Jomme Claes

Longer-term effects of home-based exercise interventions on exercise capacity and physical activity in coronary artery disease patients: A systematic review and meta-analysis.

Background Exercise-based cardiovascular rehabilitation (CR) improves exercise capacity (EC), lowers cardiovascular risk profile and increases physical functioning in the short term. However, uptake of and adherence to a physically active lifestyle in the long run remain problematic. Home-based (HB) exercise programmes have been introduced in an attempt to enhance long-term adherence to recommended levels of physical activity (PA). The current systematic review and meta-analysis aimed to compare the longer-term effects of HB exercise programmes with usual care (UC) or centre-based (CB) CR in patients referred for CR. Design Systematic review and meta-analysis. Methods Non-randomised controlled trials (RCTs) or randomised trials comparing the effects of HB exercise programmes with UC or CB rehabilitation on EC and/or PA, with a follow-up period of ≥12 months and performed in coronary artery disease patients, were searched in four databases (PubMed, EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Cochrane Central Register of Controlled trials (CENTRAL)) from their inception until September 7, 2016. Standardised mean differences (SMDs) were calculated and pooled by means of random effects models. Risk of bias, publication bias and heterogeneity among trials were also assessed. Results Seven studies could be included in the meta-analysis on EC, but only two studies could be included in the meta-analysis on PA (total number of 1440 patients). The results showed no significant differences in EC between HB rehabilitation and UC (SMD 0.10, 95% confidence interval (CI) –0.13 to 0.33). There was a small but significant difference in EC in favour of HB compared to CB rehabilitation (SMD 0.25, 95% CI 0.02–0.48). No differences were found for PA (SMD 0.37, 95% CI –0.18 to 0.92). Conclusions HB exercise is slightly more effective than CB rehabilitation in terms of maintaining EC. The small number of studies warrants the need for more RCTs evaluating the long-term effects of different CR interventions on EC and PA behaviour, as this is the ultimate goal of CR.

PATHway I: design and rationale for the investigation of the feasibility, clinical effectiveness and cost-effectiveness of a technology-enabled cardiac rehabilitation platform

Introduction Exercise-based cardiac rehabilitation (CR) independently alters the clinical course of cardiovascular diseases resulting in a significant reduction in all-cause and cardiac mortality. However, only 15%–30% of all eligible patients participate in a phase 2 ambulatory programme. The uptake rate of community-based programmes following phase 2 CR and adherence to long-term exercise is extremely poor. Newer care models, involving telerehabilitation programmes that are delivered remotely, show considerable promise for increasing adherence. In this view, the PATHway (Physical Activity Towards Health) platform was developed and now needs to be evaluated in terms of its feasibility and clinical efficacy. Methods and analysis In a multicentre randomised controlled pilot trial, 120 participants (m/f, age 40–80 years) completing a phase 2 ambulatory CR programme will be randomised on a 1:1 basis to PATHway or usual care. PATHway involves a comprehensive, internet-enabled, sensor-based home CR platform and provides individualised heart rate monitored exercise programmes (exerclasses and exergames) as the basis on which to provide a personalised lifestyle intervention programme. The control group will receive usual care. Study outcomes will be assessed at baseline, 3 months and 6 months after completion of phase 2 of the CR programme. The primary outcome is the change in active energy expenditure. Secondary outcomes include cardiopulmonary endurance capacity, muscle strength, body composition, cardiovascular risk factors, peripheral endothelial vascular function, patient satisfaction, health-related quality of life (HRQoL), well-being, mediators of behaviour change and safety. HRQoL and healthcare costs will be taken into account in cost-effectiveness evaluation. Ethics and dissemination The study will be conducted in accordance with the Declaration of Helsinki. This protocol has been approved by the director and clinical director of the PATHway study and by the ethical committee of each participating site. Results will be disseminated via peer-reviewed scientific journals and presentations at congresses and events. Trial registration number NCT02717806. This trial is currently in the pre-results stage.

