Objectively Measured Changes in Physical Activity and Sedentary Behavior in Cardiac Rehabilitation: A PROSPECTIVE COHORT STUDY

Validity of the Active Australia Survey in an Australian cardiac rehabilitation population

OBJECTIVES

To examine the long-term validity of the Active Australia Survey in a cardiac rehabilitation population using accelerometry as the reference measure.

DESIGN

Cohort validation study.

METHODS

Cardiac rehabilitation participants with coronary heart disease were recruited to a prospective cohort study. Over 7-days, 61 participants wore an ActiGraph ActiSleep accelerometer (1-second epoch, 10-minute bout) and completed the self-administered Active Australia Survey at baseline, 6-weeks, 6 and 12-months. Total daily moderate-to-vigorous physical activity from both methods was compared using Bland-Altman plots and Spearman rank-order correlations.

RESULTS

Participants tended to over-report moderate-to-vigorous physical activity, with more active participants more likely to over-report moderate-to-vigorous physical activity. There was a good level of agreement between the accelerometer 1-second epochs and Active Australia Survey at all time points (mean bias (ratio) 1.04, 1.16, 1.14, and 1.06, respectively), with weak-moderate correlations (ρ = 0.3-0.48). Conversely, there was a poor level of agreement between the accelerometer 10-minute bouts and Active Australia Survey at all time points (mean bias (ratio) 6.78, 9.09, 6.35, and 5.68, respectively), with weak-moderate correlations (ρ = 0.3-0.52). Agreement between the two measures did not improve over time for both 1-second and 10-minute bout accelerometry data.

CONCLUSIONS

The Active Australia Survey may be an acceptable self-report measure of moderate-to-vigorous physical activity in cardiac rehabilitation attendees when capturing any time spent in moderate-to-vigorous physical activity. The Active Australia Survey may be useful to routinely monitor physical activity levels over-time in Australian cardiac rehabilitation programs at both individual and group levels.

TRIAL REGISTRATION

Trial registration: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12615000995572, http://www.ANZCTR.org.au/ACTRN12615000995572.aspx.

Implementing a Sedentary Behavior Change Smartphone App in Cardiac Rehabilitation: A Qualitative Analysis Guided by the Theoretical Domains Framework and Capability, Opportunity, and Motivation-Behavior Model

BACKGROUND

Smartphone apps used in research offer a variety of capabilities to track and influence behavior; however, they often do not translate well into real-world use. Implementation strategies for using apps to reduce sedentary behavior in cardiac rehabilitation are currently unknown.

OBJECTIVE

The aim of this study was to explore (1) barriers and enablers for use of a behavioral smartphone app (Vire and ToDo-CR program) for reducing sedentary behavior in cardiac rehabilitation participants and (2) implementation strategies for future smartphone apps aimed at reducing sedentary behavior in this population.

METHODS

In-depth semistructured interviews were conducted with cardiac rehabilitation participants in the ToDo-CR randomized controlled trial. Participants had used the Vire app and a wearable activity tracker for 6 months. Interviews were audio recorded and transcribed. The researchers used thematic analysis and deductive mapping of themes to the Theoretical Domains Framework and the Capability, Opportunity, and Motivation-Behavior model. Sociodemographic and clinical variables were recorded.

RESULTS

Fifteen participants aged 59 ± 14 years were interviewed. Most were male, tertiary educated, and employed, and had varying experiences with smartphone apps and wearable activity trackers. Five core themes explaining the user experiences of cardiac rehabilitation participants with the Vire app were identified: (1) being tech savvy can be both an enabler and a barrier, (2) app messaging needs to be clear-set expectations from the beginning, (3) get to know me-personalization is important, (4) curious to know more instant feedback, and (5) first impression is key. The themes and subthemes mapped to 12 of the 14 Theoretical Domains Framework domains. Improving engagement and implementation of future smartphone apps for sedentary behavior may be aided by building psychological capability, physical opportunity, and reflective motivation.

CONCLUSIONS

Shifting to in-the-moment behavioral nudges, setting clear expectations, assisting participants to monitor their sitting time, increasing the frequency of tailoring, and understanding more about the participant as well as their experiences and needs for reducing sedentary behavior in cardiac rehabilitation are important future directions.

Improving Health Outcomes in Coronary Artery Disease Patients with Short-Term Protocols of High-Intensity Interval Training and Moderate-Intensity Continuous Training: A Community-Based Randomized Controlled Trial

Studies have shown that the higher the aerobic capacity, the lower the risk of cardiovascular mortality and morbidity. In the case of cardiac patients, high-intensity interval training (HIIT) seems to be more effective than moderate-intensity continuous training (MICT) in improving aerobic capacity. The aim of this study was to investigate the effects of two community-based exercise programs using two short-term protocols (HIIT and MICT) on physical fitness and physical activity (PA) levels in coronary artery disease (CAD) patients. Methods. In this randomized controlled trial, body composition, aerobic capacity, muscle strength, and daily PA levels were assessed before and after 6 weeks of intervention in 69 patients diagnosed with CAD. All patients were randomly (1 : 1 : 1) assigned to two exercise groups (HIIT or MICT) or a control group (no exercise). Both training programs consisted of 6 weeks of supervised treadmill exercise, three sessions per week. MICT targeted ≈70-75% of peak heart rate (HR), while HIIT aimed for ≈85-95% of peak HR. The control group only followed the medical recommendations. Results. Community-based exercise programs showed more positive effects on physical fitness variables and physical activity levels compared to control. HIIT could significantly improve waist circumference, body fat mass, VO2peak, sedentary behavior, and moderate-to-vigorous PA compared to MICT. Moreover, the control group showed poorer results. Conclusion. HIIT can improve health outcomes more positively than MICT and control. These findings indicate that HIIT may be an alternative and effective training method in community-based exercise programs for CAD patients. This trial is registered with NCT03538119.

