Rita Hwang

Efficacy of home-based exercise programmes for people with chronic heart failure: a meta-analysis:

Home-based programmes may offer an alternative to conventional programmes or as a means of maintaining physical fitness after graduating from centre-based programmes. We sought to examine the effectiveness of home-based exercise programmes on exercise capacity in patients with heart failure compared with usual medical care. Electronic databases were searched to identify randomized controlled trials. Protocols included an initial period of centre-based exercise followed by exercise at home, home-based exercise only and concurrent centre and home-based exercise. Outcome measures included peak oxygen consumption, exercise duration and the six-minute walk test. Nineteen relevant studies were identified for review. The mean improvement in peak oxygen consumption was 2.86 ml/kg per min [95% confidence interval (CI): 1.43-4.29]. Exercise duration increased by 1.94 min (95% CI: 0.89-2.98) and distance on the six-minute walk test was increased by 30.41 m (95% CI: 6.13-54.68). Other reported benefits of home-based programmes include increased quality of life and lowered hospital admission rates. In conclusion, home-based exercise programmes have been shown to benefit people with heart failure in the short term. Further research is required to investigate the long-term effects of home exercise and to determine the optimal strategies for improving exercise adherence in patients with heart failure.

A systematic review of the effects of telerehabilitation in patients with cardiopulmonary diseases

PURPOSE: To examine the effects of telerehabilitation compared with other delivery models for improving physical or functional outcomes in patients with cardiopulmonary diseases. METHODS: A search was completed for English language publications from 1990 to August 2013 across 4 electronic databases and gray literature. Inclusion criteria were: (1) home-based telerehabilitation as a core component; (2) at least 2 exercise sessions; (3) randomized controlled trials; and (4) reporting of physical or functional outcome measures in adult patients with coronary heart disease, chronic heart failure, and chronic respiratory disease. Studies were independently screened by 2 reviewers and graded by a reviewer according to the Downs and Black checklist. A narrative synthesis of the included studies was undertaken. RESULTS: Eleven studies were analyzed. It appears that telerehabilitation is no different to other delivery models for patients with cardiopulmonary diseases, in terms of exercise capacity expressed as distance on the 6-minute walk test and peak oxygen consumption and quality of life. Telerehabilitation appears to have higher adherence rates compared with center-based exercise. There has been similar or no adverse events reported in telerehabilitation compared with center-based exercise. CONCLUSIONS: Although telerehabilitation shows promise in patients with cardiopulmonary diseases, compelling evidence is still limited. There is a need for more detailed, high-quality studies and for studies on the use of video-based telerehabilitation.

Home-based telerehabilitation is not inferior to a centre-based program in patients with chronic heart failure: a randomised trial

QUESTION Is a 12-week, home-based telerehabilitation program conducted in small groups non-inferior to a traditional centre-based program in terms of the change in 6-minute walk distance? Is the telerehabilitation program also non-inferior to a centre-based program in terms of functional capacity, muscle strength, quality of life, urinary incontinence, patient satisfaction, attendance rates, and adverse events? DESIGN Randomised, parallel, non-inferiority trial with concealed allocation, intention-to-treat analysis and assessor blinding. PARTICIPANTS Patients with stable chronic heart failure (including heart failure with reduced or preserved ejection fraction) were recruited from two tertiary hospitals in Brisbane, Australia. INTERVENTION The experimental group received a 12-week, real-time exercise and education intervention delivered into the participants home twice weekly, using online videoconferencing software. The control group received a traditional hospital outpatient-based program of the same duration and frequency. Both groups received similar exercise prescription. OUTCOME MEASURES Participants were assessed by independent assessors at baseline (Week 0), at the end of the intervention (Week 12) and at follow-up (Week 24). The primary outcome was a between-group comparison of the change in 6-minute walk distance, with a non-inferiority margin of 28m. Secondary outcomes included other functional measures, quality of life, patient satisfaction, program attendance rates and adverse events. RESULTS In 53 participants (mean age 67 years, 75% males), there were no significant between-group differences on 6-minute walk distance gains, with a mean difference of 15m (95% CI -28 to 59) at Week 12. The confidence intervals were within the predetermined non-inferiority range. The secondary outcomes indicated that the experimental intervention was at least as effective as traditional rehabilitation. Significantly higher attendance rates were observed in the telerehabilitation group. CONCLUSION Telerehabilitation was not inferior to a hospital outpatient-based rehabilitation program in patients with chronic heart failure. Telerehabilitation appears to be an appropriate alternative because it promotes greater attendance at the rehabilitation sessions. TRIAL REGISTRATION ACTRN12613000390785. [Hwang R, Bruning J, Morris NR, Mandrusiak A, Russell T (2017) Home-based telerehabilitation is not inferior to a centre-based program in patients with chronic heart failure: a randomised trial. Journal of Physiotherapy 63: 101-107].

