Cardiac rehabilitation online pilot: extending reach of cardiac rehabilitation

BACKGROUND: While cardiac rehabilitation (CR) is recommended for all patients after an acute cardiac event, limitations exist in reach.

OBJECTIVE: The purpose of the current study was to develop and pilot a flexible online CR program based on self-management principles "Help Yourself Online."

METHODS: The program was designed as an alternative to group-based CR as well as to complement traditional CR. The program was based on existing self-management resources developed previously by the Heart Research Centre. Twenty-one patients admitted to Cabrini Health for an acute cardiac event were recruited to test the program. The program was evaluated using qualitative and quantitative methods.

RESULTS: Quantitative results demonstrated that patients believed the program would assist them in their self-management. Qualitative evaluation, using focus group and interview methods with 15 patients, showed that patients perceived the online CR approach to be a useful instrument for self-management.

CONCLUSIONS: Broader implications of the data include the acceptability of the intervention, timing of intervention delivery, and patients' desire for additional online community support.

The remote exercise monitoring trial for exercise-based cardiac rehabilitation (REMOTE-CR): a randomised controlled trial protocol

BACKGROUND: Exercise is an essential component of contemporary cardiac rehabilitation programs for the secondary prevention of coronary heart disease. Despite the benefits associated with regular exercise, adherence with supervised exercise-based cardiac rehabilitation remains low. Increasingly powerful mobile technologies, such as smartphones and wireless physiological sensors, may extend the capability of exercise-based cardiac rehabilitation by enabling real-time exercise monitoring for those with coronary heart disease. This study compares the effectiveness of technology-assisted, home-based, remote monitored exercise-based cardiac rehabilitation (REMOTE) to standard supervised exercise-based cardiac rehabilitation in New Zealand adults with a diagnosis of coronary heart disease. METHODS/DESIGN: A two-arm, parallel, non-inferiority, randomised controlled trial will be conducted at two sites in New Zealand. One hundred and sixty two participants will be randomised at a 1:1 ratio to receive a 12-week program of technology-assisted, home-based, remote monitored exercise-based cardiac rehabilitation (intervention), or an 8-12 program of standard supervised exercise-based cardiac rehabilitation (control).The primary outcome is post-treatment maximal oxygen uptake (V̇O2max). Secondary outcomes include cardiovascular risk factors (blood lipid and glucose concentrations, blood pressure, anthropometry), self-efficacy, intentions and motivation to be active, objectively measured physical activity, self-reported leisure time exercise and health-related quality of life. Cost information will also be collected to compare the two modes of delivery. All outcomes are assessed at baseline, post-treatment, and 6 months, except for V̇O2max, blood lipid and glucose concentrations, which are assessed at baseline and post-treatment only. DISCUSSION: This novel study will compare the effectiveness of technology-supported exercise-based cardiac rehabilitation to a traditional supervised approach. If the REMOTE program proves to be as effective as traditional cardiac rehabilitation, it has potential to augment current practice by increasing access for those who cannot utilise existing services. TRIAL REGISTRATION: Australian New Zealand Clinical Trials RegistryStudy ID number: ACTRN12614000843651. Registered 7 August 2014.

Measuring physical activity in a cardiac rehabilitation population using a smartphone-based questionnaire

BACKGROUND: Questionnaires are commonly used to assess physical activity in large population-based studies because of their low cost and convenience. Many self-report physical activity questionnaires have been shown to be valid and reliable measures, but they are subject to measurement errors and misreporting, often due to lengthy recall periods. Mobile phones offer a novel approach to measure self-reported physical activity on a daily basis and offer real-time data collection with the potential to enhance recall.

OBJECTIVE: The aims of this study were to determine the convergent validity of a mobile phone physical activity (MobilePAL) questionnaire against accelerometry in people with cardiovascular disease (CVD), and to compare how the MobilePAL questionnaire performed compared with the commonly used self-recall International Physical Activity Questionnaire (IPAQ).

METHODS: Thirty adults aged 49 to 85 years with CVD were recruited from a local exercise-based cardiac rehabilitation clinic in Auckland, New Zealand. All participants completed a demographics questionnaire and underwent a 6-minute walk test at the first visit. Subsequently, participants were temporarily provided a smartphone (with the MobilePAL questionnaire preloaded that asked 2 questions daily) and an accelerometer, which was to be worn for 7 days. After 1 week, a follow-up visit was completed during which the smartphone and accelerometer were returned, and participants completed the IPAQ.

