ArticleLiterature Review

Barriers to Participation in and Adherence to Cardiac Rehabilitation Programs: A Critical Literature Review

February 2002
Progress in Cardiovascular Nursing 17(1):8-17

February 2002
17(1):8-17

DOI:10.1111/j.0889-7204.2002.00614.x

Source
PubMed

Authors:

John Daly

University of Technology Sydney

Andrew Sindone

Concord Repatriation General Hospital

David R Thompson

Queen's University Belfast

Karen Hancock

Children's Hospital at Westmead

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Despite the documented evidence of the benefits of cardiac rehabilitation (CR) in enhancing recovery and reducing mortality following a myocardial infarction, only about one third of patients participate in such programs. Adherence to these programs is an even bigger problem, with only about one third maintaining attendance in these programs after 6 months. This review summarizes research that has investigated barriers to participation and adherence to CR programs. Some consistent factors found to be associated with participation in CR programs include lack of referral by physicians, associated illness, specific cardiac diagnoses, reimbursement, self-efficacy, perceived benefits of CR, distance and transportation, self-concept, self-motivation, family composition, social support, self-esteem, and occupation. Factors associated with non-adherence include being older, female gender, having fewer years of formal education, perceiving the benefits of CR, having angina, and being less physically active during leisure time. However, many of the studies have methodologic flaws, with very few controlled, randomized studies, making the findings tentative. Problems in objectively measuring adherence to unstructured, non-hospital-based programs, which are an increasingly popular alternative to traditional programs, are discussed. Suggestions for reducing barriers to participation and adherence to CR programs, as well as for future research aimed at clearly identifying these barriers, are discussed.

The State of Cardiac Rehabilitation in Saudi Arabia: Barriers, Facilitators, and Policy Implications

Article

Full-text available

Nov 2023

Cardiovascular disease (CVD) is a critical public health issue in Saudi Arabia, where it is the leading cause of death. The economic burden of CVD in the country is expected to triple by 2035, reaching $9.8 billion. This paper provides an overview of CVD in Saudi Arabia and its risk factors, impact on healthcare, and effects on patients' quality of life. The review emphasizes the potential of cardiac rehabilitation (CR) programs in addressing the CVD epidemic. CR programs have been shown to reduce morbidity, mortality, and hospital readmissions while improving patients' cardiovascular health and overall well-being. However, these programs are underutilized and inaccessible in Saudi Arabia. The paper highlights the urgent need for CR programs in the country and suggests key strategies for implementation. These include increasing patient referrals, tailoring programs to individual needs, enhancing patient education, and making CR accessible through home-based options. Fostering multidisciplinary collaboration and developing tailored guidelines for Arab countries can further enhance the impact of CR programs. In conclusion, this review underscores the vital importance of comprehensive CR programs in Saudi Arabia to combat the rising CVD burden, improve patient quality of life, and align with the goals of the Saudi 2030 Vision for a healthier society.

Cardiac Rehabilitation Barriers Scale (CRBS)

Chapter

Jun 2023

Translation, Cross-Cultural Adaptation and Psychometric Validation of the Arabic Version of the Cardiac Rehabilitation Barriers Scale (CRBS-A) with Strategies to Mitigate Barriers

Article

Full-text available

Apr 2023

Cardiac rehabilitation (CR) utilization is low, particularly in Arabic-speaking countries. This study aimed to translate and psychometrically validate the CR Barriers Scale in Arabic (CRBS-A), as well as strategies to mitigate them. The CRBS was translated by two bilingual health professionals independently, followed by back-translation. Next, 19 healthcare providers, followed by 19 patients rated the face and content validity (CV) of the pre-final versions, providing input to improve cross-cultural applicability. Then, 207 patients from Saudi Arabia and Jordan completed the CRBS-A, and factor structure, internal consistency, construct, and criterion validity were assessed. Helpfulness of mitigation strategies was also assessed. For experts, item and scale CV indices were 0.8–1.0 and 0.9, respectively. For patients, item clarity and mitigation helpfulness scores were 4.5 ± 0.1 and 4.3 ± 0.1/5, respectively. Minor edits were made. For the test of structural validity, four factors were extracted: time conflicts/lack of perceived need and excuses; preference to self-manage; logistical problems; and health system issues and comorbidities. Total CRBS-A α was 0.90. Construct validity was supported by a trend for an association of total CRBS with financial insecurity regarding healthcare. Total CRBS-A scores were significantly lower in patients who were referred to CR (2.8 ± 0.6) vs. those who were not (3.6 ± 0.8), confirming criterion validity (p = 0.04). Mitigation strategies were considered very helpful (mean = 4.2 ± 0.8/5). The CRBS-A is reliable and valid. It can support identification of top barriers to CR participation at multiple levels, and then strategies for mitigating them can be implemented.

Protocolos de rehabilitación cardiaca mediante realidad virtual: revisión sistemática

Article

Full-text available

Jan 2022

Introducción El desarrollo de protocolos de rehabilitación cardiaca tradicional proporciona grandes beneficios para la salud a pesar de las limitaciones espaciales y funcionales que generan. Los sistemas de realidad virtual han sido objeto de gran interés en la rehabilitación cardiaca debido a los beneficios que aportan, a la motivación de los pacientes y a la reducción de los plazos. Objetivo Evaluar la eficacia de los sistemas de realidad virtual en la aplicación de programas de rehabilitación cardiaca. Método: Se realizó una revisión sistemática sobre el uso de los sistemas de realidad virtual en rehabilitación cardiaca y su efecto. En la búsqueda se incluyeron las bases de datos Scopus, Sport-Discus, PubMed-Medline, Web of Science y Dialnet. Resultados De 280 artículos identificados, ocho fueron escogidos de acuerdo con los criterios de inclusión. Un total de 872 pacientes fueron analizados. Los resultados mostraron diferencias significativas a favor de las terapias con realidad virtual, en la adherencia y en mejores niveles de los indicadores de capacidad y de potencia aeróbica. Conclusiones Se confirma que la aplicación de sistemas de realidad virtual en programas de rehabilitación cardiaca favorece la adherencia al programa y genera mejoras en los indicadores físicos.

Artificial intelligence-driven virtual rehabilitation for people living in the community: A scoping review

Article

Full-text available

Feb 2024

Virtual Rehabilitation (VRehab) is a promising approach to improving the physical and mental functioning of patients living in the community. The use of VRehab technology results in the generation of multi-modal datasets collected through various devices. This presents opportunities for the development of Artificial Intelligence (AI) techniques in VRehab, namely the measurement, detection, and prediction of various patients’ health outcomes. The objective of this scoping review was to explore the applications and effectiveness of incorporating AI into home-based VRehab programs. PubMed/MEDLINE, Embase, IEEE Xplore, Web of Science databases, and Google Scholar were searched from inception until June 2023 for studies that applied AI for the delivery of VRehab programs to the homes of adult patients. After screening 2172 unique titles and abstracts and 51 full-text studies, 13 studies were included in the review. A variety of AI algorithms were applied to analyze data collected from various sensors and make inferences about patients’ health outcomes, most involving evaluating patients’ exercise quality and providing feedback to patients. The AI algorithms used in the studies were mostly fuzzy rule-based methods, template matching, and deep neural networks. Despite the growing body of literature on the use of AI in VRehab, very few studies have examined its use in patients’ homes. Current research suggests that integrating AI with home-based VRehab can lead to improved rehabilitation outcomes for patients. However, further research is required to fully assess the effectiveness of various forms of AI-driven home-based VRehab, taking into account its unique challenges and using standardized metrics.

Cardiac Rehabilitation and Acute Aortic Dissection: Understanding and Addressing the Evidence GAP A Systematic Review

Article

Full-text available

Jan 2024

Outcomes of a Remote Cardiac Rehabilitation Program for Patients Undergoing Atrial Fibrillation Ablation: Pilot Study

Article

Full-text available

Dec 2023

Background Risk factor modification, in particular exercise and weight loss, has been shown to improve outcomes for patients with atrial fibrillation (AF). However, access to structured supporting programs is limited. Barriers include the distance from appropriate facilities, insurance coverage, work or home responsibilities, and transportation. Digital health technology offers an opportunity to address this gap and offer scalable interventions for risk factor modification. Objective This study aims to assess the feasibility and effectiveness of a 12-week asynchronous remotely supervised exercise and patient education program, modeled on cardiac rehabilitation programs, in patients with AF. Methods A total of 12 patients undergoing catheter ablation of AF were enrolled in this pilot study. Participants met with an exercise physiologist for a supervised exercise session to generate a personalized exercise plan to be implemented over the subsequent 12-week program. Disease-specific education was also provided as well as instruction in areas such as blood pressure and weight measurement. A digital health toolkit for self-tracking was provided to facilitate monitoring of exercise time, blood pressure, weight, and cardiac rhythm. The exercise physiologist remotely monitored participants and completed weekly check-ins to titrate exercise targets and provide further education. The primary end point was program completion. Secondary end points included change in self-tracking adherence, weight, 6-minute walk test (6MWT), waist circumference, AF symptom score, and program satisfaction. Results The median participant age was 67.5 years, with a mean BMI of 33.8 kg/m2 and CHADs2VASC (Congestive Heart Failure, Hypertension, Age [≥75 years], Diabetes, Stroke/Transient Ischemic Attack, Vascular Disease, Age [65-74 years], Sex [Female]) of 1.5. A total of 11/12 (92%) participants completed the program, with 94% of expected check-ins completed and 2.9 exercise sessions per week. Adherence to electrocardiogram and blood pressure tracking was fair at 81% and 47%, respectively. Significant reductions in weight, waist circumference, and BMI were observed with improvements in 6MWT and AF symptom scores (P<.05) at the completion of the program. For program management, a mean of 2 hours per week or 0.5 hours per patient per week was required, inclusive of time for follow-up and intake visits. Participants rated the program highly (>8 on a 10-point Likert scale) in terms of the impact on health and wellness, educational value, and sustainability of the personal exercise program. Conclusions An asynchronous remotely supervised exercise program augmented with AF-specific educational components for patients with AF was feasible and well received in this pilot study. While improvements in patient metrics like BMI and 6MWT are encouraging, they should be viewed as hypothesis generating. Based on insights gained, future program iterations will include particular attention to improved technology for data aggregation, adjustment of self-monitoring targets based on observed adherence, and protocol-driven exercise titration. The study design will need to incorporate strategies to facilitate the recruitment of a diverse and representative participant cohort.

Evaluation of an application for the self-assessment of lifestyle behaviour in cardiac patients

Article

Full-text available

Dec 2023

Background Currently, no uniform, well-validated and comprehensive lifestyle behaviour self-assessment instrument exists for patients with cardiovascular disease. Purpose To evaluate the usability of a novel mobile application (LifeStyleScore) based on validated instruments for the assessment of cardiovascular risk behaviours. Secondly, the application’s acceptance by healthcare professionals (HCPs) and its association with improved patient activation and lifestyle behaviour was evaluated. Methods In this single-centre, non-randomised observational pilot study, patients with coronary artery disease or atrial fibrillation entering cardiac rehabilitation (CR) completed the LifeStyleScore application, the Patient Activation Measure (PAM-13®), and the System Usability Scale (SUS) during the CR intake and after CR completion. A focus group interview was performed with the HCPs involved. Results We analysed 20 participants, 3 of whom were women, with a mean age of 61.9 ± 6.7 years. The LifeStyleScore application was rated with a SUS score above average (> 68) before (69.6 ± 13.4) and after CR (68.6 ± 15.1). All HCPs ( n = 8) found the application usable. Patient activation did not increase significantly after CR compared with baseline (62.0 ± 8.6 versus 59.2 ± 9.5, respectively, p = 0.28) and only physical activity levels improved significantly (2.4 ± 0.7 (standardised score) at baseline, 2.8 ± 0.4 after CR, p = 0.04). Conclusion The LifeStyleScore application was found to be usable for patients receiving CR. Its use did not result in increased patient activation, and of the lifestyle behaviours only physical activity levels improved. Further research is needed to evaluate how such applications can be optimally incorporated in CR programmes.

Subverting Whiteness: A Systems Theoretical Approach to Anti-Racist Praxis

Article

Full-text available

Sep 2021

Whiteness as a is a socio-political identity characterized by expectations, conscious and/or unconscious, of power and privileges that are granted to individuals or groups conferred into a White racial classification. This identity was born out of historic conditions (e.g. laws, policies, and practices) that gave rise to a racial hierarchy in the U.S., granting social, political, and economic privileges to people considered "White" and created the expectation that these advantages should continue. This hierarchy and related structural advantages persist today. To subvert Whiteness, activists, educators, and scholars created White privilege (and other related) interventions seeking to illuminate the power inherent in Whiteness. However, these psychologically focused (implicit bias) interventions frequently fail to alter the systemic conditions that perpetuate and reinforce White privilege and BIPOC oppression. To address this issue, we provide a framework that takes a systems approach to subverting White dominance. Bringing together critical Whiteness and systems change theories, we provide readers with a framework designed to alter systems' and settings' relationship to Whiteness. Specifically, we detail how interventions may be successful in altering White dominated spaces by (1) defining local patterns of racial privilege/oppression and the system conditions reinforcing them; (2) designing interventions to disrupt and realign these system conditions to promote equity; (3) implementing interventions in ways that uphold justice; and (4) redefining patterns of privilege/oppression and system conditions to learn if efforts are starting to make a difference. We conclude by providing recommendations to change agents, stakeholders, and researchers.

Relationship Between Number of Cardiac Rehabilitation Exercise Training Sessions, Muscle Mass, and Cardiorespiratory Fitness in Rural Elderly Patients with Coronary Artery Disease

Article

Full-text available

Nov 2023

Purpose This study aimed to compare the effects of a cardiac rehabilitation (CR) exercise program on skeletal muscle index (SMI) and cardiorespiratory fitness (CRF) in patients aged ≥65 years. Patients and Methods From January 2012 to December 2021, patients living in rural regions aged ≥65 who underwent percutaneous coronary intervention for acute myocardial infarction (AMI) and at least one CR exercise session were enrolled. We retrospectively reviewed the medical records of the patients who underwent an exercise tolerance test (ETT) at initial and 3-month follow-ups. A total of 36 patients were enrolled who underwent a mean of 6.56 exercise sessions and were divided into groups based on the number of center-based CR (CBCR) sessions: 14 in Group A (≥7 sessions) and 22 in Group B (<7 sessions). In CBCR session, we comprehensively counseled them about their nutrition, smoking cessation et al. Both groups underwent an ETT after 12 weeks. The outcomes were CRF parameters examined by a cardiorespiratory exercise test and the SMI examined by bioimpedance analysis (BIA). Results The number of exercise sessions was significantly correlated with the rate of SMI change. Group A showed significant increases in metabolic equivalent of task (MET), maximal oxygen uptake (VO2max), and SMI after 3 months. There were significant differences in the rates of change in MET, VO2max, and SMI between the two groups. Conclusion CRF significantly improved in Group A in a short period. Further studies are required to increase long-term CBCR adherence in elderly patients with AMI in rural regions.

