely preventable, through either primary prevention of disease or secondary prevention of cardiac events. Monitoring cardiac status in healthy and diseased cardiovascular systems has the potential to dramatically reduce cardiac illness and injury. Smart technology in concert with mobile health platforms is creating an environment where timely prevention of and response to cardiac events are becoming a reality.

Accelerometer- and Pedometer-Based Physical Activity Interventions Among Adults With Cardiometabolic Conditions: A Systematic Review and Meta-analysis

Importance

Accelerometers and pedometers are accessible technologies that could have a role in encouraging physical activity (PA) in line with current recommendations. However, there is no solid evidence of their association with PA in participants with 1 or more cardiometabolic conditions such as diabetes, prediabetes, obesity, and cardiovascular disease.

Objectives

To assess the association of accelerometer- and pedometer-based interventions with increased activity and other improved health outcomes in adults with cardiometabolic conditions and to examine characteristics of the studies that could influence the association of both interventions in improving PA.

Data Sources

Records from MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, the Cumulative Index to Nursing and Allied Health, and PsycINFO were searched from inception until August 2018 with no language restriction.

Study Selection

Randomized clinical trials or cluster randomized clinical trials evaluating the use of wearable technology devices such as pedometers and accelerometers as motivating and monitoring tools for increasing PA were included. After removing duplicates, the searches retrieved 5762 references. Following abstract and title screening of 1439 references and full-text screening of 107 studies, 36 studies met inclusion criteria.

Data Extraction and Synthesis

Mean difference in PA was assessed by random-effects meta-analysis. Where the scale was different across studies, the standardized mean difference was used instead. Heterogeneity was quantified using the I2 statistic and explored using mixed-effects metaregression. This study was registered with PROSPERO and followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline.

Main Outcomes and Measures

The primary outcome was objectively measured PA in the short to medium term (postintervention to 8 months' follow-up).

Results

Thirty-six randomized clinical trials (20 using accelerometers and 16 using pedometers) involving 5208 participants were eligible for review. Meta-analysis involving 32 of these trials (4856 participants) showed medium improvements in PA: accelerometers and pedometers combined vs comparator showed a small significant increase in PA overall (standardized mean difference, 0.39 [95% CI, 0.28-0.51]; I2 = 60% [95% CI, 41%-73%]) in studies of short to medium follow-up over a mean (SD) of 32 (28.6) weeks. Multivariable metaregression showed improved association with PA for complex interventions that involved face-to-face consultation sessions with facilitators (β = 0.36; 95% CI, 0.17-0.55; P < .001) and pedometer-based interventions (β = 0.30; 95% CI, 0.08-0.52; P = .002).

Conclusions and Relevance

In this study, complex accelerometer- and pedometer-based interventions led to significant small to medium improvements in PA levels of people with cardiometabolic conditions. However, longer-term trials are needed to assess their performance over time. This study found no evidence that simple self-monitored interventions using either pedometers or accelerometers are associated with improvements in PA.

Interval Endurance and Resistance Training as Part of a Community-Based Secondary Prevention Program for Patients With Diabetes Mellitus and Coronary Artery Disease

PURPOSE

High-intensity interval training (HIIT) has been observed to improve health and fitness in patients with cardiovascular disease. High-intensity interval training may not be appropriate in community-based settings. Moderate-intensity interval training (MIIT) and resistance training (RT) are emerging as effective alternatives to HIIT. These have not been well investigated in a community-based cardiac maintenance program.

METHODS

Patients with coronary artery disease and/or diabetes mellitus participated in clinical examinations and a 6-mo exercise program. Center-based MIIT and home-based moderate continuous intensity exercise were performed for 3-5 d/wk for 30-40 min/session. RT, nutritional counseling, coping, and behavioral change strategies were offered to all patients. Within-group changes in clinical metrics and exercise performance were assessed on a per-protocol basis after 6 mo.

RESULTS

Two hundred ninety-two patients (74%) concluded the 6-mo program. There were no serious adverse events. The peak oxygen uptake and peak workload increased significantly, 21.8 ± 6.1 to 22.8 ± 6.3 mL/kg/min and 128 ± 39 to 138 ± 43 W, respectively (both P < .001). Submaximal exercise performance increased from 68 ± 19 to 73 ± 22 W (P < .001). Glycated hemoglobin decreased from 6.57 ± 0.93% to 6.43 ± 0.12%, (P = .023). Daily injected insulin dosage was reduced from 42 IU (interquartile range: 19.0, 60.0) to 26 IU (interquartile range: 0, 40.3, P < .001).