RESULTS: Average daily physical activity level measured using the MobilePAL questionnaire showed moderate correlation (r=.45; P=.01) with daily activity counts per minute (Acc_CPM) and estimated metabolic equivalents (MET) (r=.45; P=.01) measured using the accelerometer. Both MobilePAL (beta=.42; P=.008) and age (beta=-.48, P=.002) were significantly associated with Acc_CPM (adjusted R(2)=.40). When IPAQ-derived energy expenditure, measured in MET-minutes per week (IPAQ_met), was considered in the predicted model, both IPAQ_met (beta=.51; P=.001) and age (beta=-.36; P=.016) made unique contributions (adjusted R(2)=.47, F2,27=13.58; P<.001).There was also a significant association between the MobilePAL and IPAQ measures (r=.49, beta=.51; P=.007).

CONCLUSIONS: A mobile phone-delivered questionnaire is a relatively reliable and valid measure of physical activity in a CVD cohort. Reliability and validity measures in the present study are comparable to existing self-report measures. Given their ubiquitous use, mobile phones may be an effective method for physical activity surveillance data collection.

A mHealth cardiac rehabilitation exercise intervention: findings from content development studies

BACKGROUND: Involving stakeholders and consumers throughout the content and study design ensures interventions are engaging and relevant for end-users. The aim of this paper is to present the content development process for a mHealth (mobile phone and internet-based) cardiac rehabilitation (CR) exercise intervention.

METHODS: An innovative mHealth intervention was developed with patient input using the following steps: conceptualization, formative research, pre-testing, and pilot testing. Conceptualization, including theoretical and technical aspects, was undertaken by experts. For the formative component, focus groups and interviews with cardiac patients were conducted to discuss their perceptions of a mHealth CR program. A general inductive thematic approach identified common themes. A preliminary library of text and video messages were then developed. Participants were recruited from CR education sessions to pre-test and provide feedback on the content using an online survey. Common responses were extracted and compiled. An iterative process was used to refine content prior to pilot testing and conduct of a randomized controlled trial.

RESULTS: 38 CR patients and 3 CR nurses participated in the formative research and 20 CR patients participated in the content pre-testing. Participants perceived the mHealth program as an effective approach to inform and motivate patients to exercise. For the qualitative study, 100% (n = 41) of participants thought it to be a good idea, and 11% of participants felt it might not be useful for them, but would be for others. Of the 20 participants who completed the online survey, 17 out of 20 (85%) stated they would sign up to a program where they could receive information by video messages on a website, and 12 out of 20 (60%) showed interest in a texting program. Some older CR patients viewed technology as a potential barrier as they were unfamiliar with text messaging or did not have mobile phones. Steps to instruct participants to receive texts and view the website were written into the study protocol. Suggestions to improve videos and wording of texts were fed back to the content development team and refined.

CONCLUSIONS: Most participants thought a mHealth exercise program was an effective way to deliver exercise-based CR. The results were used to develop an innovative multimedia exercise intervention. A randomized controlled trial is currently underway.

Prespecified dose-response analysis for A Very Early Rehabilitation Trial (AVERT)

OBJECTIVE:
Our prespecified dose-response analyses of A Very Early Rehabilitation Trial (AVERT) aim to provide practical guidance for clinicians on the timing, frequency, and amount of mobilization following acute stroke.

METHODS:
Eligible patients were aged ≥18 years, had confirmed first (or recurrent) stroke, and were admitted to a stroke unit within 24 hours of stroke onset. Patients were randomized to receive very early and frequent mobilization, commencing within 24 hours, or usual care. We used regression analyses and Classification and Regression Trees (CART) to investigate the effect of timing and dose of mobilization on efficacy and safety outcomes, irrespective of assigned treatment group.

RESULTS:
A total of 2,104 patients were enrolled, of whom 2,083 (99.0%) were followed up at 3 months. We found a consistent pattern of improved odds of favorable outcome in efficacy and safety outcomes with increased daily frequency of out-of-bed sessions (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.09 to 1.18, p < 0.001), keeping time to first mobilization and mobilization amount constant. Increased amount (minutes per day) of mobilization reduced the odds of a good outcome (OR 0.94, 95% CI 0.91 to 0.97, p < 0.001). Session frequency was the most important variable in the CART analysis, after prognostic variables age and baseline stroke severity.