Unearthing Gaps in the Heart Failure Ecosystem: An Asian Pacific Society of Cardiology Online Survey

Article

Full-text available

Oct 2023

Background: Information about the availability and accessibility of diagnostics and treatments for heart failure (HF) is sparse. The aim of this study was to describe the gaps in the diagnosis and treatment of HF in member countries of the Asian Pacific Society of Cardiology using an online survey. Methods: A cross-sectional observational study was conducted among medical professionals practising in member countries of the Asian Pacific Society of Cardiology who provide care to patients with HF. The participants answered an English online self-administered questionnaire. Results: The study included 257 respondents from 26 countries or regions. The majority of respondents (58%) responded that 50% or fewer of their patients would have natriuretic peptide levels checked during the hospital stay. More than half of the respondents (52%) said that more than 50% of their patients had access to transthoracic echocardiography. For mineralocorticoid receptor antagonists, angiotensin receptor–neprolysin inhibitors and sodium–glucose cotransporter 2 inhibitors, the proportion with access was 86%, 84% and 81%, respectively. Conclusion: Healthcare professionals in the Asian Pacific Society of Cardiology member countries identified substantial gaps in the availability of diagnostic and therapeutic interventions for HF in their areas of practice. Natriuretic peptide testing was less available than transthoracic echocardiography, which is the primary diagnostic modality for HF in the region. At least 10% had no access to mineralocorticoid receptor antagonists, angiotensin receptor–neprolysin inhibitors or sodium–glucose cotransporter 2 inhibitors in their centres.

Women’s Cardiac Rehabilitation Barriers Results of the International Council of Cardiovascular Prevention and Rehabilitation’s First Global Assessment

Article

Full-text available

Sep 2023

Background: Cardiac rehabilitation (CR) programs are underutilized globally, especially by women. In this study we investigated sex differences in CR barriers across all world regions, to our knowledge for the first time, the characteristics associated with greater barriers women, and women’s greatest barriers according to enrollment status. Methods: In this cross-sectional study, the English, Simplified Chinese,Arabic, Portuguese, or Korean versions of the Cardiac Rehabilitation ministered to CR-indicated patients globally via Qualtrics from October 2021 to March 2023. Members of the International Council of Cardiovascular Prevention and Rehabilitation community facilitated participant recruitment. Mitigation strategies were provided and rated. Results: Participants were 2163 patients from 16 countries across all 6 World Health Organization regions; 916 (42.3%) were women. Women did not report significantly greater total barriers overall, but did in 2 regions (Americas, Western Pacific) and men in 1 (Eastern Mediterranean; all P < 0.001). Women’s barriers were greatest in the Western Pacific (2.6 ± 0.4/5) and South East Asian (2.5 ± 0.9) regions (P < 0.001), with lack of CR awareness as the greatest barrier in both. Women who were unemployed reported significantly greater barriers than those not (P < 0.001). Among nonenrolled referred women, the greatest barriers were not knowing about CR, not being contacted by the program, cost, and finding exercise tiring or painful. Among enrolled women, the greatest barriers to session adherence were distance, transportation, and family responsibilities. Mitigation strategies were rated as very helpful (4.2 ± 0.7/5). Conclusions: CR barriersdmen’s and women’sdvary significantly according to region, necessitating tailored approaches tomitigation. Efforts should be made to mitigate unemployed women’s barriers in particular.

Understanding the Association of Self-Efficacy, Mood, and Demographics with Physical Activity in Syrian and Iraqi Refugees: A Cross-Sectional Study in Jordan

Article

Full-text available

Sep 2023
TSWJ

Objective: This cross-sectional study aimed at investigating the influence of sociodemographic factors on physical activity among Syrian and Iraqi refugees in Jordan. In addition, it sought to determine the predictive ability of self-efficacy and mood in relation to the level of physical activity in this population. Methods: A convenient sample of refugees residing in Jordanian cities was collected. Participants completed a self-administered questionnaire pack consisting of a demographic data sheet, a physical activity level questionnaire, the Brunel Mood Scale, and the General Self-Efficacy Scale. Descriptive analysis was used to analyze demographic details, while the chi-square test examined the association between physical activity and demographic factors. The independent t-test assessed differences in self-efficacy and mood subscales in relation to physical activity. Logistic regression analysis was employed to identify potential predictors of the two categories of physical activity. Results: Most participants reported low levels of physical activity. The frequency of moderate-to-high physical activity was higher in male participants, those with higher education, better health, and higher income. Compared to participants of low physical activity, those in the moderate-to-high physical activity category expressed significantly higher mean score of self-efficacy but lower mean scores of tension, depression, anger, vigor, fatigue, and confusion, indicating better mood. The logistic regression analysis for physical activity indicated that the model was significant for education, income, good health perception, self-efficacy, and one mood subscale (vigor), with these variables collectively accounting for 11-18% of the variance (P value <0.001). Conclusion: The higher physical activity level is significantly associated with being male, higher education, higher income, better health, higher self-efficacy, and increased vigor. These findings highlight the importance of considering sociodemographic factors and psychological aspects, such as self-efficacy and mood, when addressing physical activity among refugees in Jordan.

Cardiac Rehabilitation Engagement and Predictive factors in Heart Failure patients: A cross-sectional study

Preprint

Full-text available

May 2023

Background: Chronic Heart Failure (CHF) still affects millions of people worldwide despite great advances in therapeutic approaches in the cardiovascular field. Cardiac rehabilitation (CR) is known to improve disease-related symptoms, quality of life and clinical outcomes, yet implementation was suboptimal, a frequently low engagement in rehabilitation programs has been found globally. Objective: To quantify diverse CR-engaged processes and elucidate predictors of the various levels of CR engagement in CHF patients. Methods: CHF patients admitted or discharged from cardiology departments between May 1 2022 to November 1 2022 were enrolled. Individuals who met the inclusion criteria filled the questionnaires, including the generalized anxiety disorders scale, patient health questionnaire, cardiac rehabilitation inventory, patient activation measure, Tampa scale for kinesiophobia heart, social frailty, Patient Health Engagement Scale (PHE-s®) We obtained sociodemographic characteristics and clinical data from medical records. The survey was distributed via mobile phone text messaging or face-to-face completed. Chi-square tests and multivariable logistic regression analyses were performed to examine the factors associated with CR engagement phases. Results: A total of 684 patients were included in the study. Univariate analysis showed that only kinesiophobia had no correlation with engagement phases besides socio-demographic and clinical variables. Multivariate logistic regression analysis revealed that compared with the blackout phaseprocess anxiety (Arousal: OR 0.829, 95%CI: 0.73 ~ 0.94; Adhesion: OR 0.725, 95%CI: 0.64 ~ 0.82; Eudaimonic Project: OR 0.674, 95%CI: 0.59 ~ 0.77), monthly income (RMB yuan) equal to or more than 5,000 (Arousal: OR 6.342, 95%CI: 1.30 ~ 31.01; Adhesion: OR 5.226, 95%CI: 1.09 ~ 24.96; Eudaimonic Project: OR 6.658, 95%CI 1.26 ~ 34.76) were the most important factor impacting CHF patients CR engagement. In the Arousal phase, versus the Blackout phase, regular exercise or not (OR 3.29, 95% CI: 1.19 ~ 9.10), severe depression (OR 0.019, 95% CI: 0.00 ~ 0.813), previous cardiac-related hospitalizations 1 or 2 times (OR 3.75, 95% CI: 1.19 ~ 11.86), Age (OR 0.958, 95% CI: 0.92 ~ 0.998) influenced patient CR engagement. Besides, compared to the Blackout phase, outcome anxiety (OR 1.269, 95% CI: 1.11 ~ 1.46) and activation level (level 2: OR 9.357, 95% CI: 1.44 ~ 60.68; level 3: OR 29.96, 95% CI: 3.67 ~ 244.92; level 4: OR 29.71, 95% CI: 3.62 ~ 243.61) were independent factors predicting the Eudaimonic Project phase. Conclusions: This study characterized CR engagement, and explored demographic, medical, and psychological factors— with the most important being process anxiety, monthly income, patient activation, severe depression, and previous cardiac-related hospitalizations. The predictor factors of CR engagement were not identical among different phases which strongly indicates a significant role in quantifying CR engagement. Our findings suggested that factors could potentially be targeted in clinical practice to identify low CR engagement patients, and strategies implemented to strengthen or overcome these associations to address low CR engagement in CHF patients.

Cardiac rehabilitation engagement and associated factors among heart failure patients: a cross-sectional study

Article

Full-text available

Sep 2023
BMC Cardiovasc Disord

Background Chronic Heart Failure (CHF) still affects millions of people worldwide despite great advances in therapeutic approaches in the cardiovascular field. Cardiac rehabilitation (CR) is known to improve disease-related symptoms, quality of life and clinical outcomes, yet implementation is suboptimal, a frequently low engagement in rehabilitation programs has been found globally. Objective To quantify diverse CR-engaged processes and elucidate associated factors of the various levels of CR engagement in CHF patients. Methods Discharged patients admitted from cardiology departments between May 2022 to July 2022 were enrolled by mobile phone text messaging, CHF patients from same department between August 2022 to December 2022 were enrolled by face-to-face. Individuals who met the inclusion criteria filled the questionnaires, including the generalized anxiety disorders scale, patient health questionnaire, cardiac rehabilitation inventory, patient activation measure, Tampa scale for kinesiophobia heart, social frailty, Patient Health Engagement Scale (PHE-s®). We obtained sociodemographic characteristics and clinical data from medical records. Chi-square tests and multivariable logistic regression analyses were performed to examine the factors associated with CR engagement phases. Results A total of 684 patients were included in the study. 52.49% patients were in the Adhesion phase. At the multivariate level, compared with the blackout phase process anxiety, monthly income (RMB yuan) equal to or more than 5,000 were the most important factor impacting CHF patients CR engagement. Compared with the Blackout phase, regular exercise or not, severe depression, previous cardiac-related hospitalizations 1 or 2 times, Age influenced patient CR engagement in the Arousal phase. Besides, compared with the Blackout phase, outcome anxiety and activation level were independent factors in the Eudaimonic Project phase. Conclusion This study characterized CR engagement, and explored demographic, medical, and psychological factors—with the most important being process anxiety, monthly income, patient activation, severe depression, and previous cardiac-related hospitalizations. The associated factors of CR engagement were not identical among different phases. Our findings suggested that factors could potentially be targeted in clinical practice to identify low CR engagement patients, and strategies implemented to strengthen or overcome these associations to address low CR engagement in CHF patients.

Evaluation of the efficacy and safety of an integrated telerehabilitation platform for home-based cardiac REHABilitation in patients with heart failure (E-REHAB): protocol for a randomised controlled trial

Article

Full-text available

Aug 2023

Introduction Cardiac rehabilitation (CR) is strongly recommended as a medical treatment to improve the prognosis and quality of life of patients with heart failure (HF); however, participation rates in CR are low compared with other evidence-based treatments. One reason for this is the geographical distance between patients’ homes and hospitals. To address this issue, we developed an integrated telerehabilitation platform, RH-01, for home-based CR. We hypothesised that using the RH-01 platform for home-based CR would demonstrate non-inferiority compared with traditional centre-based CR. Methods and analysis The E-REHAB trial aims to evaluate the efficacy and safety of RH-01 for home-based CR compared with traditional centre-based CR for patients with HF. This clinical trial will be conducted under a prospective, randomised, controlled and non-inferiority design with a primary focus on HF patients. Further, to assess the generalisability of the results in HF to other cardiovascular disease (CVD), the study will also include patients with other CVDs. The trial will enrol 108 patients with HF and 20 patients with other CVD. Eligible HF patients will be randomly assigned to either traditional centre-based CR or home-based CR in a 1:1 fashion. Patients with other CVDs will not be randomised, as safety assessment will be the primary focus. The intervention group will receive a 12-week programme conducted two or three times per week consisting of a remotely supervised home-based CR programme using RH-01, while the control group will receive a traditional centre-based CR programme. The primary endpoint of this trial is change in 6 min walk distance. Ethics and dissemination The conduct of the study has been approved by an institutional review board at each participating site, and all patients will provide written informed consent before entry. The report of the study will be disseminated via scientific fora, including peer-reviewed publications and presentations at conferences. Trial registration number jRCT:2052200064.

A scale for measuring home-based cardiac rehabilitation exercise adherence: a development and validation study

Article

Full-text available

Aug 2023
BMC Nurs

Background The benefits of home-based cardiac rehabilitation exercise are well-established and depend on long-term adherence. However, there is no uniform and recognized cardiac rehabilitation criterion to assess home-based cardiac rehabilitation exercise adherence for patients with cardiovascular disease. This study aimed to develop a home-based cardiac rehabilitation exercise adherence scale and to validate its psychometric properties among patients with chronic heart failure. Methods The dimensions and items of the scale were created based on grounded theory research, literature content analysis, and defined by a Delphi survey. Item analysis was completed to assess the discrimination and homogeneity of the scale. Factor analysis was adopted to explore and validate the underlying factor structure of the scale. Content validity and calibration validity were evaluated using the Delphi survey and correlation analysis, respectively. Reliability was evaluated by Cronbach’s α coefficients, split-half reliability coefficients, and test-retest reliability coefficients. Results A scale covering four dimensions and 20 items was developed for evaluating home-based cardiac rehabilitation exercise adherence. The content validity index of the scale was 0.986. In exploratory factor analysis, a four-factor structure model was confirmed, explaining 75.1% of the total variation. In confirmatory factor analysis, the four-factor structure was supported by the appropriate fitting indexes. Calibration validity of the scale was 0.726. In terms of reliability, the Cronbach’s α coefficient of the scale was 0.894, and the Cronbach’s α coefficients of dimensions ranged from 0.848 to 0.914. The split-half reliability coefficient of the scale was 0.695. The test-retest reliability coefficient of the scale was 0.745. Conclusion In this study, a home-based cardiac rehabilitation exercise adherence scale was developed and its appropriate psychometric properties were confirmed.