The development and codesign of the PATHway intervention: a theory-driven eHealth platform for the self-management of cardiovascular disease

Cardiovascular diseases (CVDs) are a leading cause of premature death worldwide. International guidelines recommend routine delivery of all phases of cardiac rehabilitation (CR). Uptake of traditional CR remains suboptimal, as attendance at formal hospital-based CR programs is low, with community-based CR rates and individual long-term exercise maintenance even lower. Home-based CR programs have been shown to be equally effective in clinical and health-related quality of life outcomes and yet are not readily available. The aim of the current study was to develop the PATHway intervention (physical activity toward health) for the self-management of CVD. Increasing physical activity in individuals with CVD was the primary behavior. The PATHway intervention was theoretically informed by the behavior change wheel and social cognitive theory. All relevant intervention functions, behavior change techniques, and policy categories were identified and translated into intervention content. Furthermore, a person-centered approach was adopted involving an iterative codesign process and extensive user testing. Education, enablement, modeling, persuasion, training, and social restructuring were selected as appropriate intervention functions. Twenty-two behavior change techniques, linked to the six intervention functions and three policy categories, were identified for inclusion and translated into PATHway intervention content. This paper details the use of the behavior change wheel and social cognitive theory to develop an eHealth intervention for the self-management of CVD. The systematic and transparent development of the PATHway intervention will facilitate the evaluation of intervention effectiveness and future replication.

Validity of heart rate measurements by the Garmin Forerunner 225 at different walking intensities

Abstract The accuracy of wrist worn heart rate monitors based on photoplethysmography (PPG) is not fully clinically accepted. Therefore, we aimed to validate heart rate measurements of a commercially available PPG heart rate monitor, i.e. the Garmin Forerunner® 225. Twelve healthy volunteers (six women; mean age: 28 years) performed a treadmill protocol consisting of: five minutes sitting, five minutes standing, 10 minutes walking at 4 km/h, 10 minutes walking at a gradient of 5% and intensity of 4–6 metabolic equivalents (METs), 10 minutes walking at a gradient of 8% and intensity of seven METs or more. Walking speeds were individually determined. Walking bouts were separated by a standardised five minute rest period. Heart rate was measured as the average of the last three minutes standing and of each walking bout. A three lead patch-based electrocardiogram (ECG; Zensor®) was used as criterion method. Statistical analyses included Pearson’s correlation (r), paired t-tests, root mean squared error (RMSE) and Bland?Altman plots. The mean values per three minutes of every condition did not differ significantly between the Garmin Forerunner® 225 and the Zensor®. RMSE was 3.01 beats per minute (bpm) or 2.89%. The Bland–Altman bias was 1.57 bpm. Limits of agreement (LoA) were wide, ranging from 32.53 to 29.40 bpm. However, Pearson’s r ranged from 0.650 to 0.868 suggesting moderate to strong validity. Generally, mean heart rates, r values, RMSE and the Bland–Altman bias indicated good overall agreement in this sample of healthy adults, but wide LoA are making it difficult to trust individual measurements.

Computerized decision support for beneficial home-based exercise rehabilitation in patients with cardiovascular disease

BACKGROUND Exercise-based rehabilitation plays a key role in improving the health and quality of life of patients with Cardiovascular Disease (CVD). Home-based computer-assisted rehabilitation programs have the potential to facilitate and support physical activity interventions and improve health outcomes. OBJECTIVES We present the development and evaluation of a computerized Decision Support System (DSS) for unsupervised exercise rehabilitation at home, aiming to show the feasibility and potential of such systems toward maximizing the benefits of rehabilitation programs. METHODS The development of the DSS was based on rules encapsulating the logic according to which an exercise program can be executed beneficially according to international guidelines and expert knowledge. The DSS considered data from a prescribed exercise program, heart rate from a wristband device, and motion accuracy from a depth camera, and subsequently generated personalized, performance-driven adaptations to the exercise program. Communication interfaces in the form of RESTful web service operations were developed enabling interoperation with other computer systems. RESULTS The DSS was deployed in a computer-assisted platform for exercise-based cardiac rehabilitation at home, and it was evaluated in simulation and real-world studies with CVD patients. The simulation study based on data provided from 10 CVD patients performing 45 exercise sessions in total, showed that patients can be trained within or above their beneficial HR zones for 67.1 ± 22.1% of the exercise duration in the main phase, when they are guided with the DSS. The real-world study with 3 CVD patients performing 43 exercise sessions through the computer-assisted platform, showed that patients can be trained within or above their beneficial heart rate zones for 87.9 ± 8.0% of the exercise duration in the main phase, with DSS guidance. CONCLUSIONS Computerized decision support systems can guide patients to the beneficial execution of their exercise-based rehabilitation program, and they are feasible.