CONCLUSIONS

MIIT and RT were feasible and effective in a community-based cardiac maintenance program for patients with cardiovascular disease, improving exercise performance, and blood glucose control.

Examining adherence to activity monitoring devices to improve physical activity in adults with cardiovascular disease: A systematic review

BACKGROUND

Activity monitoring devices are currently being used to facilitate and monitor physical activity. No prior review has examined adherence to the use of activity monitoring devices amongst adults with cardiovascular disease.

METHODS

Literature from June 2012 to October 2017 was evaluated to examine the extent of adherence to any activity monitoring device used to collect objective physical activity data. Randomized control trials comparing usual care against the use of an activity monitoring device, in a community intervention for adults from any cardiovascular diagnostic group, were included. A systematic search of databases and clinical trials registers was conducted using Joanna Briggs Institute methodology.

RESULTS

Of 10 eligible studies, two studies reported pedometer use and eight accelerometer use. Six studies addressed the primary outcome. Mean adherence was 59.1% (range 39.6% to 85.7%) at last follow-up. Studies lacked equal representation by gender (28.6% female) and age (range 42 to 82 years).

CONCLUSION

This review indicates that current research on activity monitoring devices may be overstated due to the variability in adherence. Results showed that physical activity tracking in women and in young adults have been understudied.

Physical Activity as a Determinant of Quality of Life in Working-Age People in Wrocław, Poland

Regular physical activity can greatly contribute to the improvement of physical fitness and performance, reduction of the incidence risk of some occupational diseases, and as a consequence, to a general improvement of quality of life in terms of health status. The aim of the article was to assess relationships between the quality of life and physical activity of a working-age population. The study material comprised 4460 residents of the city of Wrocław, Poland (2129 men, 2331 women) aged 18-64 years. The study was a questionnaire survey using the International Physical Activity Questionnaire Short Form (IPAQ-SF) and The World Health Organization Quality of Life (WHOQOL-BREF) questionnaires. The highest levels of overall quality of life and its four particular domains (physical, psychological, social, and environmental), as well as perceived health conditions were found among the most physically active respondents. Furthermore, the odds of high assessment of perceived overall quality of life were shown to increase with the increasing levels of physical activity. Activities aimed at the improvement of the quality of life of working-age people should involve programs enhancing the development of physical activity.

Management of Varicose Veins and Chronic Venous Insufficiency in a Comparative Registry with Nine Venoactive Products in Comparison with Stockings

The aim of this registry study was to compare products used to control symptoms of CVI. Endpoints of the study were microcirculation, effects on volume changes, and symptoms (analogue scale). Pycnogenol, venoruton, troxerutin, the complex diosmin-hesperidin, Antistax, Mirtoselect (bilberry), escin, and the combination Venoruton-Pycnogenol (VE-PY) were compared with compressions. No safety or tolerability problems were observed. At inclusion, measurements in the groups were comparable: 1,051 patients completed the registry. Best performers : Venoruton, Pycnogenol, and the combination VE-PY produced the best effects on skin flux. These products and the combination VE-PY better improved PO ₂ and PCO ₂ . The edema score was decreased more effectively with the combination and with Pycnogenol. Venoruton; Antistax also had good results. Considering volumetry, the best performers were the combination PY-VE and the two single products Venoruton and Pycnogenol. Antistax results for edema were also good. The best improvement in symptoms score were obtained with Pycnogenol and compression. A larger decrease in oxidative stress was observed with Pycnogenol, Venoruton, and with the VE-PY combination. Good effects of Antistax were also observed. Parestesias were lower with Pycnogenol and with Antistax. Considering the need for interventions, the best performers were Pycnogenol, VE-PY, and compression. The efficacy of Pycnogenol and the combination are competitive with stockings that do not have the same tolerability in warmer climates. A larger and more prolonged evaluation is suggested to evaluate cost-efficacy (and non-interference with drugs) of these products in the management of CVI. The registry is in progress; other products are in evaluation.