Testing the Effect of a Smartphone App on Hospital Admissions and Sedentary Behavior in Cardiac Rehabilitation Participants: ToDo-CR Randomized Controlled Trial

BACKGROUND

People with coronary heart disease are at an increased risk of morbidity and mortality even if they attend cardiac rehabilitation. High sedentary behavior levels potentially contribute to this morbidity. Smartphone apps may be feasible to facilitate sedentary behavior reductions and lead to reduced health care use.

OBJECTIVE

We aimed to test the effect of a sedentary behavior change smartphone app (Vire app and ToDo-CR program) as an adjunct to cardiac rehabilitation on hospital admissions and emergency department (ED) presentations over 12 months.

METHODS

A multicenter, randomized controlled trial was conducted with 120 participants recruited from 3 cardiac rehabilitation programs. Participants were randomized 1:1 to cardiac rehabilitation plus the fully automated 6-month Vire app and ToDo-CR program (intervention) or usual care (control). The primary outcome was nonelective hospital admissions and ED presentations over 12 months. Secondary outcomes including accelerometer-measured sedentary behavior, BMI, waist circumference, and quality of life were recorded at baseline and 6 and 12 months. Logistic regression models were used to analyze the primary outcome, and linear mixed-effects models were used to analyze secondary outcomes. Data on intervention and hospital admission costs were collected, and the incremental cost-effectiveness ratios (ICERs) were calculated.

RESULTS

Participants were, on average, aged 62 (SD 10) years, and the majority were male (93/120, 77.5%). The intervention group were more likely to experience all-cause (odds ratio [OR] 1.54, 95% CI 0.58-4.10; P=.39) and cardiac-related (OR 3.26, 95% CI 0.84-12.55; P=.09) hospital admissions and ED presentations (OR 2.07, 95% CI 0.89-4.77; P=.09) than the control group. Despite this, cardiac-related hospital admission costs were lower in the intervention group over 12 months (Aus $252.40 vs Aus $859.38; P=.24; a currency exchange rate of Aus $1=US $0.69 is applicable). There were no significant between-group differences in sedentary behavior minutes per day over 12 months, although the intervention group completed 22 minutes less than the control group (95% CI -22.80 to 66.69; P=.33; Cohen d=0.21). The intervention group had a lower BMI (β=1.62; P=.05), waist circumference (β=5.81; P=.01), waist-to-hip ratio (β=.03, P=.03), and quality of life (β=3.30; P=.05) than the control group. The intervention was more effective but more costly in reducing sedentary behavior (ICER Aus $351.77) and anxiety (ICER Aus $10,987.71) at 12 months. The intervention was also more effective yet costly in increasing quality of life (ICER Aus $93,395.50) at 12 months.

CONCLUSIONS

The Vire app and ToDo-CR program was not an outcome-effective or cost-effective solution to reduce all-cause hospital admissions or ED presentations in cardiac rehabilitation compared with usual care. Smartphone apps that target sedentary behavior alone may not be an effective solution for cardiac rehabilitation participants to reduce hospital admissions and sedentary behavior.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12619001223123; https://australianclinicaltrials.gov.au/anzctr/trial/ACTRN12619001223123.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2020-040479.

Test-Retest Reliability, Agreement and Criterion Validity of Three Questionnaires for the Assessment of Physical Activity and Sedentary Time in Patients with Myocardial Infarction

Regular physical activity (PA) and limited sedentary time (SED) are highly recommended in international guidelines for patients after a myocardial infarction (MI). Data on PA and SED are often self-reported in clinical practice and, hence, reliable and valid questionnaires are crucial. This study aimed to assess the test-retest reliability, criterion validity and agreement of two PA and one SED questionnaire commonly used in clinical practice, developed by the Swedish National Board of Health and Welfare (BHW) and the Swedish national quality register SWEDEHEART. Data from 57 patients (mean age 66 ± 9.2 years, 42 males) was included in this multi-centre study. The patients answered three questionnaires on PA and SED at seven-day intervals and wore an accelerometer for seven days. Test-retest reliability, criterion validity and agreement were assessed using Spearman's rho and linearly weighted kappa. Test-retest reliability was moderate for three of the six-sub questions (k = 0.43-0.54) within the PA questionnaires. For criterion validity, the correlation was fair within three of the six sub-questions (r = 0.41-0.50) within the PA questionnaires. The SED questionnaire had low agreement (k = 0.12) and criterion validity (r = 0.30). The studied questionnaires for PA could be used in clinical practice as a screening tool and/or to evaluate the level of PA in patients with an MI. Future research is recommended to develop and/or evaluate SED questionnaires in patients with an MI.