Sex differences in cardiac rehabilitation barriers among non-enrollees in the context of lower gender equality: a cross-sectional study

Article

Full-text available

Jun 2023
BMC Cardiovasc Disord

Background Despite the benefits of cardiac rehabilitation (CR), it remains under-utilized, particularly by women. This study compared CR barriers between non-enrolling men and women in Iran, which has among the lowest gender equality globally. Methods In this cross-sectional study, CR barriers were assessed via phone interview in phase II non-attenders from March 2017 to February 2018 with the Persian version of the Cardiac Rehabilitation Barriers Scale (CRBS-P). T-tests were used to compare scores, with each of 18 barriers scored out of 5, between men and women. Results 357 (33.9%) of the sample of 1053 were women, and they were older, less educated and less often employed than men. Total mean CRBS scores were significantly greater in women (2.37 ± 0.37) than men (2.29 ± 0.35; effect size[ES] = 0.08, confidence interval[CI]: 0.03–0.13; p < 0.001). The top CR barriers among women were cost (3.35; ES = 0.40, CI:0.23–0.56; P < 0.001), transportation problems (3.24; ES = 0.41, CI:0.25–0.58; P < 0.001), distance (3.21; ES = 0.31, CI:0.15–0.48; P < 0.001), comorbidities (2.97; ES = 0.49, CI:0.34–0.64; P < 0.001), low energy (2.41; ES = 0.29, CI:0.18–0.41; P < 0.001), finding exercise as tiring or painful (2.22; ES = 0.11, CI:0.02–0.21; P = 0.018), and older age (2.27; ES = 0.18, CI:0.07–0.28; P = 0.001). Men rated “already exercise at home or in community” (2.69; ES = 0.23, CI:0.1–0.36; P = 0.001), time constraints (2.18; ES = 0.15, CI:0.07–0.23; P < 0.001) and work responsibilities (2.24; ES = 0.16, CI:0.07–0.25; P = 0.001) as greater CR barriers than women. Conclusion Women had greater barriers to CR participation than men. CR programs should be modified to address women’s needs. Home-based CR tailored to women’s exercise needs and preferences should be considered.

Physical therapy for sleep apnea: a smartphone application for home-based physical therapy for patients with obstructive sleep apnea

Article

Full-text available

May 2023

Purpose In this study, we described “PT for Sleep Apnea”, a smartphone application for home-based physical therapy of patients with Obstructive Sleep Apnea (OSA). Methods The application was created in a joint program between the University of Medicine and Pharmacy at Ho Chi Minh City (UMP), Vietnam, and National Cheng Kung University (NCKU), Taiwan. Exercises maneuvers were derived from the exercise program previously published by the partner group at National Cheng Kung University. They included exercises for upper airway and respiratory muscle training and general endurance training. Results The application provides video and in-text tutorials for users to follow at home and a schedule function to assist the user in organizing the training program, which may improve the efficacy of home-based physical therapy in patients with Obstructive Sleep Apnea. Conclusion In the future, our group plans to conduct a user study and randomized-controlled trials to investigate whether our application can benefit patients with OSA.

REHABILITATION OF CARDIOLOGICAL AND CARDIOSURGICAL PATIENTS IN MODERN CONDITIONS: POSSIBILITIES AND MILITARY HEALTH CARE PROBLEMS

Article

Jan 2021

Evaluation of Counselling Materials for Hybrid Cardiac Rehabilitation in a Low-Resource Setting: Perceptions of Patients and Providers

Article

Apr 2023
PATIENT EDUC COUNS

Objective: This study evaluated the usefulness of a booklet as support material for counseling focused on self-efficacy and therapist interaction in the course of counseling in a hybrid CR program (i.e., supervised and unsupervised sessions) developed for low-resource settings. Methods: Counseling material was developed by a multidisciplinary team, with patient input. Using multi-methods, first input from patients from six centers in Chile was sought through a telephone survey (cross-sectional). Second, input from physiotherapists delivering the intervention at all centres was solicited qualitatively through a focus group on Zoom. Content analysis was performed using a deductive-thematic approach. Results: Seventy-one patients were included. All (100 %) participants responded that the materials were easy to understand, contained suggestions applicable to daily life, captured their attention and was useful for future questions. The booklet overall was rated 6.7 ± 0.6/7 %, and 98.2 % were satisfied with the counselling. Overall themes from the six deliverers related to the CR intervention (e.g., well manualized protocols for counselling), the deliverer (e.g., expertise to deliver) and patients (e.g., found information useful). Conclusion: The usefulness of the counseling together with the supporting booklet was established by patients and delivering professionals. Practice implications: Thus, with some final refinement, this resource can be disseminated for use by other Spanish CR programs.

Postur ve postural bozukluklar

Article

Mar 2020

Yeli̇z Kahraman

Postur nedir? Postural hareketler nedir? Postur neden önemlidir? Sporcuda postur değerlendirme yöntemleri? Değerlendirme formları

Financial incentives and case management to improve cardiac rehabilitation participation among patients with lower socio-economic status: Rationale and protocol for a randomized controlled trial

Article

Apr 2023
CONTEMP CLIN TRIALS

Background: Participation in phase 2 cardiac rehabilitation (CR) is associated with significant decreases in morbidity and mortality. Unfortunately, attendance at CR is not optimal and certain populations, such as those with lower-socioeconomic status (SES), are less likely to participate. In order to remedy this disparity we have designed a trial to examine the efficacy of early case management and/or financial incentives for increasing CR participation among lower-SES patients. Methods: We will employ a randomized controlled trial with a sample goal of 209 patients who will be randomized 2:3:3:3 to either a usual care control, to receive a case manager starting in-hospital, to receive financial incentives for completing CR sessions, or to receive both interventions. Results: Treatment conditions will be compared on attendance at CR and end-of-intervention (four months) improvements in cardiorespiratory fitness, executive function, and health-related quality of life. The primary outcome measures for this project will be number of CR sessions completed and the percentage who complete ≥30 sessions. Secondary outcomes will include improvements in health outcomes by condition, as well as the cost-effectiveness of the intervention with a focus on potential reductions in emergency department visits and hospitalizations. We hypothesize that either intervention will perform better than the control and that the combination of interventions will perform better than either alone. Conclusions: This systematic examination of interventions will allow us to test the efficacy and cost-effectiveness of approaches that have the potential to increase CR participation substantially and significantly improve health outcomes among patients with lower-SES.

A prospective and preliminary observation of cardiovascular responses to the head-up tilting test in patients with over 1-year follow-up after coronary artery bypass grafting

Preprint

Full-text available

Jan 2023

Hori et al. have suggested previously that blood pressure during a head-up tilt (HUT) in a patient after CABG at discharge was likely to decrease, even they took exercise therapy. Medication status after CABG and reduced stroke volume, one of index for blood volume, would be related with it. On the other hand, some natural adaptations to orthostatic stress in the patients may be expected over long-term recovery. However, there was no study to assess blood pressure during HUT after CABG while monitoring medication status and stroke volume over a long period. Changes in cardiovascular responses to HUT in 6 patients were preliminarily tested during supine and 15-min 60°HUT before (P0) and after coronary artery bypass grafting (CABG) (P1) and over 1-year after surgery (P2). Mean arterial pressure (MAP) decreased during HUT at P0 and P1 and the decrease at P1 was greater than P0, while it remained unchanged at P2. Heart rate (HR) increased during HUT at P0 and P1 and the increase at P1 tended to be greater than P0, while that at P2 were comparable to P0. Stroke volume (SV) was 30% lower during baseline at P1 and P2 than P0. Cardiac output reduced by HUT at P0, but was not affected at P1 and P2, while the baseline at P2 was lower than P0. Ejection fraction remained unchanged at 3 periods. In conclusion, baseline SV at P2 remained lower than P0, but MAP was maintained during HUT. The present results suggest that although the poor control of blood pressure just after is improved over 1 year after CABG, hypovolemia might not be corrected. Assessments of an exercise regimen over long term after CABG would be expected in the future.

Sex Differences in Cardiac Rehabilitation Barriers among Non-Enrollees in the Context of Lower Gender Equality

Preprint

Full-text available

Dec 2022

Background Despite the benefits of cardiac rehabilitation (CR), it remains under-utilized, particularly by women. This study compared CR barriers between non-enrolling men and women in Iran, which has among the lowest gender equality globally. Methods In this cross-sectional study, CR barriers were assessed via phone interview in phase II non-attenders from March 2017 to February 2018 with the Persian version of the Cardiac Rehabilitation Barriers Scale (CRBS-P). T-tests were used to compare scores, with each of 18 barriers scored out of 5, between men and women. Results 357 (33.9%) of the sample of 1053 were women, and they were older, less educated and less often employed than men. Total mean CRBS scores were significantly greater in women (2.37 ± .37) than men (2.29 ± .35; p < .001). The top CR barriers among women were cost (3.35, P < 0.001), transportation problems (3.24, P < 0.001), distance (3.21, P < 0.001), comorbidities (2.97, P < 0.001), low energy (2.41, P < 0.001), finding exercise as tiring or painful (2.22, P = 0.018), and older age (2.27, P = 0.001). Men rated "already exercise at home or in community" (2.69, P = 0.001), time constraints (2.18, P < 0.001) and work responsibilities (2.24, P = 0.001) as greater CR barriers than women. Conclusion Women had greater barriers to CR participation than men. CR programs should be modified to address women’s needs. Home-based CR tailored to women’s exercise needs and preferences should be considered.

Spor ve kalp hastalıkları

Chapter

Full-text available

Dec 2020

Barriers to hospital-based phase 2 cardiac rehabilitation among patients with coronary heart disease in China: a mixed-methods study

Article

Full-text available

Nov 2022
BMC Nurs

Background Coronary heart disease (CHD) has become a leading cause of morbidity and premature death worldwide. Cardiac rehabilitation (CR) was proved to have substantial benefits for patients with CHD. The CR was divided into three phases. Phase 2 is the important part of CR which involves hospital-based structured and closely monitored exercises and activities. However, CR utilization is low worldwide. The barriers to hospital-based phase 2 CR in China have not been well identified. Aims To investigate barriers to hospital-based phase 2 cardiac rehabilitation among coronary heart disease patients in China and to explore the reasons. Methods This study employed an explanatory sequential mixed-methods design. The study was conducted in a university hospital in China from July 2021 to December 2021. Quantitative data was collected through the Cardiac Rehabilitation Barrier Scale. Qualitative data was collected through unstructured face-to-face interviews. Data analysis included descriptive statistics and inductive qualitative content analysis. Results One hundred and sixty patients completed the Cardiac Rehabilitation Barrier Scale and 17 patients participated in unstructured face-to-face interviews. The main barriers identified were distance (3.29 ± 1.565), transportation (2.99 ± 1.503), cost (2.76 ± 1.425), doing exercise at home (2.69 ± 1.509) and time constraints (2.48 ± 1.496). Six themes were identified; logistical factors, social support, misunderstanding of cardiac rehabilitation, program and health system-level factors, impression of CR team and psychological distress. The first four themes confirmed the quantitative results and provide a deeper explanation for the quantitative results. The last two themes were new information that emerged in the qualitative phase. Conclusion This study provides a better understanding of the barriers to hospital-based phase 2 cardiac rehabilitation among coronary heart disease patients in the Chinese context during the Covid-19 pandemic. Innovative programs such as home-based CR, mobile health, and hybrid programs might be considered to overcome some of these barriers. In addition, psychosocial intervention should be included in these programs to mitigate some of the barriers associated with the impression of CR team and psychological distress.

Clinical Determinants and Barriers to Cardiac Rehabilitation Enrollment of Patients with Heart Failure with Reduced Ejection Fraction: A Single-Center Study in Portugal

Article

Full-text available

Oct 2022

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.

Determinants of Physical Activity in the Cardiac Population: Protocol for a Systematic Review

Article

Full-text available

Sep 2022

Background Lack of physical activity is a critical contributing risk factor to cardiovascular disease. Hence, regular physical activity is a mainstay in the primary and secondary prevention of cardiovascular disease. Despite the extensive promotion of physical activity in both primary and secondary prevention programs, including cardiac rehabilitation, physical activity levels in the cardiac population remain low. Therefore, it is crucial to understand critical determinants that influence physical activity behavior. Objective This study aims to deliver a systematic review of studies with collated observational data exploring the association between determinants and physical activity behavior in the target population. These new insights inform the design of future interventions targeted at lasting heart-healthy physical activity behavior in the cardiac population. Methods Primary studies with observational quantitative data on determinants and their association with physical activity behavior in the cardiac population will be included. Information on relevant primary studies will be retrieved from various databases, including Embase, CINAHL, MEDLINE, PsycInfo, and Web of Science Core Collection. Six reviewers will independently double-screen articles. Studies will be selected according to the prespecified inclusion and exclusion criteria. Data will be extracted and entered into suitable worksheets. The US-based National Heart, Lung, and Blood Institute’s Study Quality Assessment Tool for Observational Studies will be used to assess the quality of all eligible primary studies. The results will be presented in a descriptive and narrative synthesis. If the type and quality of data are suitable, meta-analyses will be conducted. Study reporting will follow the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Results Data collection started in September 2020, and the literature search was updated in July 2021. Data synthesis is ongoing, and the literature search will be updated in October 2022. Conclusions This review will be valuable to relevant stakeholders, including clinicians and health care professionals, intervention developers, and decision makers in health care. It lays a comprehensive foundation for understanding the determinants of physical activity to inform the design of secondary prevention interventions relevant to the cardiac population. Trial Registration PROSPERO CRD42020206637; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=206637 International Registered Report Identifier (IRRID) RR1-10.2196/39188

Barreiras da reabilitação cardíaca em uma cidade do nordeste do Brasil

Article

Full-text available

Jun 2017

Averiguar as barreiras por regiões do Brasil, pode ser uma valiosa estratégia para melhorar a inserção e adesão dos pacientes cardiopatas a programas de reabilitação cardiovascular. Objetivo: Identificar e descrever os motivos que levam a não inclusão de indivíduos cardiopatas em programas de reabilitação cardiovascular. Métodos: Estudo descritivo de corte transversal com 79 indivíduos de ambos sexos, com idade superior a 50 anos, cardiopatas provenientes de cinco clínicas particulares de cardiologia. Para identificação dos fatores que interferiam na inclusão dos pacientes aos programas de reabilitação cardiovascular, foi aplicada a escala de barreiras para reabilitação cardíaca. Esse instrumento é composto de 22 itens, sendo que 21 são questões fechadas e objetivas. Os indivíduos foram instruídos a assinalar "SIM" ou "NÃO" para cada item objetivo da escala, caso identificassem o item como uma barreira ou não para a inclusão/adesão. Resultados: 64(81%) da amostra não sabia da existência da reabilitação cardiovascular e dos seus benefícios. Para 50(63%) a distância da residência até o centro de reabilitação foi uma barreira. Além disso, o custo com mobilidade urbana 37 (47%) e a não indicação do médico por achar desnecessário 32 (40%) também foram apontadas como barreiras. Conclusão: Os resultados deste estudo indicam que as principais bramireis para a não inserção em programas de reabilitação cardiovascular foram a falta de conhecimento sobre os benefícios desse tipo de programa, a distância da residência dos pacientes até o centro mais próximo e o custo com deslocamento.