A Computer-Assisted System with Kinect Sensors and Wristband Heart Rate Monitors for Group Classes of Exercise-Based Rehabilitation

Exercise-based rehabilitation for chronic conditions such as cardiovascular disease, diabetes, and chronic obstructive pulmonary disease, constitutes a key element in reducing patient symptoms and improving health status and quality of life. However, group exercise in rehabilitation programmes faces several challenges imposed by the diversified needs of their participants. In this direction, we propose a novel computer-assisted system enhanced with sensors such as Kinect cameras and wristband heart rate monitors, aiming to support the trainer in adapting the exercise programme on-the-fly, according to identified requirements. The proposed system design facilitates maximal tailoring of the exercise programme towards the most beneficial and enjoyable execution of exercises for patient groups. This work contributes in the design of the next-generation of computerised systems in exercise-based rehabilitation.

Home-Based Rehabilitation With Telemonitoring Guidance for Patients With Coronary Artery Disease (Short-Term Results of the TRiCH Study): Randomized Controlled Trial

Background Cardiac rehabilitation (CR) is an essential part of contemporary coronary heart disease management. However, patients exiting a center-based CR program have difficulty retaining its benefits. Objective We aimed to evaluate the added benefit of a home-based CR program with telemonitoring guidance on physical fitness in patients with coronary artery disease (CAD) completing a phase II ambulatory CR program and to compare the effectiveness of this program in a prolonged center-based CR intervention by means of a randomized controlled trial. Methods Between February 2014 and August 2016, 90 CAD patients (unblinded, mean age 61.2 years, SD 7.6; 80/90, 89.0% males; mean height 1.73 m, SD 0.7; mean weight 82.9 kg, SD 13; mean body mass index 27.5 kg/m2, SD 3.4) who successfully completed a 3-month ambulatory CR program were randomly allocated to one of three groups: home-based (30), center-based (30), or control group (30) on a 1:1:1 basis. Home-based patients received a home-based exercise intervention with telemonitoring guidance consisting of weekly emails or phone calls; center-based patients continued the standard in-hospital CR, and control group patients received the usual care including the advice to remain physically active. All the patients underwent cardiopulmonary exercise testing for assessment of their peak oxygen uptake (VO2 P) at baseline and after a 12-week intervention period. Secondary outcomes included physical activity behavior, anthropometric characteristics, traditional cardiovascular risk factors, and quality of life. Results Following 12 weeks of intervention, the increase in VO2 P was larger in the center-based (P=.03) and home-based (P=.04) groups than in the control group. In addition, oxygen uptake at the first (P-interaction=.03) and second (P-interaction=.03) ventilatory thresholds increased significantly more in the home-based group than in the center-based group. No significant changes were observed in the secondary outcomes. Conclusions Adding a home-based exercise program with telemonitoring guidance following completion of a phase II ambulatory CR program results in further improvement of physical fitness and is equally as effective as prolonging a center-based CR in patients with CAD. Trial Registration ClinicalTrials.gov NCT02047942; https://clinicaltrials.gov/ct2/show/NCT02047942 (Archived by WebCite at http://www.webcitation.org/70CBkSURj)Background: Cardiac rehabilitation (CR) is an essential part of coronary heart disease (CHD) management. However, patients exiting a center-based CR program have difficulty retaining its benefits. Objective: The purpose of the TRiCH study is to evaluate the added benefit of a home-based (HB) CR program with telemonitoring guidance on physical fitness in patients with coronary artery disease (CAD) who are being discharged from a phase II ambulatory CR program, and to compare its effectiveness to a prolonged center-based (CB) CR intervention. Methods: Between February 2014 and August 2016, 90 CAD patients (61.2±7.6yrs, 89% males, 1.73±0.7m, 82.9±13kg, 27.5±3.4kg/m2) who successfully completed a three month ambulatory CR program were randomly allocated to one of three groups: HB (=30), CB (=30) or a control group (CG) (=30) on a 1:1:1 basis. HB patients received a home-based exercise intervention with telemonitoring guidance consisting of weekly emails or phone calls, CB patients continued the ambulatory-hospital CR and CG patients received usual care including the recommendation to remain physically active. All patients underwent cardiopulmonary exercise testing to assess peak oxygen uptake (VO2P) at baseline and after the 12 week intervention period. Secondary outcomes included physical activity behavior, anthropometric characteristics, cardiovascular risk factors and quality of life. Results: The increase in VO2P was larger following 12 weeks of intervention in the CB group (P = .03) and HB group (P = .04) compared to the control group. In addition, oxygen uptake at the first ventilatory threshold (P-interaction = .03) and the second ventilatory threshold (P-interaction = .03) increased significantly more in the HB group compared to CB. No significant changes were found in the secondary outcomes. Conclusions: Adding a HB exercise program with telemonitoring guidance following completion of a phase II ambulatory CR program results in further improvement of physical fitness and is as equally effective as prolonging a CB CR in patients with coronary artery disease.