Physical activity and sedentary behaviour following combined aerobic and resistance training in coronary artery disease patients: A randomised controlled trial

BACKGROUND

Effective training modalities and potential determinants to induce favourable changes in physical activity (PA) and sedentary behaviour (SB) remains elusive in patients with coronary artery disease.

AIMS

This study aimed to investigate the effects of high-load resistance training and low-load RT combined with aerobic training in comparison to aerobic training alone on PA and SB, and whether baseline level of SB modifies PA outcomes in coronary artery disease patients.

METHODS

We randomised 79 patients to aerobic training, low-load resistance training and aerobic training or high-load resistance training and aerobic training. PA and SB were measured using triaxial accelerometer at baseline and post-training for 8 days.

RESULTS

There was no difference between training modalities in post-training PA and SB. When stratified by baseline SB, the very sedentary patients improved SB (-52 min/day, p = 0.001) and light intensity PA (+27 min/day, p = 0.009) following intervention. The improvement in PA was greater in the very sedentary patients (SB: +27%, p = 0.002; light intensity PA: +24%, p = 0.004) and in sedentary patients (SB: +24%, p = 0.009) compared to the very active patients.

CONCLUSIONS

Post-training improvement in PA and SB was determined by baseline SB, while the addition of low-load or high-load resistance training provided no further benefits in coronary artery disease patients.

CLINICAL TRIALS REGISTRATION NUMBER

NCT04638764.

Cardiovascular Rehabilitation for transient ischaemic Attack and Mild Stroke: the CRAMS effectiveness-implementation hybrid study protocol

BACKGROUND

Internationally, stroke and cardiac rehabilitation clinicians agree that current cardiac rehabilitation models are a suitable secondary prevention program for people following a transient ischaemic attack (TIA) or mild stroke. There is strong evidence for exercise-based cardiac rehabilitation in people with heart disease, however, the evidence for cardiac rehabilitation post-TIA or stroke is limited. Here we will explore the effectiveness and implementation of an integrated (TIA, mild stroke, heart disease) traditional exercise-based cardiovascular rehabilitation (CVR) program for people with TIA or mild stroke over 6-months.

METHODS

This type 1 effectiveness-implementation hybrid study will use a 2-arm single-centre assessor-blind randomised controlled trial design, recruiting 140 participants. Adults who have had a TIA or mild stroke in the last 12-months will be recruited by health professionals from hospital and primary healthcare services. Participants will be assessed and randomly allocated (1:1) to the 6-week CVR program or the usual care 6-month wait-list control group. Distance completed in the 6-min walk test will be the primary effectiveness outcome, with outcomes collected at baseline, 6-weeks (complete CVR) and 6-months in both groups. Other effectiveness outcome measures include unplanned cardiovascular disease-related emergency department and hospital admissions, daily minutes of accelerometer moderate-to-vigorous physical activity, body mass index, waist circumference, blood pressure, quality of life, anxiety and depression. Implementation outcomes will be assessed using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework, including a cost-effectiveness analysis. Semi-structured interviews will be conducted with participants and CVR program health professionals, investigating the acceptability, value, and impact of the CVR program. Qualitative analyses will be guided by the Consolidated Framework for Implementation Research.

DISCUSSION

Few studies have assessed the effectiveness of cardiac rehabilitation for people with TIA and mild stroke, and no studies appear to have investigated the cost-effectiveness or implementation determinants of such programs. If successful, the CVR program will improve health outcomes and quality of life of people who have had a TIA or mild stroke, guiding future research, policy, and clinical practice, reducing the risk of repeat heart attacks and strokes for this population.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12621001586808 , Registered 19 November 2021.

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.

Association of device-measured physical activity and sedentary behaviour with cardiovascular risk factors, health-related quality-of-life and exercise capacity over 12-months in cardiac rehabilitation attendees with coronary heart disease

Background

Few studies have considered the relationship between risk factors, physical activity and sedentary behaviour in people with heart disease. Here we examine the independent relationship of device-measured physical activity and sedentary behaviour on risk factors, quality-of-life and exercise capacity over 12-months in cardiac rehabilitation attendees.

Methods

Hospital-based phase II cardiac rehabilitation participants with coronary heart disease were assessed at the start and end of cardiac rehabilitation (6-weeks), 6 and 12-months. Physical activity (moderate-to-vigorous (MVPA), light-intensity (LIPA); min/day) and sedentary behaviour (min/day, bouts, breaks) were measured using an ActiGraph accelerometer. Risk factors included waist circumference, body mass index, systolic blood pressure (SBP), fasting blood lipid and glucose levels, anxiety and depression. Quality-of-life and exercise capacity were also collected. Associations were assessed with Generalized Estimating Equation modeling.

Results

Sixty-seven participants were included (mean age = 64 (SD 9) years; 81% male). An association was found between higher MVPA and lower high density lipoprotein (p ≤ 0.001). No significant (p ≤ 0.001) associations were found between sedentary behaviour variables and other outcomes. At p < 0.05 several associations were significant. Increased MVPA and LIPA were associated with decreased total cholesterol. Higher MVPA was associated with decreased SBP, whereas higher LIPA was associated with decreased waist circumference and body mass index. Higher sedentary behaviour bouts and breaks were associated with increased total cholesterol, anxiety and depression, and decreased SBP over time.