Cardiovascular responses to high‐intensity stair climbing in individuals with coronary artery disease

Article

Full-text available

May 2022

Exercise-based cardiac rehabilitation leads to improvements in cardiovascular function in individuals with coronary artery disease. The cardiac effects of coronary artery disease (CAD) can be quantified using clinical echocardiographic measures, such as ejection fraction (EF). Measures of cardiovascular function typically only used in research settings can provide additional information and maybe more sensitive indices to assess changes after exercise-based cardiac rehabilitation. These additional measures include endothelial function (measured by flow-mediated dilation), left ventricular twist, myocardial performance index, and global longitudinal strain. To investigate the cardiovascular response to 12 week of either traditional moderate-intensity (TRAD) or stair climbing-based high-intensity interval (STAIR) exercise-based cardiac rehabilitation using both clinical and additional measures of cardiovascular function in individuals with CAD. Measurements were made at baseline (BL) and after supervised (4wk) and unsupervised (12 week) of training. This study was registered as a clinical trial at clinicaltrials.gov (NCT03235674). Participants were randomized into either TRAD (n = 9, 8M/1F) and STAIR (n = 9, 8M/1F). There was a training-associated increase in one component of left ventricular twist: Cardiac apical rotation (TRAD: BL: 5.6 ± 3.3º, 4 week: 8.0 ± 3.9º, 12 week: 6.2 ± 5.1º and STAIR: BL: 5.1 ± 3.6º, 4 week: 7.4 ± 3.9º, 12 week: 7.8 ± 2.8º, p (time) = 0.03, η2 = 0.20; main effect) and post-hoc analysis revealed a difference between BL and 4 week (p = 0.02). There were no changes in any other clinical or additional measures of cardiovascular function. The small increase in cardiac apical rotation observed after 4 weeks of training may indicate an early change in cardiac function. A larger overall training stimulus may be needed to elicit other cardiovascular function changes.

Exercise Training in Patients with Heart Failure: From Pathophysiology to Exercise Prescription

Article

Full-text available

Apr 2022

Heart failure (HF) is a chronic, progressive, and inexorable syndrome affecting worldwide billion of patients (equally distributed among men and women), with prevalence estimate of 1–3% in developed countries. HF leads to enormous direct and indirect costs, and because of ageing population, the total number of HF patients keep rising, approximately 10% in patients >65 years old. Exercise training (ET) is widely recognized as an evidence-based adjunct treatment modality for patients with HF, and growing evidence is emerging among elderly patients with HF. We used relevant data from literature search (PubMed, Medline, EMBASE) highlighting the epidemiology of HF; focusing on central and peripheral mechanisms underlying the beneficial effect of ET in HF patients; and on frail HF elderly patients undergoing ET. Since many Countries ordered a lockdown in early stages pandemic trying to limit infections, COVID-19 pandemic, and its limitation to exercise-based cardiac rehabilitation operativity was also discussed. ET exerts both central and peripheral adaptations that clinically translate into anti-remodeling effects, increased functional capacity and reduced morbidity and mortality. Ideally, ET programs should be prescribed in a patient-tailored approach, particularly in frail elderly patients with HF. In conclusion, given the complexity of HF syndrome, combining, and tailoring different ET modalities is mandatory. A procedural algorithm according to patient’s baseline clinical characteristics [i.e., functional capacity, comorbidity, frailty status (muscle strength, balance, usual daily activities, hearing and vision impairment, sarcopenia, and inability to actively exercise), logistics, individual preferences and goals] has been proposed. Increasing long-term adherence and reaching the frailest patients are challenging goals for future initiatives in the field.

Barriers and facilitators to participating in cardiac rehabilitation and physical activity: A cross-sectional survey

Article

Full-text available

Feb 2022
World J Cardiol

Background: Cardiovascular diseases (CVD) have been shown to be the greatest cause of death worldwide and rates continue to increase. It is recommended that CVD patients attend cardiac rehabilitation (CR) following a cardiac event to reduce mortality, improve recovery and positively influence behaviour around CVD risk factors. Despite the recognised benefits and international recommendations for exercise-based CR, uptake and attendance remain suboptimal. A greater understanding of CR barriers and facilitators is required, not least to inform service development. Through understanding current cardiac patients' attitudes and opinions around CR and physical activity (PA) could inform patient-led improvements. Moreover, through understanding aspects of CR and PA that participants like/dislike could provide healthcare providers and policy makers with information around what elements to target in the future. Aim: To investigate participants' attitudes and opinions around CR and PA. Methods: This study employed a cross-sectional survey design on 567 cardiac patients. Cardiac patients who were referred for standard CR classes at a hospital in the Scottish Highlands, from May 2016 to May 2017 were sampled. As part of a larger survey, the current study analysed the free-text responses to 5 open-ended questions included within the wider survey. Questions were related to the participants' experience of CR, reasons for non-attendance, ideas to increase attendance and their opinions on PA. Qualitative data were analysed using a 6-step, reflexive thematic analysis. Results: Two main topic areas were explored: "Cardiac rehabilitation experience" and "physical activity". Self-efficacy was increased as a result of attending CR due to exercising with similar individuals and the safe environment offered. Barriers ranged from age and health to distance and starting times of the classes which increased travel time and costs. Moreover, responses demonstrated a lack of information and communication around the classes. Respondents highlighted that the provision of more classes and classes being held out with working hours, in addition to a greater variety would increase attendance. In terms of PA, respondents viewed this as different to the CR experience. Responses demonstrated increased freedom when conducting PA with regards to the location, time and type of exercise conducted. Conclusion: Changes to the structure of CR may prove important in creating long term behaviour change after completing the rehabilitation programme.

Barriers to and motives for engagement in an exercise-based cardiac rehabilitation programme in Ireland: a qualitative study

Article

Full-text available

Feb 2022

Background Insufficient physical activity (PA) is a leading risk factor for premature death worldwide. Ireland’s public healthcare system, the Health Service Executive (HSE), has supported the development of the National Exercise Referral Framework (NERF) to tackle low levels of PA amongst those with non-communicable diseases (NCDs). ‘NERF centres’ are medically supervised PA programmes across Ireland that have established referral pathways with local hospitals and general practitioners. ULMedX is one such NERF centre offering exercise-based cardiac rehabilitation (EBCR) with the aim of intervention development to reduce early drop-out and maximise adherence for optimal health benefits. Aim The purpose of this research was to identify the major factors influencing participants’ adherence and early drop-out at ULMedX. Exploring areas for future development were also prioritised. Design & setting Qualitative interviews were conducted with long-term attenders and people who have dropped out (PWDO) from ULMedX. Methods Guided by the Theory of Planned Behaviour the 1–1 semi-structured interviews were performed, transcribed, and evaluated through thematic analysis. Results Analysis was performed on 14 participants (50% female; mean age 67.3 years), comprising long-term attenders (n = 7; 13-month duration, 64% of classes) and PWDO (n = 7; 2.8-month duration, 22% of classes). Three major factors affecting adherence and drop-out were identified: social support, perceived outcomes from participation and practical barriers to attendance. Areas for future development included the provision of evening and advanced classes, psychological support, more exercise variety, more educational seminars and new members start as their own group. Conclusion The findings suggest participants at ULMedX are more likely to have had a better experience and commit to the programme if they believed involvement would benefit their physical and mental health, increase their exercise motivation by engendering a positive attitude to exercise, and that the ability to attend was within their control. Future interventions at ULMedX should have their structures centred around these motives for engagement. ULMedX should also test the participant recommendations to overcome the common barriers to adherence.

Journal of Cancer Biology Pyscho-oncological considerations for Indigenous populations

Article

Full-text available

Nov 2021

Cancer is one of the most dreaded diagnosis, with significant impact on the patient, carer and family. The diagnosis can lead to variety of emotions like confusion, anger, despair and fear. In case of Indigenous peoples, the process of sickness, disease and treatment are all closely related to connection to land, country, family and community. This paper evaluates the different responses recorded as a part of a larger Indigenous Australian study, regarding the feelings and emotions one feels when they hear of cancer (“the Big C”) in the community or family. The evaluation follows a brief discussion on the evidence available regarding the emotions recorded and the relevance in Indigenous peoples and circumstances. A deeper understanding of the impact of cancer in the community will also be beneficial, in providing informal carers or family members with the appropriate support they need to concur their own stress and anxiety.

A systematic review of provider-and system-level factors influencing the delivery of cardiac rehabilitation for heart failure

Article

Full-text available

Nov 2021
BMC HEALTH SERV RES

Background There is a longstanding research-to-practice gap in the delivery of cardiac rehabilitation for patients with heart failure. Despite adequate evidence confirming that comprehensive cardiac rehabilitation can improve quality of life and decrease morbidity and mortality in heart failure patients, only a fraction of eligible patients receives it. Many studies and reviews have identified patient-level barriers that might contribute to this disparity, yet little is known about provider- and system-level influences. Methods A systematic review using narrative synthesis. The aims of the systematic review were to a) determine provider- and system-level barriers and enablers that affect the delivery of cardiac rehabilitation for heart failure and b) juxtapose identified barriers with possible solutions reported in the literature. A comprehensive search strategy was applied to the MEDLINE, Embase, PsycINFO, CINAHL Plus, EThoS and ProQuest databases. Articles were included if they were empirical, peer-reviewed, conducted in any setting, using any study design and describing factors influencing the delivery of cardiac rehabilitation for heart failure patients. Data were synthesised using inductive thematic analysis and a triangulation protocol to identify convergence/contradiction between different data sources. Results Seven eligible studies were identified. Thematic analysis identified nine overarching categories of barriers and enablers which were classified into 24 and 26 themes respectively. The most prevalent categories were ‘the organisation of healthcare system’, ‘the organisation of cardiac rehabilitation programmes’, ‘healthcare professional’ factors and ‘guidelines’. The most frequent themes included ‘lack of resources: time, staff, facilities and equipment’ and ‘professional’s knowledge, awareness and attitude’. Conclusions Our systematic review identified a wide range of provider- and system-level barriers impacting the delivery of cardiac rehabilitation for heart failure, along with a range of potential solutions. This information may be useful for healthcare professionals to deliver, plan or commission cardiac rehabilitation services, as well as future research.

Determinants of physical activity behaviour in the cardiac population: a systematic review

Preprint

Full-text available

Nov 2023

Background: Physical inactivity is one of the most detrimental modifiable cardiovascular risk factors. Despite the well-established benefits of physical activity (PA) on the overall health of people with cardiovascular disease (CVD), challenges remain in maintaining heart-healthy PA behaviour after completing a cardiac rehabilitation programme. This study aimed to collect and analyse observational data on the relative importance of determinants for heart-healthy PA levels in people with CVD, to inform behaviour change research and intervention development in CVD secondary prevention. Methods: This systematic review included studies reporting bivariate association statistics of determinants and PA behaviour in adults fulfilling the medical indications for cardiac rehabilitation. Included were peer-reviewed journal articles published in English, Dutch, or German since 2005. Five electronic databases (CINAHL, Embase, MEDLINE via PubMed, PsycINFO, Web of Science Core Collection) were last searched in April 2023. Risk of bias of included studies was assessed using the National Heart, Lung, and Blood Institute's Study Quality Assessment Tool for Observational Studies. Data were analysed using descriptive analysis and narrative synthesis. Results:Included were 57 articles reporting on 54 primary studies from 23 countries, with the majority from North America (n=22), Europe (n=18) and Asia (n=10). Twenty-nine studies were rated good quality and 25 studies fair quality. The studies report on altogether 17,639 individual participants, providing collated empirical evidence for 51 determinants and their patterns of association with PA behaviour in the cardiac population. Those determinants showing distinct positive associations with PA behaviour are self-efficacy, life attitude, intention, exercise belief, education, weather, exercise behaviour, habit formation, social support, psychological wellbeing and employment; whereas those determinants showing distinct negative associations with PA behaviour are age, emotion (including anxiety and kinesiophobia), depression and comorbidity. Conclusions: This systematic review has identified determinants of PA behaviour that bear particular relevance for the cardiac population. Developers of behaviour change interventions may draw on these findings to inform intervention concepts, methods and designs. Further research in underrepresented geographic regions, and studies into underrepresented determinants of PA and dynamic changes of PA behaviours over time are warranted. Systematic review registration: International Prospective Register of Systematic Reviews (PROSPERO) CRD42020206637

Effectiveness of a virtual vs. in-person group-based education curriculum to increase disease-related knowledge and change health behaviour among cardiac rehabilitation participants

Article

Oct 2023

A Systematic Review of Interventions With an Educational Component Aimed at Increasing Enrollment and Participation in Cardiac Rehabilitation

Article

Oct 2023
J CARDIOPULM REHABIL

Objective The aim of this study was to systematically review the impact and characteristics of interventions with an educational component designed to improve enrollment and participation in cardiac rehabilitation (CR) among patients with cardiovascular disease. Review Methods Five electronic databases were searched from data inception to February 2023. Randomized controlled trials and controlled, cohort, and case-control studies were considered for inclusion. Title, abstract, and full text of records were screened by two independent reviewers. The quality of included studies was rated using the Mixed Methods Assessment Tool. Results were analyzed in accordance with the Synthesis Without Meta-analysis reporting guideline. Results From 7601 initial records, 13 studies were included, six of which were randomized controlled trials (“high” quality = 53%). Two studies evaluated interventions with an educational component for health care providers (multidisciplinary team) and 11 evaluated interventions for patient participants (n = 2678). These interventions were delivered in a hybrid (n = 6; 46%), in-person (n = 4; 30%), or virtual (n = 3; 23%) environment, mainly by nurses (n = 4; 30%) via discussion and orientation. Only three studies described the inclusion of printed or electronic materials (eg, pamphlets) to support the education. Eleven of 12 studies reported that patients who participated in interventions with an educational component or were cared for by health care providers who were educated about CR benefits (inhospital and/or after discharge) were more likely to enroll and participate in CR. Conclusion Interventions with an educational component for patients or health care providers play an important role in increasing CR enrollment and participation and should be pursued. Studies investigating the effects of such interventions in people from ethnic minority groups and living in low-and-middle-income countries, as well as the development of standard educational materials are recommended.