CONCLUSION:
These data suggest that shorter, more frequent mobilization early after acute stroke is associated with greater odds of favorable outcome at 3 months when controlling for age and stroke severity.

CLASSIFICATION OF EVIDENCE:
This study provides Class III evidence that shorter, more frequent early mobilization improves the chance of regaining independence after stroke.

End-of-life care in an Australian rehabilitation facility for older people: staff focus groups

A qualitative study of staff experiences of end-of-life care for older people in a subacute rehabilitation facility was undertaken using three focus groups with senior multidisciplinary staff (5), junior nurses (8), and junior allied health staff (7). Content analysis revealed four major themes: being a key contact person; the quality of end–of-life care; referring to off-site service providers; and differing perspectives. These data have implications for multidisciplinary practice including staff education and capacity to change focus of care in facilities for older people dedicated to rehabilitation rather than palliation or end-of-life care.

End-of-life care in a rehabilitation centre for older people in Australia

Aim
To investigate processes at the end of life for patients who died in a subacute evaluation and management facility for older people.

Methods
A retrospective chart audit for patients (n = 55) who died in the previous 2 years was undertaken, recording a number of significant variables.


Results
Despite diagnosis of comorbid medical conditions, most participants were admitted for improved functioning or assessment for alternative accommodation. Consistent with this focus, the key contact person was most often an allied health team member. Not For Resuscitation order and/or power of attorney documents on admission were uncommon (<30%) as were referrals to palliative care specialist staff (13%), although an end-of-life discussion was recorded (90%) and often included as a new goal of care (71%).

Conclusion
Factors likely to improve end-of-life care include advance care planning, earlier recognition of short prognosis and staff education.

Self-efficacy, imagery use, and adherence during injury rehabilitation

Previous observational studies examining imagery, self-efficacy, and adherence during injury rehabilitation have been cross-sectional and thus have not provided a clear representation of what occurs over the course of the rehabilitation period. The objectives of this research were (1) to examine the temporal patterns of imagery, self-efficacy, and rehabilitation adherence during an 8-week rehabilitation program and (2) to identify the time-order relationships between imagery, self-efficacy, and adherence. The design of the study was prospective and observational. 90 injured people (n=57 males; n=33 females) aged 18-78 years attending an injury rehabilitation clinic participated. The main outcome measures were imagery (cognitive, motivational, and healing), self-efficacy (task and coping), and rehabilitation adherence (duration, quality, and frequency). Results indicated that task efficacy, imagery use, and adherence levels remained stable, while coping efficacy declined over time. During the course of rehabilitation, moderate to strong reciprocal relationships existed between self-efficacy and adherence to rehabilitation. Weak to moderate relationships were found between imagery use and rehabilitation adherence. The results of this study can be used to inform the development of interventions steeped in self-efficacy and imagery aimed at improving rehabilitation adherence and treatment outcome.

Telehealth exercise-based cardiac rehabilitation: a systematic review and meta-analysis

OBJECTIVE: Despite proven effectiveness, participation in traditional supervised exercise-based cardiac rehabilitation (exCR) remains low. Telehealth interventions that use information and communication technologies to enable remote exCR programme delivery can overcome common access barriers while preserving clinical supervision and individualised exercise prescription. This meta-analysis aimed to determine the benefits of telehealth exCR on exercise capacity and other modifiable cardiovascular risk factors compared with traditional exCR and usual care, among patients with coronary heart disease (CHD). METHODS: CINAHL, The Cochrane Library, Embase, MEDLINE, PubMed and PsycINFO were searched from inception through 31 May 2015 for randomised controlled trials comparing telehealth exCR with centre-based exCR or usual care among patients with CHD. Outcomes included maximal aerobic exercise capacity, modifiable cardiovascular risk factors and exercise adherence. RESULTS: 11 trials (n=1189) met eligibility criteria and were included in the review. Physical activity level was higher following telehealth exCR than after usual care. Compared with centre-based exCR, telehealth exCR was more effective for enhancing physical activity level, exercise adherence, diastolic blood pressure and low-density lipoprotein cholesterol. Telehealth and centre-based exCR were comparably effective for improving maximal aerobic exercise capacity and other modifiable cardiovascular risk factors. CONCLUSIONS: Telehealth exCR appears to be at least as effective as centre-based exCR for improving modifiable cardiovascular risk factors and functional capacity, and could enhance exCR utilisation by providing additional options for patients who cannot attend centre-based exCR. Telehealth exCR must now capitalise on technological advances to provide more comprehensive, responsive and interactive interventions.