A narrative review on home-based exercise training for patients with chronic heart failure

Abstract Objective: In view of the growing incidence of chronic heart failure (CHF) and its poor prognosis, there has been increasing interest in optimising management of people with this condition. Exercise has been widely accepted as part of the management plan for patients with CHF. Traditionally, exercise training for this group of patients has concentrated on supervised centre-based training. However, home-based training may offer an alternative to conventional training or a means of maintaining physical fitness after graduating from the centre-based training. This review was undertaken to examine the literature for home-based exercise training in patients with CHF. Methods: Literature searches were performed initially using electronic databases. The obtained papers were cross-referenced and appropriate articles were ordered through interlibrary loans. Results: A total of 21 relevant papers were identified for review. The majority of studies documented benefits with home-based training including increased exercise capacity, improved self-efficacy and increased muscle strength. Conclusions: Home-based exercise training has been shown to benefit people with CHF in the short term. Further research is required to investigate the long-term effects of home exercise and to determine the optimal strategies for improving exercise adherence in patients with CHF.

The Self-care Educational Intervention for Patients With Heart Failure: A Study Protocol

Background: A variety of educational interventions have been implemented to assist patients with heart failure (HF) to maintain their own health, develop self-care behaviors, and decrease readmissions. The most effective approach to education has yet to be established. Objective: The aim of this study is to determine the effectiveness of a multimedia educational intervention for patients with HF in reducing hospital readmissions. Secondary outcomes include changes in knowledge and self-care behaviors. Methods: A randomized controlled trial in a large tertiary referral hospital in Australia has recruited 200 patients and will follow them for 12 months. Patients diagnosed with HF have been randomly allocated 1:1 to either usual education or a multimedia educational intervention. Framed by the principles of adult learning, this individualized intervention was delivered face to face by a specialized HF nurse, with a targeted educational assessment and subsequent development of an educational plan. The multimedia approach combined viewing a DVD and verbal discussion supported by a written manual. The teach-back strategy at the conclusion of the intervention evaluated the patient’s learning through 5 key questions about self-management of HF. Readmissions are assessed at 28 days, 3 months, and 12 months. Knowledge and self-care behavior are assessed at baseline, 3 months, and 12 months. Conclusions: This study evaluates the effectiveness of a targeted multimedia educational intervention. Study results may inform the design of in-hospital education for HF patients.

Self-care educational intervention to reduce hospitalisations in heart failure: A randomised controlled trial

Background: A variety of educational interventions have been implemented to assist patients with heart failure to maintain their own health, develop self-care behaviours and decrease readmissions. Aims: The purpose of this study was to determine the effectiveness of a multimedia educational intervention for patients with heart failure in reducing unplanned hospital readmissions. Methods: The study, a randomised controlled trial in a large tertiary referral hospital in Australia, recruited 200 patients. Patients diagnosed with heart failure were randomly allocated 1:1 to usual education or a multimedia educational intervention. The multimedia approach began with an individual needs assessment to develop an educational plan. The educational intervention included viewing a DVD, and verbal discussion supported by a written manual with a teach-back evaluation strategy. The primary outcome was all-cause unplanned hospital readmission at 28 days, three months and 12 months post-recruitment. The secondary outcomes were changes in knowledge and self-care behaviours at three months and 12 months post-recruitment. Results: At 12 months, data on 171 participants were analysed. There were 24 participants who had an unplanned hospital readmission in the intervention group compared to 44 participants in the control group (p=0.005). The self-care educational intervention reduced the risk of readmission at 12 months by 30% (relative risk: 0.703; 95% confidence interval: 0.548–0.903). Conclusion: A targeted multimedia educational intervention can be effective in reducing all-cause unplanned readmissions for people with heart failure.

Aquatic Exercise Training is Effective in Maintaining Exercise Performance in Trained Heart Failure Patients: A Randomised Crossover Pilot Trial

BACKGROUND Providing flexible models and a variety of exercise options are fundamental to supporting long-term exercise participation for patients with heart failure (HF). The aim of this pilot study was to determine the feasibility and efficacy of aquatic exercise training during a maintenance phase for a clinical heart failure population. METHODS In this 2 x 2 crossover design trial, individuals who had previously completed HF rehabilitation were randomised into either a land-based or aquatic training program once per week for six weeks, after which time they changed to the alternate exercise training protocol for an additional six weeks. Six-minute walk test (6MWT), grip strength, walk speed, and measures of balance were compared for the two training protocols. RESULTS Fifty-one participants (43 males, mean age 69.2 yrs) contributed data for the analysis. Both groups maintained function during the follow-up period, however improvements in 6MWT were greater in the land-based training group (95% CI: 0.7, 22.5; p=0.038), by a mean difference of 10.8 metres. No significant difference was observed for other parameters when the two training protocols were compared. CONCLUSION Attending an aquatic exercise program once per week is feasible for patients with stable HF and may provide a suitable option to maintain functional performance in select patients.

Assessing functional exercise capacity using telehealth: Is it valid and reliable in patients with chronic heart failure?