Interprofessional survey of Perceived Barriers regarding Cardiac rehabilitation in Greece

Article

Sep 2023

The implementation of a value-based learning health system for preventative care in Ontario, Canada

Article

Apr 2023

Objective: While value-based learning health systems may address challenges associated with the integrative delivery of therapeutic lifestyle management in usual care, the extent to which they have been evaluated in real-world settings have remained limited. Methods: To explore the feasibility and user-experiences, associated with the first-year implementation of a preventative Learning Health System (LHS), consecutive patients were evaluated following referral from primary and/or specialty care providers from the Halton and Greater Toronto Area in Ontario, Canada, between December 2020 and December 2021. The integration of a LHS into medical care was facilitated using a digital e-learning platform, and consisted of exercise, lifestyle, and disease-management counselling. The dynamic monitoring of user-data allowed patients and providers to modify goals, treatment plans, and care-delivery in real-time in accordance with patient engagement, weekly exercise, and risk-factor targets. All program costs were covered by the public-payer health care system using a physician fee-for-service payment model. Descriptive statistics evaluated attendance to prescheduled visits, drop-out rates, changes in self-reported weekly Metabolic Expenditure Task-Minutes (MET-MINUTES), perceived changes in health knowledge, lifestyle behaviours, health status, satisfaction with care, and programmatic costs. Results: 378 of 437 patients (86.5%) enrolled in the 6-month program; The average age of patients was 61.2 ± 12.2, 156 (41.3%) of which were female and 140 (37.0%) with established coronary disease. After 1 year, 15.6% dropped out of the program. On average, weekly MET-MINUTES rose by 191.1 throughout the program (95% CI [331.82, 57.96], P=0.007), with increases most prominent among sedentary populations. Participants reported significant improvements in perceived health status and health knowledge, at a total health-care delivery cost of $517.70 per patient for a completed program. Conclusion: The implementation of an integrative preventative learning health system was feasible, with high patient engagement and favourable user-experiences. Further research is required to compare health outcomes against usual care.

Factors Affecting Referral and Patient Access to Heart Function Clinics in Ontario: A Qualitative Study of Stakeholders

Article

Mar 2023

Background: Though heart failure patients benefit from multidisciplinary care in heart function clinics (HFCs), utilization is suboptimal and inequitable. This study investigated factors influencing referral and patient access to HFCs from multiple stakeholders' perspectives, namely policy-makers (PM), providers at HFCs and patients. Methods: In this qualitative study, semi-structured interviews with a purposive sample of Ontario stakeholders were conducted between February-June 2020 and July-December 2022 (paused due to pandemic) via Teams. Interview transcripts were concurrently analyzed using systematic text condensation with Nvivo. Two authors coded individually, with disagreements discussed with senior author. Results: Interviews with 7 HFCs (6 physicians, 1 nurse), 6 PM and 4 patients were completed before saturation; 5 themes emerged. First, with regard to health system organization, stakeholders reported gaps related to continuity of care, limited capacity and insufficient funding. Second, with regard to referral appropriateness and timeliness, sub-themes related to unclear referral criteria, varying clinic scope, and delays in triage, testing and time-to-visit. The third theme related to clinic characteristics, raised issues of varying clinic services and composition of healthcare professions/expertise. The fourth theme regarding patient factors related to comorbidity/frailty, socioeconomic status, barriers due to location (parking, traffic) and affinity to specific providers. The final theme related to the COVID-19 pandemic concerned increased referral volumes, loss to follow-up care, transition to online delivery modalities and patient refusal of in-person visits. Many facilitators to improve HFC referral and access were raised. Conclusions: Resources must be provided, and stakeholders brought together to standardize and integrate the HF care continuum.

THE USE OF VIRTUAL REALITY IN CARDIOVASCULAR REHABILITATION PROGRAMS: SCOPE REVIEW

Article

Full-text available

Oct 2021

Introduction: Cardiovascular rehabilitation (CVR) is defined as a necessary activity to ensure best physical, psychological and social conditions, for people with cardiovascular disease (CD), being considered an important low-cost non-pharmacological treatment. New technologies in health field, especially in CVR programs, using virtual reality (VR), are shown as promising assistants with the objective of increasing adherence and satisfaction to programs. Objective:Map available evidence to provide an overview of the use of VR in the context of CVR. Methods:This is a study based on scope review, that were researched studies using VR, interfaces like glasses in CVR programs with clinical and / or surgical patients. The databases used were: Pubmed, Medline, Lilacs, PEDro,Science Direct, Cochrane Database of Systematic Reviews e JBI Database of Systematic Reviews and Implementation Reports Journal. Results:RV in CVR programs has been described as safe and viable and has resulted in improve cardiorespiratory capacity, in addition to being motivating. Conclusion: VR can be considered a complementary tool in CVR programs, allowing to improve performance and adherence to programs.

Virtual Healthcare Solutions for Cardiac Rehabilitation: A Literature Review

Article

Full-text available

Feb 2023

Aims Adherence to cardiac rehabilitation following a primary event has been demonstrated to improve quality of life, increase functional capacity, and decrease hospitalizations and mortality. Mobile technologies offer an opportunity to improve both the quality and utilization of cardiac rehabilitation and recent clinical studies investigated this technology. This literature review summarizes the current use of mobile health, wearable activity monitors, and other multi-component technologies deployed to support home-based virtual cardiac rehabilitation. Methods and results Methodology was adapted from the Cochrane Handbook for Systematic Reviews of Interventions. We identified 2,094 records, of which 113 were eligible for qualitative analysis. Different virtual cardiac rehabilitation solutions were implemented in the studies, (1) multi-component interventions in 48 studies (42.5%), (2) wearable activity monitors in 27 studies (23.9%), (3) web-based communications solutions, and (4) mobile apps, both in 19 studies (16.4%). Functional capacity was the most frequently reported primary outcome (k=37, 32.7%), followed by user adherence/compliance (k=35, 31.0%), physical activity (k=27, 23.9%), and quality of life (k=14, 12.4%). Studies provided a mixed assessment of the efficacy of virtual cardiac rehabilitation in attaining either significant improvements over baseline, or significant improvements in outcomes compared with conventional rehabilitation. Conclusions Efficacy outcomes with virtual cardiac rehabilitation sometimes improve on the centre-based outcomes, however, superior clinical efficacy may not necessarily be the only outcome of interest. The promise of virtual cardiac rehabilitation includes the potential for increased user adherence and longer-term patient engagement. If these outcomes can be improved, that would be a significant justification for using this technology.

Desafios da reabilitação cardiovascular no Brasil: da atenção primária à quaternária

Book

Full-text available

Jan 2023

O uso de realidade virtual em programas de reabilitação cardiovascular revisão de escopo

Article

Full-text available

Dec 2022

Cardiovascular rehabilitation (CVR) is defined as a necessary activity to ensure best physical, psychological and social conditions, for people with cardiovascular disease (CD), being considered an important low-cost non-pharmacological treatment. New technologies in health field, especially in CVR programs, using virtual reality (VR), are shown as promising assistants with the objective of increasing adherence and satisfaction to programs. Objective: Map available evidence to provide an overview of the use of VR in the context of CVR. Methods: This is a study based on scope review, that were researched studies using VR, interfaces like glasses in CVR programs with clinical and / or surgical patients. The databases used were: Pubmed, Medline, Lilacs, PEDro, Science Direct, Cochrane Database of Systematic Reviews e JBI Database of Systematic Reviews and Implementation Reports Journal. Results: RV in CVR programs has been described as safe and viable and has resulted in improve cardiorespiratory capacity, in addition to being motivating. Conclusion: VR can be considered a complementary tool in CVR programs, allowing to improve performance and adherence to programs.

Actual vs. perceived exertion during active virtual reality game exercise

Article

Full-text available

Aug 2022

Background Virtual exercise has become more common as emerging and converging technologies make active virtual reality games (AVRGs) a viable mode of exercise for health and fitness. Our lab has previously shown that AVRGs can elicit moderate to vigorous exercise intensities that meet recommended health benefit guidelines. Dissociative attentional focuses during AVRG gameplay have the potential to widen the gap between participants' perception of exertion and actual exertion. Objective The aim of this study was to determine actual exertion (AEx) vs. perceived exertion (PEx) levels during AVRGs by measuring heart rate (HR) and ratings of perceived exertion (RPE) in two different settings. Materials and methods HR and RPE were collected on participants ( N = 32; age 22.6 ± 2.6) during 10 min of gameplay in LabS and GymS using the HTC VIVE with the following games played: Fruit Ninja VR (FNVR), Beat Saber (BS), and Holopoint (HP). Results Participants exhibited significantly higher levels of AEx compared to reported PEx for all three AVRGs (Intensity): FNVR [AEx = 11.6 ± 1.8 (Light), PEx = 9.0 ± 2.0 (Very Light)], BS [AEx = 11.3 ± 1.7 (Light), PEx = 10.3 ± 2.1 (Very Light)], HP [AEx = 13.1 ± 2.3 (Somewhat Hard), PEx = 12.3 ± 2.4 (Light–Somewhat Hard)]. Additionally, participants playing in the GymS experienced significantly higher levels of AEx [12.4 ± 2.3 (Light–Somewhat Hard)] and PEx [10.8 ± 2.5 (Very Light–Light)] compared to the LabS [AEx = 11.6 ± 1.8 (Light), PEx = 10.3 ± 2.6 (Very Light–Light)]. Conclusion Perceptions of exertion may be lower than actual exertion during AVRG gameplay, and exertion levels can be influenced by the setting in which AVRGs are played. This may inform VR developers and health clinicians who aim to incorporate exercise/fitness regimens into upcoming ‘virtual worlds' currently being developed at large scales (i.e., the “metaverse”).

Impact Of Cardiac Rehabilitation on Patients with Myocardial Infarction: Cardiac Rehabilitation for Myocardial Infraction

Article

Full-text available

Jul 2022

Myocardial Infarction (MI) renowned as “Heart attack” is of 2 main categories ST-Elevation Myocardial Infarction (STEMI) which is symptomatic and Non-ST-Elevation Myocardial Infarction (NSTEMI) with no clear symptoms, killing silently. Cardiac Rehabilitation (CR) is a multidimensional standard of patient care individually tailored to specific needs of participants. Objective: To find out the impact of CR on cardiac abnormalities and associated malfunctions and promote awareness and facilitation of CR. Methods: A descriptive cross-sectional study was done via “The Minnesota Living with Heart Failure Questionnaire” (MLHFQ). Data was collected from 90 cardiac patients. Results: According to MLHFQ, 7.8% of the population had good QOL, 71.1% had moderate QOL, and 21.1% had poor QOL from age 45 to 60 with MI. Conclusion: 71.1% of total participants with MI who followed CR observed enhanced energy levels, managed symptoms effectively, prevented progression, and boosted up confidence level hence results showed positive impact of rehabilitation. Factor affected results were age, cooperation, duration of diagnosis before participating in CR and duration of rehabilitation. Whereas, it had almost similar impact for both male and female of age 45 to 60.

Perceptions and preferences of patients with cardiac conditions to the inclusion of virtual reality-based therapy with conventional cardiovascular rehabilitation: A qualitative study

Article

Full-text available

May 2022
REV BRAS FISIOTER

Background Virtual reality-based therapy (VRBT) has been recently used in rehabilitation programs, as it can improve patient's adherence to treatment. However, patients’ acceptance of VRBT has been scarcely investigated. Objective To qualitatively analyze the perceptions and preferences of patients about the inclusion of VRBT to a conventional cardiovascular rehabilitation program (CRP). Methods Fifteen patients from a randomized clinical trial participated in focus groups for qualitative assessment. Results Patients demonstrated good acceptance and satisfaction of VRBT. Physical and psychosocial benefits were highlighted, and patients reported the perception of higher exercise intensity in VRBT then when doing conventional training. In addition, the frequency of VRBT (once a week), associated with conventional treatment was reported as satisfactory. Cognitive aspects that influenced participation to the new approach were also raised by study participants. Conclusion Patients with cardiac conditions demonstrated satisfaction with the inclusion of VRBT in a conventional CRP, demonstrating that VRBT has the potential to be a new approach for this patient population, allowing training diversification. Benefits perceived by patients include physical, mental, and social aspects. Trial Registered NCT04336306 (https://clinicaltrials.gov/ct2/show/NCT04336306)

How to Reduce Inequity of Access to Cardiac Rehabilitation After Surgical Aortic Valve Replacement. Recommendations for the Post–COVID-19 Era From a Real-World, Population-Based Study

Article

Mar 2022
CLIN THER

Purpose Cardiac rehabilitation (CR) is a class I recommendation after valvular surgery. Few data exist on the level of access to CR after surgical aortic valve replacement (SAVR), and the factors affecting the probability of timely access to CR after SAVR have never been empirically investigated. This study aims at estimating the proportion of SAVR patients who initiated timely CR and understanding to what extent timely access to CR for SAVR patients is influenced by specific characteristics of patients and hospitals. Methods We conducted a real-world, retrospective, population-based study by identifying from the Italian National Hospital Discharge Records all the discharged alive SAVR patients who accessed timely CR from 2009-2016. Two different cutoffs for timely access were considered, i.e. one and 21 days after discharge. A unique dataset was constructed by merging several data sources. Multiple logistic regressions were performed to identify the factors influencing the probability to access to timely CR. Findings 107,545 patients underwent SAVR in Italy from 2009-2016 and were discharged alive. Overall, 71,593 SAVR patients (66.6%) accessed timely CR, with an increasing trend over time. Additional 6,149 patients (5.7%) started CR from 2-21 days after discharge, slightly decreasing over time. The probability of timely CR (one-day cutoff) was significantly higher in older (OR=1.025, p<0.001) female patients (OR = 1.003, p<0.05) and patients with cardiovascular and cerebrovascular comorbidities. Presence of rehabilitation wards and number of rehabilitation beds in the index hospital significantly increased the probability of timely access to CR (OR = 1.105, p<0.001 and OR = 1.006, p<0.001 respectively). Patients hospitalized in private teaching hospitals had the highest predicted probability of timely CR after SAVR. A substantial variation in access to CR was found across Italian regions. Similar results were obtained with the alternative 21-days cutoff. Implications Approximately one-third of SAVR patients did not benefit from CR in Italy, mainly due to shortness of rehabilitation facilities, with relevant disparities across the country. The cessation of CR services during the COVID-19 pandemic provides the opportunity to re-think and innovate CR, shifting from center-based to home-based models. Digital health technologies can supplement traditional health services and grant safe, effective, and equitable access to care, especially for countries with insufficient rehabilitation bed capacity. As CR is associated with better outcomes, we recommend decision-makers to use our results to plan adequate healthcare services, also investing in digital health, to ensure patients’ access to cost-effective care.