Conclusions

Any intensity of physical activity was associated with decreased total cholesterol. Increased LIPA was associated with improved measures of adiposity, while breaking up sedentary behaviour and increasing MVPA may decrease SBP over time. Further investigation of MVPA, LIPA and the distribution of sedentary behaviour is indicated in cardiac rehabilitation attendees to explore their relationship with risk factors.

Trial registration: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12615000995572, http://www.ANZCTR.org.au/ACTRN12615000995572.aspx. Registered 22 September 2015.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13102-022-00562-7.

Observational Studies: Specific Considerations for the Physical and Rehabilitation Medicine Physician

ABSTRACT

The development of high-quality research is desired in all healthcare fields. Experimental and nonexperimental designs are used to investigate the effect or association of an intervention and clinical or surrogate outcome. The aims of these methods are to improve knowledge and to develop new strategies to manage a disease or condition. Randomized clinical trials are considered one of the standard methods to test the efficacy of a new drug or intervention; however, they are costly, have reduced generalizability, and cannot be feasible in all scenarios. Well-designed observational studies can provide valuable information regarding exposure factor and the event under investigation. In physical and rehabilitation medicine, where complex procedures and multiple risk factors can be involved in the same disease, the use of observational study must be planned in detail and a priori to avoid overestimations. In this article, we will give an overview of the methods used for observational design studies in physical and rehabilitation medicine using clinical examples to illustrate each method. We will describe when it is appropriate and how to use the observational studies in different scenarios explaining how to deal with potential bias and confounders using the adequate design and statistical plan for the situation.

Self-report Versus Measured Physical Activity Levels During Outpatient Cardiac Rehabilitation

PURPOSE

Many patients with coronary artery disease (CAD) do not achieve the recommended physical activity (PA) levels during and after cardiac rehabilitation (CR). The aim of this study was to analyze moderate to vigorous physical activity (MVPA) levels and the differences between perceived (self-reported) and measured (activity monitor) MVPA in CAD patients during CR. The second aim was to analyze which patient characteristics were associated with this difference.

METHODS

A two-center observational-sectional study was conducted within the Department of Rehabilitation Medicine of the University Medical Center Groningen between January and April 2018. Adults with CAD, following an outpatient CR program, were included. Perceived MVPA was assessed with the Short Questionnaire to Assess Health-enhancing Physical Activity and compared with ActivPAL3 activity monitor outcomes over a period of 7 d.

RESULTS

Fifty-one patients with CAD (age 59.4 ± 7.1 yr, eight females) were recruited. Four patients (8%) did not achieve the recommended guideline level of ≥150 min/wk of MVPA. Patients spent ≥80% of the week in sedentary activities. Patients overestimated MVPA with a median of 805 (218, 1363) min/wk (P< .001). The selected patient characteristics (age, body mass index, type of CAD, type of CR, social support, and self-efficacy) were not associated with this overestimation.

CONCLUSIONS

Most patients with CAD, participating in an outpatient CR program, do achieve MVPA exercise recommendations but spend simultaneously too much time in sedentary activities.

Cardiac Rehabilitation in Patients With Ventricular Assist Device

PURPOSE

The aim of this study was to investigate changes in exercise capacity (EC) and quality of life (QoL) of patients with ventricular assist devices (VADs) during cardiac rehabilitation (CR).

METHODS

Data from patients with VAD implantation and subsequent CR between 2007 and 2017 were analyzed retrospectively. Measures of the 6-min walk test [6MWT] distance, Functional Independence Measure [FIM], ergometry, MacNew Heart Disease Questionnaire [MNH], and Hospital Anxiety and Depression Scale [HADS] at entry and discharge were examined.

RESULTS

Data from 110 patients (age 53 ± 12 yr; male 82%) were analyzed. Patients improved during CR significantly in the 6MWT (114 ± 85 m, P < .001), ergometry (20 ± 17 W, P = .002), FIM (8 ± 7 points, P < .001), and MNH (0.8 ± 0.7 points, P < .001). Initial HADS levels were high with a mean value of 9 and did not improve during CR (-0.4 ± 5 points, P = .637). Significant differences of improvements in the 6MWT were observed between left and biventricular VAD (129 ± 90 m vs 85 ± 67 m, P = .043) as well as destination therapy and bridge-to-transplant (184 ± 88 m vs 102 ± 82 m, P = .005).

CONCLUSIONS

Patients with VAD implantation had statistically and clinically significant improvements in EC and QoL as assessed with the MNH during CR. Patients on destination therapy showed a larger benefit from CR than bridge-to-transplant patients and patients with left VAD improved more than biventricular VAD patients.

[Digital home-based multidisciplinary cardiac rehabilitation: How to counteract physical inactivity during the COVID-19 pandemic]

Introduction and Objectives

Center-based cardiac rehabilitation (CR) programs have been forced to close due to COVID-19. Alternative delivery models to maintain access to CR programs and to avoid physical inactivity should be considered. The aim of this study was to assess physical activity (PA) levels after completing a home-based digital CR program.