Introduction This study aimed to determine the validity and reliability of video-based telerehabilitation assessments in patients with heart failure. Methods Seventeen consecutive participants (mean age 69 years, SD 12 years and 88% males) undertook assessments of three functional tests via both telerehabilitation and face-to-face approaches, on the same day. The assessment order was randomised and conducted by independent assessors. Outcome measures included functional tests: timed up and go (time), six-minute walk (distance), grip strength (kilograms); system usability scale to rate participant experience with telerehabilitation assessment; and number of technical issues encountered. Validity and inter- and intra-rater reliability of telerehabilitation assessments were examined using limits of agreement, intra-class correlation coefficients (ICC), and paired t-tests. Results The limits of agreement for telerehabilitation assessments were within the clinically acceptable limits for timed up and go and grip strength. Telerehabilitation assessments for all functional tests were strongly associated with face-to-face assessments, with ICCs of between 0.85 and 0.96. Inter- and intra-rater reliability of telerehabilitation assessments for all functional tests were excellent (all ICC > 0.95). The mean (SD) system usability scale score was 85 (15)/100. Some incidences of Internet drop-outs, video freezing and auditory fading occurred. Discussion The use of telehealth for the assessment of functional exercise capacity appears to be valid and reliable in patients with heart failure.

Exploring patient experiences and perspectives of a heart failure telerehabilitation program: a mixed methods approach

Objectives To describe patient experiences and perspectives of a group‐based heart failure (HF) telerehabilitation program delivered to the homes via online video‐conferencing. Background Limited information currently exists on patient experiences of telerehabilitation for HF. Patient feedback and end‐user perspectives provide important information regarding the acceptability of this new delivery model which may have a substantial impact on future uptake. Methods We used mixed‐methods design with purposive sampling of patients with HF. We used self‐report surveys and semi‐structured interviews to measure patient experiences and perspectives following a 12‐week telerehabilitation program. The telerehabilitation program encompassed group‐based exercise and education, and were delivered in real‐time via videoconferencing. Interviews were transcribed and coded, with thematic analysis undertaken. Results Seventeen participants with HF (mean age [SD] of 69 [12] years and 88% males) were recruited. Participants reported high visual clarity and ease of use for the monitoring equipment. Major themes included motivating and inhibiting influences related to telerehabilitation and improvement suggestions. Participants liked the health benefits, access to care and social support. Participants highlighted a need for improved audio clarity and connectivity as well computer training for those with limited computer experience. The majority of participants preferred a combined face‐to‐face and online delivery model. Conclusion Participants in this study reported high visual clarity and ease‐of‐use, but provided suggestions for further improvements in group‐based video telerehabilitation for HF.

Aquatic exercise training is effective in maintaining exercise performance in trained heart failure patients

Recent trends in diagnostic work-up among unselected patients newly diagnosed with heart failure : a Swedish population-based studyMitral regurgitation severity correlates with symptoms and extent of left atrial dysfunction : effect of mitral valve repairHeart failure can occur in any age, no depend on sex, but in men and women the mechanism, even if is the same, the fact is that the compromise on pumping function is diferent. AIM We realized a follow-up with 100 female patients during hospitalization with heart failure as a mean diagnostic. These are patient between 60 and 75 years old, with different pathologies: diabetes mellitus, arterial hypertension, obesity, atrial fibrillation, and hypothyroidism. We observed their treatment comparing with a control group (100 men in heart failure) by administering vasodilator and diuretic drugs. Performed echocadiography doppler control, daily renal function, NT pro BNP levels control, oxide nitric response. Results: We observed that ventricular dilation, hypertrophy as tachycardia is more typical in men. Our group demonstrated very fast response to beta blockers and diuretics. The ejection fraction increased in 10-15% faster than in control group. Oxide nitric had not the result we expected. But in men the effect is very high. NT pro BNP levels no were increased as a control group. Recovering renal function in women during heart failure depends on risk factors as diabetes mellitus, obesity, more characteristics for women. Conclusions: In women heart failure has the same mechanism that in men, but more of the cardiac compensatory mechanisms during heart failure as Frank-Starling mechanism, ventricular dilation or hypertrophy and tachycardia present more complications in men; women recover sinus rhythm faster than men, hypertrophy is not characteristic and dilation recovers EF as pumping function is near normal. We do not observed increased sympathetic adrenergic activity in our patients and increased vagal activity to heart. Renin-angiotensin-aldosterone and antidiuretic hormone systems in women is compensated by vasoconstriction improving ventricular stroke volume by reducing afterload on the ventricle. Table 3. NT-pro BN characteristics NT-proBNP cutoff value of 125 pg/mL had the best sensitivity-to-specificity ratio and NPV to rule out asymptomatic LV moderate to severe diastolic or systolic dysfunction in patients at risk for heart failure: 1. Men younger than 60 years (sensitivity, 87.5%; specificity, 92.7%; NPV, 99.5%; positive predictive value [PPV], 33.3%) 2. Women younger than 60 years (sensitivity, 100%; specificity, 84.1%; NPV, 100%; PPV, 33.3%) 3. Men at least age 60 years (sensitivity, 100%; specificity, 77.1%; NPV, 100%; PPV, 32.5%) 4. Women at least age 60 years (sensitivity, 100%; specificity, 69.9%; NPV, 100%; PPV, 21%)