Psychological response to an acute coronary event and its effect on subsequent rehabilitation and lifestyle change

Article

Full-text available

Apr 1987
CLIN CARDIOL

We assessed anxiety, depression, body image, motivation, and coping ability in 264 patients admitted with a first myocardial infarction. They were followed over 1 year to determine the relationship between psychological factors and subsequent return to work, smoking cessation, weight reduction, and adoption of a leisure exercise program. Females showed a poorer reaction to illness than did males. The better-educated, and patients in white-collar occupations showed less depression and expressed greater motivation. Anxiety and poor body image, however, tended to be least common in the intermediate educational and occupational group. All psychological factors predicted leisure exercise change, and all but anxiety predicted smoking cessation. Poor body image was linked with failure to reduce weight. Low expressed motivation was the only factor predicting delayed return to work.

Predictors of cardiac rehabilitation participation in older coronary patients

Article

May 1992
ARCH INTERN MED

P. A. Ades

Emotional and behavioral problems in cardiac rehabilitation patients

Article

Mar 1985

An approach to managing behavioral and mental health problems in cardiac patients is described based on the principles of learning theory and the behavioral techniques derived from those principles. This approach can be applied to stress management, sick role prevention, improved compliance, life-style modification, and treatment of psychotic or suicidal behavior. The basis for the approach is the belief that both discrete physiologic events and social behaviors are the outcome of individual learning influenced by environmental events as well as by the patient’s biologic status and predisposition. This biopsychosocial model implies that a patient’s maladaptive responses can be modified and influenced not only by medical interventions but also by the participation of all staff members with patients and their families in the consistent application of the principles and strategies outlined.

Improving cardiac patient adherence to exercise regimens: A clinical trial of health education

Article

Jan 1985

L.H. Daltroy

An educational intervention, consisting of telephone counseling for patient and spouse and a mailed pamphlet, was designed to improve cardiac patient attendance at six exercise programs. Attendance was tested against the pamphlet alone in a randomized, controlled trial with 174 patients and 134 spouses. Unadjusted results showed a nonsignificant increase (2%) in the first three months9 attendance of the experimental group over the comparison group. However, adjustment for covariates showed that the intervention significantly increased attendance by 12% (P =.03) and had the strongest effect on subjects with a high school education or less. Evidence regarding the effect of spouse support was contradictory. Nonexperimental variables that significantly affected attendance, when controlling for all other variables, included exercise site, smoking, cardiac diagnosis, and patients anticipation that their job would make them miss exercise sessions. Three quarters of the patients continued to exercise on their own after dropping out, but only one third of these people exercised at levels sufficient to maintain cardiorespiratory benefits.

Compliance and dropout in cardiac exercise rehabilitation

Article

May 1984

Neil B. Oldridge

Factors associated with and reasons for compliance and dropout in cardiac exercise rehabilitation programs are discussed. Although certain factors may he associated with compliance or dropout, they do not predict compliance or dropout accurately. There is evidence that lack of spousal support, inconvenient programming, impersonal and unreceptive staff, and lack of long-term commitment are important reasons for dropout. These, and other factors, provide useful guidelines for the program director. Behavior management strategies and techniques for improving compliance need further investigation in patients who are interested in becoming physically active in a safe and appropriate manner.

A statement for healthcare professionals from the American Heart Association

Article

Sep 1994
CIRCULATION

Cardiac rehabilitation after myocardial infarction. Combined experience of randomized clinical trials

Article

Aug 1988

N. B. Oldridge

The Awareness-to-Adherence Model of the Steps to Clinical Guideline Compliance

Article

Sep 1996
MED CARE

OBJECTIVES: This article proposes, tests, and explores the potential applications of a model of the cognitive and behavioral steps physicians take when they comply with national clinical practice guidelines. The authors propose that when physicians comply with practice guidelines, they must first become aware of the guidelines, then intellectually agree with them, then decide to adopt them in the care they provide, then regularly adhere to them at appropriate times. METHODS: Data used to test this model address physicians' responses to national pediatric vaccine recommendations. Questionnaires were mailed to 3,014 family physicians and pediatricians who were working in communities of various sizes in nine states. RESULTS: The survey response rate was 66.2%. In the case of the recommendation to provide hepatitis B vaccine to all infants, guideline awareness among respondents was 98.4%, agreement 70.4%, adoption 77.7%, and adherence 30.1%. The data for 87.9% of physicians fit the model at every step. Significant deviation from the model occurred only for the 11% of all physicians who adopted the hepatitis B recommendation without agreeing with it. In the case of the recommendation to provide the acellular variety of the pertussis vaccine for children's fourth and fifth pertussis doses, guideline awareness among respondents was 89.8%, agreement 66.5%, adoption 46.3%, and adherence 35.2%. Data fit the model at every step for 90.6% of physicians. Greater likelihood of movement from each step to the next in the path to adherence was found for physicians with certain characteristics, information sources, and beliefs about the vaccines, and those in certain types of practice settings. Specific physician and practice characteristics typically predicted movement along only one or two of the steps to adherence to either the hepatitis B or acellular pertussis recommendations. CONCLUSIONS: These data on physicians' use of pediatric vaccine recommendations generally support the awareness-to-adherence model. This model may prove useful in identifying ways to improve physicians' adherence to a variety of guidelines by demonstrating where physicians fall off the path to adherence, which physicians are at greatest risk for not attaining each step in the path, and factors associated with a greater likelihood of attaining each step toward guideline adherence.

Psychosocial Interventions for Patients With Coronary Artery Disease

Article

Apr 1996
ARCH INTERN MED

Wolfgang Linden

Background: Narrative review strategies and meta-analyses have shown that drug treatment and exercise rehabilitation regimens can reduce psychological distress and postmyocardial infarction mortality and recurrence. Objective: To question whether the addition of psychosocial interventions improves the outcome of a standard rehabilitation regimen for patients with coronary artery disease. Methods: We performed a statistical meta-analysis of 23 randomized controlled trials that evaluated the additional impact of psychosocial treatment of rehabilitation from documented coronary artery disease. Anxiety, depression, biological risk factors, mortality, and recurrence of cardiac events were the clinical end points that were studied. Mortality data were available from 12 studies, and recurrence data were available from 10 of the 23 studies. Results: The studies had evaluated 2024 patients who received psychosocial treatment vs 1156 control subjects. The psychosocially treated patients showed greater reductions in psychological distress, systolic blood pressure, heart rate, and cholesterol level (with effect size differences of 0.34, -0.24, -0.38, and -1.54, respectively). Patients who did not receive psychosocial treatment showed greater mortality and cardiac recurrence rates during the first 2 years of follow-up with log-adjusted odds ratios of 1.70 for mortality (95% confidence interval [CI], 1.09 to 2.64) and 1.84 for recurrence (CI, 1.12 to 2.99). Conclusions: The addition of psychosocial treatments to standard cardiac rehabilitation regimens reduces mortality and morbidity, psychological distress, and some biological risk factors. The benefits were clearly evident during the first 2 years and were weaker thereafter. At the clinical level, it is recommended to include routinely psychosocial treatment components in cardiac rehabilitation. The findings also suggest an urgent need to identify the specific, most effective types of psychosocial interventions via controlled research.(Arch Intern Med. 1996;156:745-752)

Exercise Training for Cardiac Patients

Article

Jan 1986
J Cardpulm Rehabil

The relationships of exercise adherence and aerobic fitness to a spectrum of biologic and psychologic benefits were examined in the context of a three-stage model of exercise training: recruitment, participation, and continuation. Ninety-five men consecutively admitted for uncomplicated acute myocardial infarction or for coronary artery bypass graft surgery were screened for exercise training based on their ability to exercise and the distance of their residence from the exercise site, yielding a final sample of 50. Patients were followed up for a period of one year posthospitalization. Fifty percent of the patients attempted training. Exercise adherence declined by 50% after the completion of training and stabilized at that level for the rest of the year. Six variables predicted adherence at two of the three stages of the program throughout the year, while six other variables predicted adherence at only one of the stages. Adherence was positively associated with improvement in mood state as well as with improvement in ischemic and dyspneic symptoms. Neither the extent of participation in exercise training (beyond six weeks of the 12-week program), nor the continuation of exercise activity after training was related significantly to improvement in fitness. Further, improvement in fitness was not significantly associated with improvement in benefits. The pattern of positive relationships between exercise adherence and benefits and null relationships between exercise aerobic fitness and benefits are discussed in terms of a possible psychologic mechanism through which exercise training may exert its positive effects.

Cardiac Rehabilitation Exercise Programme

Article

Jul 1988

Neil B. Oldridge

Compliance-enhancing strategies in cardiac rehabilitation should be investigated only if it has been shown that the condition under consideration is an important cause of mortality and premature disability, that the intervention or therapy is effective, and that compliance with the intervention is poor. Coronary artery disease is the leading cause of death and premature disability in industralised countries. Evidence from randomised controlled trials of supervised exercise rehabilitation after documentation of coronary artery disease suggests a reduction in fatal event rates, and an initial improvement in both exercise tolerance and psychosocial status, although these differences between experimental and control subjects are reduced over time. Poor compliance with supervised exercise programmes is a problem. This suggests that compliance enhancement with programmes of exercise rehabilitation for cardiac patients is an appropriate area of research. A number of issues recur in compliance research including the investigation of compliance-enhancing strategies in exercise rehabilitation. These relate to the specification of definition of compliance, the description of the experimental protocol or strategy, the selection and description of the sample to be studied, the randomisation of the sample, the selection of compliance measures, contamination and co-intervention, monitoring for decay, and various ethical issues. Compliance-enhancing strategies must be designed with these methodological issues in mind. These issues are discussed with specific reference to randomised controlled trials of compliance-enhancing strategies to cardiac exercise rehabilitation.

Predictors of Cardiac Rehabilitation Participation in Older Coronary Patients

Article

May 1992
ARCH INTERN MED

Philip A. Ades

Background.— While older coronary patients have a lower exercise capacity than younger coronary patients and have been demonstrated to improve exercise capacity to a degree similar to younger coronary patients, they are less likely to be referred to an outpatient cardiac rehabilitation program. The goal of this study was to determine demographic, medical, and psychosocial predictors of outpatient cardiac rehabilitation participation in hospitalized older post—coronary event patients. Methods.— An in-hospital—guided interview was performed by the clinical research nurse of the cardiac rehabilitation program with 226 hospitalized patients, aged 62 years and older, who had recently suffered a myocardial infarction or coronary bypass surgery. Demographic, medical, and psychosocial data were analyzed. Results. — Overall cardiac rehabilitation participation rate in a population with a mean age of 70.4±6 years (range, 62 to 92 years) was 21%. By multivariate analysis, the strength of the primary physician's recommendation for participation was the most powerful predictor of cardiac rehabilitation entry. Also, significant predictors of participation included commute time, patient "denial" of severity of illness, and history of depression. Medical factors such as cardiac diagnosis and left ventricular ejection fraction did not predict participation. Conclusions.— Demographic, medical, and psychosocial data, collected in hospitalized post—coronary event patients are powerful predictors of subsequent participation in cardiac rehabilitation. ( Arch Intern Med. 1992;152:1033-1035)

Preventing heart attack and death in patients with coronary disease

Article

Jul 1995

Social Foundations of Thought & Action: A Social Cognitive Theory

Book

Jan 1986

Albert Bandura

Measures of Personality and Social Psychological Attitudes:

Article

Oct 1992
Behav Soc Sci Libr

Robert P. Jordan

This index is intended to facilitate finding information on instruments discussed in Robinson, Shaver, and Wrightsman (1991). The book has a detailed table of contents, but no index. When required to find information quickly on a particular instrucment, librarians and researchers would rather consult an index than peruse a lengthy table of contents.

Cardiovascular Rehabilitation in Ontario (Canada)

Article

Apr 1990
J CARDIOPULM REHABIL

Hospitals, YM-YWCAs, regional health units, and university physical education and athletics departments (n = 423) were surveyed to determine the number and locations of existing cardiovascular rehabilitation units (CRUs). A total of 43 CRUs were identified by these inquiries and 135 additional institutions expressed interest in future establishment of a CRU. Hospitals and medical clinics (n = 25) were the most common sponsoring institutions for CRUs, followed by YM-YWCAs (n = 10), community organizations (n = 5) and university physical education/kinesiology departments (n = 3). Contact persons at 37 of the 43 existing CRUs subsequently completed and returned written questionnaires which described their unit's status and operating procedures. The replies suggested the following conclusions: (1) an outpatient (OP) exercise program was the most commonly offered program component; (2) nutritional counselling, stress management, smoking cessation programs, and exercise programs for inpatients were also frequently offered; (3) the majority of patients treated were post-myocardial infarction and post-cardiac-surgery patients, with lesser numbers of angina and coronary-prone patients; (4) adequate facilities and equipment were usually available; (5) considerable variability existed regarding qualifications of staff and methods for enhancing staff education; (6) respondents were often unfamiliar with the CASS/ACSM, Exercise Specialist Certification program, and few certified individuals were employed; and (7) health insurance and professional liability insurance coverage, were often inadequate suggesting an urgent need for development of a Canadian procedural guidelines and better communication among practitioners in this field. (C) Lippincott-Raven Publishers.

Compliance With Cardiac Rehabilitation Services

Article

Mar 1991
J CARDIOPULM REHABIL

Neil B. Oldridge

Rehabilitation, i.e., regaining normal, active, productive life, is an integral part of treatment in the recovery process after myocardial infarction (M I) and requires adequate provision of health education and risk factor management services by the health professional and adequate utilization of the proper services by the patient. Benefits of these services include a reduction in cardiovascular risk factors, decrease in activit y-induced symptoms, and an improved functional capacity, in short, an improved quality of life. This goal will most likely be achieved when the intervention or prescription needed to confer benefits is attainable and attractive enough for long-term compliance. The evidence, where possible from randomized clinical trials, demonstrates that the benefits of risk factors modification strategies to alter hypercholesterolemia, hypertension, smoking, Type A behavior, and physical inactivity are greatest in patients actively complying with the prescribed intervention. Whether these benefits are observed in routine clinical care will depend on an adequate level of compliance maintained over extended periods of time. The patient has a right t o refuse the prescribed treatment; however, as the patient has presumably asked for help, the provider has a responsibility to try to improve compliance i f it is low and i f the treatment has been shown to be efective. Although the available data do not necessarily increase our theoretical understanding of compliant and noncompliant exercise behaviors, there is considerable useful and clinically relevant information for the practicing cardiac rehabilitation specialist. The challenge is, therefore, twofold: to motivate patients unwilling to take the first step to modify risk factors, and to provide strategies to help patients maintain long-term compliance. A model, which assumes that education and cardiovascular risk factor management are essential services and that lines of communication must be carefully nurtured at all times, has been proposed to optimize costefective utilization of individualized cardiac rehabilitation services. (C) Lippincott-Raven Publishers.