Methods

A total of 116 cardiovascular disease (CVD) patients (62.6±8.9 years, 95 male) who had been attending a face-to-face CR program were recruited and assessed (baseline and at three months) on the following parameters: PA, sedentary behavior, adherence, cardiovascular and non-cardiovascular symptoms, feelings toward the pandemic, dietary habits, risk factor control, safety and adverse events. The intervention consisted of a multidisciplinary digital CR program, including regular patient assessment, and exercise, educational and psychological group sessions.

Results

Ninety-eight CVD patients successfully completed all the online assessments (15.5% drop-out rate). A favorable main effect of time was an increase in moderate to vigorous PA and a decrease in sedentary time at three months. Almost half of the participants completed at least one online exercise training session per week and attended at least one of the online educational sessions. No major adverse events were reported and only one minor event occurred.

Conclusion

During the pandemic, levels of moderate to vigorous PA improved after three months of home-based CR in CVD patients with previous experience in a face-to-face CR model. Diversified CR programs with a greater variety of content tailored to individual preferences are needed to meet the motivational and clinical requirements of CVD patients.

Wearable inertial sensors for human movement analysis: a five-year update

INTRODUCTION

The aim of the present review is to track the evolution of wearable IMUs from their use in supervised laboratory- and ambulatory-based settings to their application for long-term monitoring of human movement in unsupervised naturalistic settings.

AREAS COVERED

Four main emerging areas of application were identified and synthesized, namely, mobile health solutions (specifically, for the assessment of frailty, risk of falls, chronic neurological diseases, and for the monitoring and promotion of active living), occupational ergonomics, rehabilitation and telerehabilitation, and cognitive assessment. Findings from recent scientific literature in each of these areas was synthesized from an applied and/or clinical perspective with the purpose of providing clinical researchers and practitioners with practical guidance on contemporary uses of inertial sensors in applied clinical settings.

EXPERT OPINION

IMU-based wearable devices have undergone a rapid transition from use in laboratory-based clinical practice to unsupervised, applied settings. Successful use of wearable inertial sensing for assessing mobility, motor performance and movement disorders in applied settings will rely also on machine learning algorithms for managing the vast amounts of data generated by these sensors for extracting information that is both clinically relevant and interpretable by practitioners.

Objectively Measured Physical Activity in Patients with Coronary Artery Disease: A Cross-Validation Study

Physical activity (PA) and sedentary behavior (SB) levels in healthy adults are predominately based on self-reporting measures, which generally overestimate PA but underestimate SB. Patients with coronary artery disease (CAD) eligible for cardiac rehabilitation (CR) follow an individualized program; thus, objective assessment of physical performance and regular daily activity is required. This study aimed to compare self-reported and objectively measured PA and SB in patients with CAD prior to out-patient CR. We included 91 patients with CAD and assessed their PA with an accelerometer for 8 days prior to CR, along with the short form of the international physical activity questionnaire. We found that most patients were sedentary (61%, ~8 h/day), and on average performed 63 min/day of moderate-to-vigorous-intensity physical activity (MVPA). Males performed less daily light-intensity physical activity (−5%, p = 0.011) and performed more MVPA (+2%, p = 0.002) compared to females. Maximal aerobic capacity was significantly associated with MVPA (Spearman rho = 0.483, p < 0.001) and MVPA > 10 min bouts (Spearman rho = 0.391, p < 0.001). Self-reported measures overestimated MVPA (total MVPA, +108 min/day, p < 0.001; MVPA > 10 min bouts, +152 min, p < 0.001) and underestimated SB (−174 min/day, p < 0.001) compared to objective measures. There was no significant correlation between methods in MVPA (Spearman rho = 0.147, p = 0.165)), MVPA > 10 min bouts (Spearman rho = −0.059, p = 576), and SB (Spearman rho = 0.139, p = 0.187). Quantitative analysis demonstrated the huge proportional bias for MVPA, MVPA > 10 min bouts, and SB. Our findings demonstrate that self-reported physical activity provides inaccurate estimates of MVPA and SB in patients with CAD entering the ambulatory CR. This strongly supports the more objective assessments of daily PA, preferably using an accelerometer.

Location-Based Sedentary Time and Physical Activity in People Living With Coronary Artery Disease

PURPOSE

Sedentary time (ST) and lack of physical activity increase the risk of adverse outcomes for those living with coronary artery disease (CAD). Little is known about how much ST, light physical activity (LPA), and moderate to vigorous physical activity (MVPA) that CAD participants not attending cardiac rehabilitation engage in, the locations where they engage in these behaviors, and how far from home the locations are.

METHODS

Participants completed a survey and wore an accelerometer and global positioning system receiver for 7 d at baseline and 6 mo later.

RESULTS

Accelerometer analyses (n = 318) showed that participants averaged 468.4 ± 102.7 of ST, 316.1 ± 86.5 of LPA, and 32.9 ± 28.9 of MVPA min/d at baseline. ST and LPA remained stable at 6 mo, whereas MVPA significantly declined. The global positioning system (GPS) analyses (n = 315) showed that most of participant ST, LPA, and MVPA time was spent at home followed by other residential, retail/hospitality, and work locations at baseline and 6 mo. When not at home, the average distance to a given location ranged from approximately 9 to 18 km.