Computerised decision support in physical activity interventions: A systematic literature review

BACKGROUND The benefits of regular physical activity for health and quality of life are unarguable. New information, sensing and communication technologies have the potential to play a critical role in computerised decision support and coaching for physical activity. OBJECTIVES We provide a literature review of recent research in the development of physical activity interventions employing computerised decision support, their feasibility and effectiveness in healthy and diseased individuals, and map out challenges and future research directions. METHODS We searched the bibliographic databases of PubMed and Scopus to identify physical activity interventions with computerised decision support utilised in a real-life context. Studies were synthesized according to the target user group, the technological format (e.g., web-based or mobile-based) and decision-support features of the intervention, the theoretical model for decision support in health behaviour change, the study design, the primary outcome, the number of participants and their engagement with the intervention, as well as the total follow-up duration. RESULTS From the 24 studies included in the review, the highest percentage (n = 7, 29%) targeted sedentary healthy individuals followed by patients with prediabetes/diabetes (n = 4, 17%) or overweight individuals (n = 4, 17%). Most randomized controlled trials reported significantly positive effects of the interventions, i.e., increase in physical activity (n = 7, 100%) for 7 studies assessing physical activity measures, weight loss (n = 3, 75%) for 4 studies assessing diet, and reductions in glycosylated hemoglobin (n = 2, 66%) for 3 studies assessing glycose concentration. Accelerometers/pedometers were used in almost half of the studies (n = 11, 46%). Most adopted decision support features included personalised goal-setting (n = 16, 67%) and motivational feedback sent to the users (n = 15, 63%). Fewer adopted features were integration with electronic health records (n = 3, 13%) and alerts sent to caregivers (n = 4, 17%). Theoretical models of decision support in health behaviour to drive the development of the intervention were not reported in most studies (n = 14, 58%). CONCLUSIONS Interventions employing computerised decision support have the potential to promote physical activity and result in health benefits for both diseased and healthy individuals, and help healthcare providers to monitor patients more closely. Objectively measured activity through sensing devices, integration with clinical systems used by healthcare providers and theoretical frameworks for health behaviour change need to be employed in a larger scale in future studies in order to realise the development of evidence-based computerised systems for physical activity monitoring and coaching.