Self-Efficacy: The Exercise of Control

Book

Jan 1997

Albert Bandura

Identifying Participation Rates at Outpatient Cardiac Rehabilitation Programs in Victoria, Australia

Article

Nov 1999
J Cardpulm Rehabil

Much has been achieved in implementing structured outpatient cardiac rehabilitation (CR) programs in Victoria, Australia, but little is known about the percentage of eligible patients who participate. This study was undertaken to determine the feasibility of establishing a database of CR participants and comparing it to the Victorian Inpatient Minimum Database (VIMD), a routinely collected hospital morbidity data set documenting all admissions to Victorian public and private hospitals. This would enable program participants and nonparticipants to be identified and program participation rates to be calculated. Data on program participants were collected from a sample of eight CR programs. Records from the VIMD were extracted for the concurrent time period for patients discharged home after acute myocardial infarction (AMI), coronary artery bypass graft (CABG) surgery, and percutaneous transluminal coronary angioplasty (PTCA), and therefore considered eligible to participate. Victorian Inpatient Minimum Database data were aggregated according to program catchment areas. Data were compared for program participants and patients eligible to participate. Seven hundred fifty-eight patients were identified as being eligible to attend; 240 (32%) were identified as participating at least once. Discharged CABG patients participated on average at a rate of 53.1%, compared with 27.2% of AMI patients and only 10.3% of PTCA patients. Despite a comprehensive network of CR programs in Victoria, they are used on average by only a minority of eligible patients. Further work is required to determine barriers to participation to develop strategies to increase participation rates.

Exercise Compliance in Cardiac Rehabilitation

Article

Jul 1989

Karen L. Radtke

The purpose of this study was to determine whether myocardial infarction (MI) patients comply with their prescribed home exercise programs following hospital discharge, and whether this compliance is related to self-motivation. Thirty-five patients treated for acute MI and discharged with home exercise programs were mailed a Self-Motivation Inventory (SMI) and an Exercise Compliance Questionnaire (ECQ). Twenty-eight returned the questionnaires, and 25 of the 28 reported that they were exercising, a compliance rate of 89%. Six months later, the SMI and ECQ were mailed to the 25 subjects who were compliant, and 17 responded. Of those, 14 (82%) reported that they were still exercising (49% of the original sample). The overall mean indicated that the patients were moderately and consistently self-motivated.

Self-motivation: A driving force for elders in cardiac rehabilitation

Article

Mar 1992
GERIATR NURS

Why is Cardiac Rehabilitation Not Widely Used?

Article

Mar 1992
West J Med

R F De Busk

Cardiac Rehabilitation Program Participation and Outcomes After Myocardial Infarction

Article

Mar 1992
REHABIL NURS

Rehabilitation programs for myocardial infarction (MI) survivors are designed to alter survivors' self-care patterns and to improve long-term physical and psychological outcomes. The purpose of this study was to examine the relationship between participation in cardiac rehabilitation and health state; days of reduced activity; anxiety; depression; self-esteem; quality of life; and performance of exercise, diet, medication, stress-modification, and smoking-reduction self-care behaviors after MI. Interviews were conducted with 197 women and men 1 to 2 years after their initial MI to measure health state, mood, self-esteem, quality of life, and relevant self-care behaviors. Rehabilitation center records were reviewed to determine participation in rehabilitation programs. Rehabilitation participation was significantly associated with health state; days of reduced activity; self-esteem; quality of life; and performance of exercise, diet, and medication self-care. These findings suggest that participation in cardiac rehabilitation is a worthwhile intervention that facilitates recovery from myocardial infarction.

Predictors of Adoption and Maintenance of Vigorous Activity in Men and Women ’ Physical

Article

Apr 1992

This study examined predictors of adoption and maintenance of vigorous physical activity over time in a sample of 1,719 randomly selected women and men. Based on reported frequency of vigorous exercise in a mail survey at baseline, subjects were classified as sedentary (zero sessions per week), intermediate (one to two sessions per week), or active (three or more sessions per week). On the same survey subjects reported on 25 potential determinants of physical activity based on a comprehensive learning model. Twenty-four months later, 85% of subjects were resurveyed, and their physical activity levels were classified. Within each baseline category and gender subgroup, predictors of follow-up physical activity were identified. In multivariate analyses, adoption of vigorous exercise by sedentary men was predicted by self-efficacy, age (inverse), and neighborhood environment (inverse). Adoption by sedentary women was predicted by education, self-efficacy, and friend and family support for exercise. Maintenance of vigorous physical activity was predicted by self-efficacy and age (inverse) for initially active men and by education for initially active women. These results suggest that factors influencing adoption are different for men and women, and there may be different factors influencing adoption versus maintenance of vigorous physical activity.

Predictors of cardiac rehabilitation in older coronary patients

Article

Jun 1992
ARCH INTERN MED

While older coronary patients have a lower exercise capacity than younger coronary patients and have been demonstrated to improve exercise capacity to a degree similar to younger coronary patients, they are less likely to be referred to an outpatient cardiac rehabilitation program. The goal of this study was to determine demographic, medical, and psychosocial predictors of outpatient cardiac rehabilitation participation in hospitalized older post--coronary event patients. An in-hospital-guided interview was performed by the clinical research nurse of the cardiac rehabilitation program with 226 hospitalized patients, aged 62 years and older, who had recently suffered a myocardial infarction or coronary bypass surgery. Demographic, medical, and psychosocial data were analyzed. Overall cardiac rehabilitation participation rate in a population with a mean age of 70.4 +/- 6 years (range, 62 to 92 years) was 21%. By multivariate analysis, the strength of the primary physician's recommendation for participation was the most powerful predictor of cardiac rehabilitation entry. Also, significant predictors of participation included commute time, patient "denial" of severity of illness, and history of depression. Medical factors such as cardiac diagnosis and left ventricular ejection fraction did not predict participation. Demographic, medical, and psychosocial data, collected in hospitalized post-coronary event patients are powerful predictors of subsequent participation in cardiac rehabilitation.

Comparison of the clinical profile and outcome of women and men in cardiac rehabilitation

Article

Jun 1992
AM J CARDIOL

Few data are available regarding the outcome of women in cardiac rehabilitation. To determine whether women differ from men in clinical profile and outcome, 225 consecutive patients were prospectively evaluated in an urban, multidisciplinary, exercise-based cardiac rehabilitation program. Among the 51 women (age 56 +/- 10) and 174 men (age 54 +/- 10), most were: white (84%), married (64%), employed (63%), had had myocardial infarction or revascularization, or both (66%), and traveled less than 10 miles to the program (92%). Risk profiles revealed obesity in 48% (mean Metropolitan Relative Weight = 124 +/- 22%), hypertension in 47%, smoking in 23%, diabetes in 16%, and mean cholesterol of 236 +/- 45 mg/dl. Compared with men, more women were nonwhite, unemployed, unmarried, hypertensive or diabetic (p less than 0.0001) and had higher cholesterol (p less than 0.01). Compliance rates were similar for women (51%) and men (63%) (p = not significant). Univariate predictors of program noncompliance differed between women and men. Initial exercise capacity was less for women than for men, but both groups achieved a similar training effect. Women increased their exercise time by 31% and peak METs by 30%, whereas men showed a 21% increase in exercise time and 16% increase in peak METs achieved (p less than 0.001). Thus, in this cardiac rehabilitation program, women have a less favorable risk factor profile and differ from men with regard to baseline demographics and predictors of program completion. Women, however, have similar rates of compliance and achieve the same improvement in functional capacity with training.

Referral patterns and exercise response in the rehabilitation of female coronary patients aged ≥62 years

Article

Jul 1992
AM J CARDIOL

Gender-related differences in cardiac rehabilitation referral patterns and response to an aerobic conditioning program were examined in 226 hospitalized older coronary patients (aged greater than or equal to 62 years). Overall, the outpatient cardiac rehabilitation participation rate in this population was 21%. Older women were less likely to enter cardiac rehabilitation than were older men (15 vs 25%; p = 0.06), despite similar clinical profiles. This was explained primarily by a greater likelihood of primary physicians to strongly recommend cardiac rehabilitation to men. Before conditioning, women who entered cardiac rehabilitation were less fit than were men; peak oxygen consumption was 18% lower in women (16 +/- 5 vs 20 +/- 5 ml/kg/min; p = 0.02). However, both groups improved aerobic capacity similarly in response to a 12-week aerobic conditioning program, with maximal oxygen consumption increasing by 17% in women and by 19% in men. Thus, older female coronary patients are less likely to be referred for cardiac rehabilitation, despite a similar clinical profile and improvement in functional capacity from the training component.

Acute Myocardial Infarction in Women

Article

Jul 1992
Crit Care Nurs Clin

Barbara Loveys Cochrane

Although CHD is the leading cause of death in women, little is known about their response to and recovery from an acute MI. The medical and nursing care offered to women following an MI is based primarily on research studies of men. Few studies have included only women, and those that have compared women and men are limited by sample sizes that are too small for meaningful comparisons and study variables that reflect men's concerns (e.g., specific risk factors or return to work issues). Women's cardiovascular anatomy and physiology differ somewhat from men's. Women average smaller chests, hearts, and coronary artery vessel diameters and different body fat distributions. Their cardiovascular systems are designed to adapt to the extraordinary demands of pregnancy and childbirth and do so by modifying diastolic, rather than systolic, function. Similar physiologic changes are often seen in response to exercise. Women's higher levels of estrogen and progesterone influence lipid metabolism and hormone receptor activity. Thus, diagnostic tests that are based on research with men (e.g., ECGs and exercise stress tests), show more false-positive and false-negative results in women. Additionally, therapeutic interventions (e.g., PTCA and CABG) that were developed for men have been less effective for women. CHD is apparently expressed differently in women. Diabetes mellitus is a strong, independent risk factor for CHD in women and results in a risk similar to that of nondiabetic men. More women present with angina as an initial manifestation of CHD than with MI and rarely have sudden cardiac death. Women experience more complications than men and a higher mortality following acute MI. They derive less benefit from medical or surgical therapy and experience more side effects. Many aspects of women's response to acute MI reflect gender rather than biologic differences. Women's worlds, the sociocultural contexts within which they live, and their activities are qualitatively different from men's. The nursing care offered to women should be based on sound scientific rationale that responds to these unique experiences and concerns.

Cardiovascular benefits and assessment of physical activity and physical fitness in adults

Article

Jul 1992

Relationships among health beliefs, self-efficacy, and exercise adherence in patients with coronary artery disease

Article

Feb 1992
HEART LUNG

Management of the pathologic progression of coronary artery disease requires life-style changes in patients, but the level of compliance with medical recommendations is low. Critical care nurses have a unique opportunity to encourage patients to assume responsibility for their health care and life-style behavior. In this study we developed a model to identify the relationships among variables that explained adherence to a recommended exercise regimen. The variables studied included self-efficacy, perceived severity, barriers, benefits, and cues to action.

Gender Differences in Cardiac Rehabilitation Patients

Article

Sep 1991
REHABIL NURS

Gender differences in anxiety, self-efficacy, activity tolerance, and adherence were assessed in 101 patients (80 males, 21 females) with coronary artery disease consecutively admitted to three phase II cardiac rehabilitation centers. The percentage of women in rehabilitation is 20% lower than anticipated based on coronary morbidity data. On admission to rehabilitation, men were significantly better able to tolerate physical activity, were less anxious, and perceived themselves as having greater efficacy in enduring exercise and activities of daily living than women. During the first month of rehabilitation, 24% of males and 33% of females missed 1 week or more of scheduled sessions. There were no significant differences in demographic or diagnostic characteristics between sexes.

Anxiety, Depression, Quality of Life, and Self-Care Among Survivors of Myocardial Infarction

Article

Jul 2009

This article examines the relationship between anxiety, depression, quality of life, and performance of suggested self-care behaviors among older adult myocardial infarction survivors. Interviews were conducted with 94 adults aged 65 years and older. The Profile of Mood States was used to measure anxiety and depression. Quality of life was measured with the Perceived Quality of Life scale. The Health Behavior Scale was used to measure performance of suggested self-care behaviors (modify diet, administer medications, manage stress, exercise, and reduce smoking). Depression scores accounted for 49% of the variance in quality of life scores. Depression scores predicted each of the self-care behavior scores. Anxiety scores did not predict quality of life scores or any self-care behavior score. Findings suggest that mental health interventions should become an integral part of formal cardiac rehabilitation programs soon after the infarction; interventions for depression long after the infarction are needed as well.

Adherence to the cardiac diet: Attitudes of patients after myocardial infarction

Article

Dec 1991
J AM DIET ASSOC

Cardiac rehabilitation—A cost analysis

Article

Dec 1991

This economic evaluation is based on a 5-year follow-up study comparing a comprehensive cardiac rehabilitation programme with standard care after myocardial infarction (MI). The intervention group consisted of 147 non-selected MI patients aged less than 65 years, who were participating in a rehabilitation programme consisting of follow-up at a post-MI clinic, health education and physical training in out-patient groups. The control group consisted of a non-selected MI-population aged less than 65 years (n = 158), who were receiving standard care. The rehabilitation programme did not increase the health-care costs of post-MI care, as the increase in cost due to participation in the programme was balanced by a decrease in readmissions for cardiovascular diseases. On average, the rehabilitated patient returned to work more frequently, resulting in decreased costs due to loss of production. The mean patient total cost of a 5-year MI follow-up was SEK 73,500 lower in the rehabilitated group. The outstanding winner of the rehabilitation programme was the Swedish National Health Insurance System (NHIS). It must be concluded that the comprehensive cardiac rehabilitation programme is a major strategy that leads to both lowered costs and positive health effects. The cardiac rehabilitation programme is therefore highly cost-effective.