CONCLUSIONS

Participants with CAD spent the majority of their time being sedentary. Home was the location used the most to engage in ST, LPA, and MVPA. When not home, ST, LPA, and MVPA were distributed across a variety of locations. The average distance from home to a given location suggests that proximity to home may not be a barrier from an intervention perspective.

Do Wearable Activity Trackers Increase Physical Activity Among Cardiac Rehabilitation Participants? A SYSTEMATIC REVIEW AND META-ANALYSIS

PURPOSE

The objective of this study was to review randomized controlled trials (RCT), which included a wearable activity tracker in an intervention to promote physical activity among cardiac rehabilitation (CR) participants, and to conduct a meta-analysis for the outcomes of step counts and aerobic capacity (V˙o2max).

METHODS

Eight databases were searched for RCTs that included an activity tracker, enrolled adults eligible for CR, and reported outcomes of step count or aerobic capacity. Mean differences were calculated for outcomes in the meta-analyses.

RESULTS

Nineteen RCTs with 2429 participants were included in the systematic review and 10 RCTs with 891 participants were included in the meta-analysis. Meta-analysis of three RCTs using a pedometer or accelerometer demonstrated a significant increase in daily step count compared with controls (n = 211, 2587 steps/d [95% CI, 916-5257]; I2 = 74.6% and P = .002). Meta-analysis of three RCTs using a pedometer or accelerometer intervention demonstrated a significant increase in V˙o2max compared with controls (n = 260, 2.6 mL/min/kg [95% CI, 1.6-3.6]; I2 = 0.0% and P < .0001). Meta-analysis of four RCTs using a heart rate monitor demonstrated a significant increase in V˙o2max compared with controls (n = 420, 1.4 mL/min/kg [95% CI, 0.4-2.3]; I2 = 0.0% and P = .006).

CONCLUSIONS

Use of activity trackers among CR participants was associated with significant increases in daily step count and aerobic capacity when compared with controls. However, study size was small and variability in intervention supports the need for larger trials to assess use of activity trackers in CR.

A smartphone app for sedentary behaviour change in cardiac rehabilitation and the effect on hospital admissions: the ToDo-CR randomised controlled trial study protocol

INTRODUCTION

Cardiac rehabilitation (CR) is recommended for secondary prevention of cardiovascular disease and reducing the risk of repeat cardiac events. Physical activity is a core component of CR; however, studies show that participants remain largely sedentary. Sedentary behaviour is an independent risk factor for all-cause mortality. Strategies to encourage sedentary behaviour change are needed. This study will explore the effectiveness and costs of a smartphone application (Vire) and an individualised online behaviour change program (ToDo-CR) in reducing sedentary behaviour, all-cause hospital admissions and emergency department visits over 12 months after commencing CR.

METHODS AND ANALYSIS

A multicentre, assessor-blind parallel randomised controlled trial will be conducted with 144 participants (18+ years). Participants will be recruited from three phase-II CR centres. They will be assessed on admission to CR and randomly assigned (1:1) to one of two groups: CR plus the ToDo-CR 6-month programme or usual care CR. Both groups will be re-assessed at 6 months and 12 months for the primary outcome of all-cause hospital admissions and presentations to the emergency department. Accelerometer-measured changes in sedentary behaviour and physical activity will also be assessed. Logistic regression models will be used for the primary outcome of hospital admissions and emergency department visits. Methods for repeated measures analysis will be used for all other outcomes. A cost-effectiveness analysis will be conducted to evaluate the effects of the intervention on the rates of hospital admissions and emergency department visits within the 12 months post commencing CR.

ETHICS AND DISSEMINATION

This study received ethical approval from the Australian Capital Territory Health (2019.ETH.00162), Calvary Public Hospital Bruce (20-2019) and the University of Canberra (HREC-2325) Human Research Ethics Committees (HREC). Results will be disseminated through peer-reviewed academic journals. Results will be made available to participants on request.

TRIAL REGISTRATION NUMBER

ACTRN12619001223123.

Physical Activity and Cardiac Self-Efficacy Levels During Early Recovery After Acute Myocardial Infarction: A Jordanian Study

BACKGROUND

Regular physical activity is important for patients with established coronary heart disease as it favorably influences their coronary risk profile. General self-efficacy is a powerful predictor of health behavior change that involves increases in physical activity levels. Few studies have simultaneously measured physical activity and self-efficacy during early recovery after a first acute myocardial infarction (AMI).

PURPOSE

The aims of this study were to assess changes in objectively measured physical activity levels at 2 weeks (T2) and 6 weeks (T3) and self-reported cardiac self-efficacy at hospital discharge (T1) and at T2 and T3 in patients recovering from AMI.

METHODS

A repeated-measures design was used to recruit a purposive sample of patients from a single center in Jordan who were diagnosed with first AMI and who did not have access to cardiac rehabilitation. A body-worn activity monitor (activPAL) was used to objectively measure free-living physical activity levels for 7 consecutive days at two time points (T2 and T3). An Arabic version of the cardiac self-efficacy scale was administered at T1, T2, and T3. Paired t tests and analysis of variance were used to examine differences in physical activity levels and cardiac self-efficacy scores, respectively.