Prediction of motivation and behavior change following health promotion: Role of health beliefs, social support, and self-efficacy

Article

Feb 1991

Dimensions of health beliefs (perceived risk of behavior and benefit of behavior change), social support (family and others' support for change), and self-efficacy (magnitude and strength) were examined in 215 patients undergoing a prospective trial of health promotion in a primary care medical practice. Discriminant analyses were performed to evaluate how well these dimensions predicted motivation for change and lifestyle behavior change. These relationships were examined for six lifestyle areas: cigarette smoking, dealing with stress, amount and type of food eaten, use of seat belts, and exercise habits. The analyses demonstrated a statistically and clinically significant prediction of motivation by one or more health belief and self-efficacy dimensions for most lifestyle areas. The strongest single predictors were perceived benefits and self-efficacy strength, which were each significant predictors of motivation in four lifestyle areas (P less than 0.05). Support dimensions, as measured, were not shown to have predictive value in most areas. Behavior change was poorly predicted by beliefs, support, and self-efficacy for most lifestyle areas. However, adding motivation to the discriminant function equation resulted in significant predictions in all six lifestyle areas (P less than 0.05), with an average correct classification rate of 71%. This finding strongly suggests that motivation is a very important intervening variable when evaluating health promotion and resulting behavior change.

Recovery from Acute Myocardial Infarction in Women

Article

Feb 1990

Glenys A Hamilton

This paper is a review of the literature on recovery from acute myocardial infarction in women. The topic has been subdivided into three areas for presentation: cardiac rehabilitation, return to work and sexual activity. The exploration of the literature revealed the paucity of research on women, but some comparisons could be made between men and women. Compared to men, women appear to utilize cardiac rehabilitation programs less frequently than men and have higher dropout rates, they return to work less frequently and after a longer period of time and resume sexual activity after a longer period of time reporting more symptoms during and after the activity. Investigation of the literature showed that the recovery period for women is incompletely explored and that there is a critical need for research.

The Health Belief Model: Predicting compliance and dropout in cardiac rehabilitation

Article

Nov 1990

We investigated the health belief model and the health locus of control constructs as predictors of group membership (compliers or dropouts) with cardiac rehabilitation and whether they added predictive utility to routinely assessed patient demographics and health behaviors. Questionnaires were completed on entry into the study by 120 patients with coronary artery disease, and by the end of the 6 month program there were 58 compliers and 62 dropouts. Discriminant function analyses were carried out to determine prediction of group membership. The health belief model predicted group membership 64.6% of the time, explaining 5.2% of the variance. Demographics, health behaviors, and health belief model factors accounted for 21.1% of the variance between compliers and total dropouts with group membership correctly predicted 74.4% of the time; avoidable and unavoidable dropout was correctly predicted 84.2% of the time with 56.9% of the variance explained. Health locus of control did not distinguish between compliers and dropouts. The addition of the health belief model provided additional information about compliance with cardiac rehabilitation beyond that explained by demographic and health behavior variables alone, particularly when predicting avoidable/unavoidable dropout.

The structure of readjustment after heart attack

Article

Feb 1990

A comprehensive multivariate framework aimed at predicting the factors that enhance or impede readjustment after a heart attack, has been developed and empirically supported by a study among convalescents after heart attack. Application of multivariate techniques of data analysis revealed a 'structure' highlighting the relative weight of various 'demands' in impeding readjustment, and the relative significance of the individual's self-controlled resources in coping with these demands and thus enhance readjustment. The data further show the crucial role of the spouse in both enhancing resources and furthering readjustment. By distinguishing between three dimensions of readjustment--the affective, the instrumental, and the cognitive--the data further the understanding of the differential effects of various demands, resources, and spouse support on readjustment. The herein theoretically justified and empirically supported structure expands the earlier developed structure of readjustment of traumatically irreversible disabled persons, taking into consideration the peculiar situation of the convalescents after heart attack, the trilateral conceptualization of readjustment.

Regaining control: The process of adjustment after myocardial infarction

Article

Apr 1990
HEART LUNG

The purpose of this study was to examine the process of adjustment that individuals experience after having a myocardial infarction (MI). The study used a grounded theory approach. Interviews with 14 individuals who had an MI provided the major source of data. The findings of this study indicate that the process of adjustment after MI is variable and incorporates four stages. In each of these stages the individual focuses on the core process of regaining a sense of personal control. The first stage of the adjustment process involves attempts to defend oneself against a threatened loss of control. In the second stage, the individual struggles to come to terms with the MI. Throughout the third stage, numerous strategies are used to reestablish a sense of control. If control is reestablished the individual progresses to the final stage of adjustment. The hallmarks of the final stage include an acceptance of limitations, a refocusing on issues other than the MI, and a perceived sense of mastery.

Wives' response to counseling early after myocardial infarction

Article

Feb 1990
J PSYCHOSOM RES

Self-ratings of anxiety and depression were studied over six months in 60 wives of first time myocardial infarction patients. Couples were randomly assigned to either a treatment group, where they received a simple programme of education and psychological support in addition to routine care, or to a control group, where they received routine care only. All wives completed the Hospital Anxiety and Depression scale and a battery of visual analogue scales measuring anxiety on a range of topics related to recovery from a heart attack. Wives in the treatment group reported statistically significantly less anxiety than controls. This effect was sustained for six months after the counselling. It is concluded that a simple programme of in hospital counselling is efficacious and should be routinely offered to the wives of coronary patients.

Multiple Coronary Arteriovenous Fistulas Associated with Polymyositis

Article

Feb 1990

We report a case of a 60-year-old female presenting a histologically proven polymyositis with multiple coronary arteriocameral fistulas draining into the left ventricle. The exact pathogenesis of coronary artery fistulas and their relation to polymyositis are not clear.

Factors influencing patient entrance into a cardiac rehabilitation program

Article

Sep 1990

The purpose of this descriptive pilot study was to identify factors that influence patient participation in a cardiac rehabilitation program. Thirty-nine patients who were admitted to a midwestern hospital with a coronary problem and who were candidates for cardiac rehabilitation completed the Patient Entrance Into a Cardiac Rehabilitation Program (PECRP) questionnaire. The PECRP evaluates a subject's responses to Health Belief Model-based statements. Analysis by t test revealed significant differences for perceived benefits and barriers, indicating that patients who participated in a cardiac rehabilitation program perceived more benefits and fewer barriers to entering such a program than those who did not. No significant differences were found between groups for perceived susceptibility and perceived severity constructs. Analysis of demographic variables revealed significant differences for income and marital status on the perceived benefits and barriers construct, indicating that those who had an income greater than $20,000 and those who were married perceived more benefits and fewer barriers than those whose income was less than $20,000 and who were not married. Nursing implications for these patients are discussed, particularly those related to patient teaching before discharge.

An Overview of Randomized Trials of Rehabilitation With Exercise After Myocardial Infarction

Article

Sep 1989

Of 22 randomized trials of rehabilitation with exercise after myocardial infarction (MI), one trial had results that achieved conventional statistical significance. To determine whether or not these studies, in the aggregate, show a significant benefit of rehabilitation after myocardial infarction, we performed an overview of all randomized trials, involving 4,554 patients; we evaluated total and cardiovascular mortality, sudden death, and fatal and nonfatal reinfarction. For each endpoint, we calculated an odds ratio (OR) and 95% confidence interval (95% CI) for the trials combined. After an average of 3 years of follow-up, the ORs were significantly lower in the rehabilitation than in the comparison group: specifically, total mortality (OR = 0.80 [0.66, 0.96]), cardiovascular mortality (OR = 0.78 [0.63, 0.96]), and fatal reinfarction (OR = 0.75 [0.59, 0.95]). The OR for sudden death was significantly lower in the rehabilitation than in the comparison group at 1 year (OR = 0.63 [0.41, 0.97]). The data were compatible with a benefit at 2 (OR = 0.76 [0.54, 1.06]) and 3 years (OR = 0.92 [0.69, 1.23]), but these findings were not statistically significant. For nonfatal reinfarction, there were no significant differences between the two groups after 1 (OR = 1.09 [0.76, 1.57]), 2 (OR = 1.10 [0.82, 1.47]), or 3 years (OR = 1.09 [0.88, 1.34]) of follow-up. The observed 20% reduction in overall mortality reflects a decreased risk of cardiovascular mortality and fatal reinfarction throughout at least 3 years and a reduction in sudden death during the 1st year after infarction and possibly for 2-3 years. With respect to the independent effects of the physical exercise component of cardiac rehabilitation, the relatively small number of "exercise only" trials, combined with the possibility that they may have had a formal or informal nonexercise component precludes the possibility of reaching any definitive conclusion. To do so would require a randomized trial of sufficient size to distinguish between no effect and the most plausible effect based on the results of this overview.

Exercise compliance in cardiac rehabilitation

Article

Jul 1989
REHABIL NURS

Karen L. Radtke

Cardiac rehabilitation exercise programme. Compliance and compliance-enhancing strategies

Article

Aug 1988

Neil B. Oldridge

Compliance-enhancing strategies in cardiac rehabilitation should be investigated only if it has been shown that the condition under consideration is an important cause of mortality and premature disability, that the intervention or therapy is effective, and that compliance with the intervention is poor. Coronary artery disease is the leading cause of death and premature disability in industrialized countries. Evidence from randomised controlled trials of supervised exercise rehabilitation after documentation of coronary artery disease suggests a reduction in fatal event rates, and an initial improvement in both exercise tolerance and psychosocial status, although these differences between experimental and control subjects are reduced over time. Poor compliance with supervised exercise programmes is a problem. This suggests that compliance enhancement with programmes of exercise rehabilitation for cardiac patients is an appropriate area of research. A number of issues recur in compliance research including the investigation of compliance-enhancing strategies in exercise rehabilitation. These relate to the specification of definition of compliance, the description of the experimental protocol or strategy, the selection and description of the sample to be studied, the randomisation of the sample, the selection of compliance measures, contamination and co-intervention, monitoring for decay, and various ethical issues. Compliance-enhancing strategies must be designed with these methodological issues in mind. These issues are discussed with specific reference to randomised controlled trials of compliance-enhancing strategies to cardiac exercise rehabilitation.

Trends in physician management of uncomplicated acute myocardial infarction, 1970 to 1987

Article

Apr 1988
AM J CARDIOL

To document current management of uncomplicated acute myocardial infarction (AMI), a national survey of 1,065 physicians was performed. Items from previous surveys in 1970 and 1979 were included to permit analysis of time trends in management. Median hospital stay dropped from 21 days in 1970 to 9 days in 1987. Use of beta blockers and aspirin doubled between 1979 and 1987, while use of anticoagulation and sulfinpyrazone dropped 4- to 10-fold. In 1987, coronary angiography was used commonly, especially in younger patients or those with either a non-Q-wave AMI, intravenous thrombolytic therapy or a positive exercise test. These findings document the increasingly aggressive approach to the management of patients with uncomplicated AMI.

Strategies for Rebuilding Self-Esteem for the Cardiac Patient

Article

Jan 1988

ReNeI McGlashan

Program Director, Cardiology/Gerontology Services at Lutheran Medical Center, Wheat Ridge, Colorado. She has 12 years of experience in critical care and cardiac rehabilitation, in both inpatient and outpatient settings.

Cardiac Rehabilitation After Myocardial InfarctionCombined Experience of Randomized Clinical Trials

Article

Sep 1988

Randomized clinical trials of cardiac rehabilitation following myocardial infarction have typically demonstrated a lower mortality in treated patients, but with a statistically significant reduction in only one trial. To overcome the problem of not being able to detect small but clinically important benefits in mortality in randomized clinical trials of exercise and risk factor rehabilitation after myocardial infarction with small numbers of patients, we carried out a meta-analysis on the combined results of ten randomized clinical trials that included 4347 patients (control, 2145 patients; rehabilitation, 2202 patients). The pooled odds ratios of 0.76 (95% confidence intervals, 0.63 to 0.92) for all-cause death and of 0.75 (95% confidence intervals, 0.62 to 0.93) for cardiovascular death were significantly lower in the rehabilitation group than in the control group, with no significant difference for nonfatal recurrent myocardial infarction. These results suggest that, for appropriately selected patients, comprehensive cardiac rehabilitation has a beneficial effect on mortality but not on nonfatal recurrent myocardial infarction.

Myocardial Infarction Survival: How important Are Patients’ Attitudes and Adherence Behaviors?

Article

May 1987
AM J PREV MED

Positive attitudes toward and adherence to prescribed medical regimens among patients recovering from initial episodes of myocardial infarction (MI) intuitively have been viewed as beneficial. A cohort of 157 post-MI patients who participated in a cardiac rehabilitation program was tested for compliance with the Health Adherence Scale and Miller Attitude Scale during hospitalization and again six months later. This study reports on follow-up conducted two to five years after initial MI to determine whether patients' attitudes and adherence behaviors had a significant effect on subsequent cardiovascular morbidity and overall mortality after controlling for known risk factors. The data were analyzed using the Cox proportional hazard regression model. Neither positive patient attitudes nor adherence behaviors were associated with a reduced risk of a morbid or fatal event. However, this study found, as have many others, that the known risk factors of alcoholism, widowhood, cigarette smoking, and diabetes were significantly associated with repeat episodes of MI, while the only risk factor associated with mortality was repeat MI. The study suggests that the benefits of positive attitudes and adherence behaviors are outweighed by the influence of existing cardiovascular risk factors. Thus, the prevention of these risk factors remains the primary determinant in the reduction of MI.

Major depressive disorder in coronary artery disease

Article

Jan 1988
AM J CARDIOL

Depression has been reported to be common in patients with coronary artery disease (CAD), using a variety of criteria for the diagnosis of depression. However, many studies have relied solely on the presence of symptoms such as a dysphoric mood and fatigue in making a diagnosis of depression. Both fatigue and dysphoric mood are also associated with medical illnesses, and psychiatric diagnoses based on such nonspecific symptoms may lack the specificity necessary to predict the need for psychiatric treatment. To assess the incidence of depression likely to require and respond to psychiatric treatment, 50 patients documented to have CAD by coronary angiography underwent psychiatric diagnostic interviews. Current research-based criteria (DSM-III) were used to make diagnoses of major depressive disorder. In addition, the applicability of a brief screening inventory the (Beck depression inventory) for detecting the presence of depression in these patients was tested. Nine patients (18%) met criteria (DSM-III) for major depressive episode. Depression was not related to the extent of CAD, age or use of beta blockers. There was a relation between depression and smoking. Only 2 of the 9 depressed patients had been diagnosed previously and were being treated for depression. When a score of greater than or equal to 10 on the Beck depression inventory was used to distinguish patients with depression, it had moderate sensitivity (78%) and specificity (90%) for the identification of depression.

Barriers to Participation in and Adherence to Cardiac Rehabilitation Programs: A Critical Literature Review

Abstract

No full-text available

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