RESULTS

A sample of 100 participants was recruited, of which 62% were male. The mean age of the sample was 54.5 ± 9.9 years. No statistically significant difference in physical activity levels was measured at 2 weeks (T2) and 6 weeks (T3). Cardiac self-efficacy scores improved significantly between T1, T2, and T3 across subscales and global cardiac self-efficacy.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

Participants recovering from AMI in Jordan did not increase their physical activity levels during the early recovery phase, although cardiac self-efficacy scores improved. This may be because the increase in cardiac self-efficacy was not matched by the practical skills and knowledge required to translate this positive psychological construct into behavioral change. This study provides a first step toward understanding the complex relationship between cardiac self-efficacy and physical activity in this population. The authors hope that these findings support the design of culturally appropriate interventions to increase physical activity levels in this population.

Comparison of device-based physical activity and sedentary behaviour following percutaneous coronary intervention in a cohort from Sweden and Australia: a harmonised, exploratory study

Background

Few studies have measured device-based physical activity and sedentary behaviour following a percutaneous coronary intervention (PCI), with no studies comparing these behaviours between countries using the same methods. The aim of the study was to compare device-based physical activity and sedentary behaviour, using a harmonised approach, following a PCI on-entry into centre-based cardiac rehabilitation in two countries.

Methods

A cross-sectional study was conducted at two outpatient cardiac rehabilitation centres in Australia and Sweden. Participants were adults following a PCI and commencing cardiac rehabilitation (Australia n = 50, Sweden n = 133). Prior to discharge from hospital, Australian participants received brief physical activity advice (< 5 mins), while Swedish participants received physical activity counselling for 30 min. A triaxial accelerometer (Actigraph GT3X/ActiSleep) was used to objectively assess physical activity (light (LPA), moderate-to-vigorous (MVPA)) and sedentary behaviour. Outcomes included daily minutes of physical activity and sedentary behaviour, and the proportion and distribution of time spent in each behaviour.

Results

There was no difference in age, gender or relationship status between countries. Swedish (S) participants commenced cardiac rehabilitation later than Australian (A) participants (days post-PCI A 16 vs S 22, p < 0.001). Proportionally, Swedish participants were significantly more physically active and less sedentary than Australian participants (LPA A 27% vs S 30%, p < 0.05; MVPA A 5% vs S 7%, p < 0.01; sedentary behaviour A 68% vs S 63%, p < 0.001). When adjusting for wear-time, Australian participants were doing less MVPA minutes (A 42 vs S 64, p < 0.001) and more sedentary behaviour minutes (A 573 vs S 571, p < 0.001) per day. Both Swedish and Australian participants spent a large part of the day sedentary, accumulating 9.5 h per day in sedentary behaviour.

Conclusion

Swedish PCI participants when commencing cardiac rehabilitation are more physically active than Australian participants. Potential explanatory factors are differences in post-PCI in-hospital physical activity education between countries and pre-existing physical activity levels. Despite this, sedentary behaviour is high in both countries. Internationally, interventions to address sedentary behaviour are indicated post-PCI, in both the acute setting and cardiac rehabilitation, in addition to traditional physical activity and cardiac rehabilitation recommendations.

Trial registrations

Australia: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12615000995572. Registered 22 September 2015, Sweden: World Health Organization Trial Registration Data Set: NCT02895451.

Pedometer Feedback Interventions Increase Daily Physical Activity in Phase III Cardiac Rehabilitation Participants

PURPOSE

To determine the effects of individually tailored interventions designed to increase physical activity (PA) in cardiac patients.

METHODS

A total of 99 (77 men and 22 women, 61.5 ± 10.7 yr) patients entering a phase III cardiac rehabilitation program completed a 12-wk PA intervention. Patients were randomized to usual care (UC, time-based recommendation), pedometer feedback (PF), newsletter-based motivational messaging (MM), or PF + MM. Both PF groups were given a goal of increasing steps/d by 10% of individual baseline value each week. If the goal for the week was not reached, the same goal was used for the next week. Physical activity was assessed for 7 d before beginning and after completing the program. The change in steps/d, moderate to vigorous intensity PA minutes, and sedentary time were compared among intervention groups.

RESULTS

Average change in steps/d was found to be significantly greater (P < .01) in the PF (2957 ± 3185) and the PF + MM (3150 ± 3007) compared with UC (264 ± 2065) and MM (718 ± 2415) groups. No group experienced changes in moderate to vigorous intensity PA time and only the PF intervention group decreased sedentary time (baseline 470.2 ± 77.1 to postintervention 447.8 ± 74.9 min/d, P = .01).

CONCLUSION

The findings from this study demonstrate that using PF was superior to the usual time-based PA recommendations and to newsletter-based MM in patients starting a phase III CR program. Cardiac rehabilitation programs are encouraged to implement PA feedback with individualized PA goals in order to support the increase in PA.

Validity of the Past-day Adults' Sedentary Time Questionnaire in a Cardiac Rehabilitation Population

PURPOSE

Self-report measures of sedentary behavior are easier to use in a clinical setting; yet, no self-report measures of sedentary behavior appear to be validated in cardiac rehabilitation over time. The aim of this study was to assess the validity of the Past-day Adults' Sedentary Time (PAST) questionnaire in a cardiac rehabilitation population over 12 mo.

METHODS

Seventy-two cardiac rehabilitation participants were recruited to a prospective cohort study. Participants wore an ActiGraph ActiSleep accelerometer (sedentary time <100 counts/min) for 7 consecutive days and completed the self-administered PAST questionnaire at baseline, 6 wk, and 6 and 12 mo. Total daily sedentary time from both methods were compared using Bland-Altman plots and Spearman rank-order correlations.

RESULTS

Agreement between the 2 measures of sedentary time improved over 12 mo. At 6 and 12 mo, there was a good level of agreement between measures (mean difference between accelerometer and PAST 57 and -0.7 min, respectively), although the dispersion of the differences was wide (95% limits of agreement -428 to 541 and -500 to 498 min, respectively). There were weak correlations between the PAST questionnaire and average accelerometer measured sedentary time at all time points (α = -0.249 to 0.188).

CONCLUSIONS

Following repeated assessments, the PAST questionnaire may be useful to determine sedentary time in cardiac rehabilitation participants at a group level, with participants appearing to more accurately recall their time spent in sedentary behavior. Further research is indicated to assess the validity of sedentary behavior questionnaires in cardiac rehabilitation, with a combination of objective and self-reported measures currently recommended.

Physical activity promotion in daily exercise therapy: the perspectives of exercise therapists in German rehabilitation settings

Background

This study aims to explore exercise therapists' perspectives on the topic of physical activity promotion (PAP) with a focus on identifying (i) the intervention content and methodological approaches used for promoting physical activity (PA) in daily practice and (ii) the barriers and facilitators that affect PAP.

Methods

This qualitative study comprised the heads of exercise therapy departments (n = 58; 41% women; mean age = 45 years) from different rehabilitation clinics in Germany. Each participant took part in a semi-structured focus-group discussion on PAP in exercise therapy. The findings of the focus groups were processed and interpreted using a conventional qualitative content analysis.

Results

The exercise therapists demonstrated detailed didactic-methodological strategies and action orientations for PAP. The identified core topics of the content and methods of PAP were (1) conceptualization, (2) exercise and PA for enjoyment and pleasure, (3) education with practice-theory combinations, (4) media and materials for self-directed training, and (5) strategies to enhance personal responsibility and independence. The core topics for the associated barriers and facilitators were (1) structural conditions, (2) the role of exercise therapists, (3) the interdisciplinary rehabilitation team, (4) rehabilitant experiences and expectations, and (5) aftercare services.

Conclusion

The topic of PAP is addressed with a high level of variability; exercise therapists involved in this study identify various methods and content for the promotion of PA within their individual practices. However, they display a limited awareness of existing evidence- and theory-based concepts for the promotion of PA as well as underlying theories of behavioural change. This variability may be due to the lack of a defined common framework for promoting PA, insufficient emphasis being placed on PA promotion in the current curricula and training, or extensive conceptual differences within German exercise therapy departments (e.g. different weighting of PAP).

High sedentary behaviour and low physical activity levels at 12 months after cardiac rehabilitation: A prospective cohort study

BACKGROUND

International cardiac rehabilitation guidelines recommend that participants meet public health physical activity guidelines. Few studies have objectively measured how much time cardiac rehabilitation participants spend in physical activity and sedentary behaviour, particularly over the long term.

OBJECTIVE

The aim of this study was to objectively assess physical activity and sedentary behaviour of cardiac rehabilitation participants over 12 months and determine whether they met the public health physical activity and sedentary behaviour guidelines.

METHODS

Cardiac rehabilitation participants with coronary heart disease were recruited in a prospective cohort study (n=72). Participants wore an ActiGraph ActiSleep accelerometer for 7 consecutive days at baseline, 6 weeks, and 6 and 12 months to assess daily minutes of moderate-to-vigorous physical activity and sedentary behaviour (<100 counts/min). Other outcomes collected were self-reported physical activity and sedentary behaviour, body mass index, waist-to-hip ratio, lipid profile, blood glucose level, quality of life, exercise capacity, anxiety and depression.

RESULTS

By intent-to-treat analysis, during the 6-week cardiac rehabilitation program, participants increased their light physical activity (P<0.01), which was maintained up to 12 months. Moderate-to-vigorous physical activity and sedentary behaviour did not change during the 6-week cardiac rehabilitation program but did improve over 6 months (sedentary behaviour decreased [P<0.001], moderate-to-vigorous physical activity increased [P<0.05]), which was maintained up to 1 year. Completion of moderate-to-vigorous physical activity in 10-min bouts did not change over 12 months, nor did the proportion of participants meeting physical activity guidelines (15-21%). Sedentary behaviour remained high throughout (11 hr/day).

CONCLUSION

Most cardiac rehabilitation participants did not meet the physical activity guidelines during and after a 6-week program up to 12 months. Reducing sedentary behaviour may be a more achievable first-line strategy for cardiac patients, moving participants along the energy expenditure continuum, aiming to increase their physical activity levels over the medium to long term.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12615000995572, http://www.ANZCTR.org.au/ACTRN12615000995572.aspx.