Cerebral responses to innocuous somatic pressure stimulation following aerobic exercise rehabilitation in chronic pain patients: a functional magnetic resonance imaging study

Objective: The purpose of this research was to assess the functional brain activity and perceptual rating of innocuous somatic pressure stimulation before and after exercise rehabilitation in patients with chronic pain.

Materials and methods: Eleven chronic pain patients and eight healthy pain-free controls completed 12 weeks of supervised aerobic exercise intervention. Perceptual rating of standardized somatic pressure stimulation (2 kg) on the right anterior mid-thigh and brain responses during functional magnetic resonance imaging (fMRI) were assessed at pre- and postexercise rehabilitation.

Results: There was a significant difference in the perceptual rating of innocuous somatic pressure stimulation between the chronic pain and control groups (P=0.02) but no difference following exercise rehabilitation. Whole brain voxel-wise analysis with correction for multiple comparisons revealed trends for differences in fMRI responses between the chronic pain and control groups in the superior temporal gyrus (chronic pain > control, corrected P=0.30), thalamus, and caudate (control > chronic, corrected P=0.23). Repeated measures of the regions of interest (5 mm radius) for blood oxygen level-dependent signal response revealed trend differences for superior temporal gyrus (P=0.06), thalamus (P=0.04), and caudate (P=0.21). Group-by-time interactions revealed trend differences in the caudate (P=0.10) and superior temporal gyrus (P=0.29).

Conclusion: Augmented perceptual and brain responses to innocuous somatic pressure stimulation were shown in the chronic pain group compared to the control group; however, 12-weeks of exercise rehabilitation did not significantly attenuate these responses.

Robust real-time bio-kinematic movement tracking using multiple kinects for tele-rehabilitation

This paper investigates the robust and accurate capture of human joint poses and bio-kinematic movements for exercise monitoring in real-time tele-rehabilitation applications. Recently developed model-based estimation ideas are used to improve the accuracy, robustness, and real-time characteristics considered vital for applications, where affordability and domestic use are the primary focus. We use the spatial diversity of the arbitrarily positioned Microsoft Kinect receivers to improve the reliability and promote the uptake of the concept. The skeleton-based information is fused to enhance accuracy and robustness, critical for biomedical applications. A specific version of a robust Kalman filter (KF) in a linear framework is employed to ensure superior estimator convergence and real-time use, compared to other commonly used filters. The algorithmic development was conducted in a generic form and computer simulations were conducted to verify our assertions. Hardware implementations were carried out to test the viability of the proposed state estimator in terms of the core requirements of reliability, accuracy, and real-time use. Performance of the overall system implemented in an information fusion context was evaluated against the commercially available and industry standard Vicon system for different exercise routines, producing comparable results with much less infrastructure and financial investment.

Rehabilitation staff perspectives on training for problem-solving therapy for primary care in a low vision service

Vision rehabilitation staff were trained to deliver problem-solving therapy for primary care (PSTPC) over the telephone to adults with depressive symptoms and low vision. Training was a 2-day workshop, completion of training cases, and assessment of treatment fidelity. Staff perspectives of training and challenges in PST-PC delivery were explored. Telephone-administered semistructured interviews were conducted pre- and post-workshop and following PST-PC competency. In all, 14 staff (mean age = 47.64 years, SD = 12.68 years, 93% females) achieved competency and 6 withdrew. Results showed an increased understanding of PST-PC from pre- to post-workshop (Z = −2.71, p = .007) and pre-workshop to post-competency (Z = −3.09, p = .002). A high level of satisfaction with training was reported. Staff challenges included the clients’ ability to define problems and brainstorm solutions. Training enabled staff to competently deliver PST-PC and may serve as a model for integrating depression care into vision rehabilitation services recommended by international guidelines.

Clinicians’ perceptions of decision making regarding discharge from public hospitals to in-patient rehabilitation following trauma

Objective: The aim of the present study was to investigate the perceptions of consultant surgeons, allied health clinicians and rehabilitation consultants regarding discharge destination decision making from the acute hospital following trauma.Methods: A qualitative study was performed using individual in-depth interviews of clinicians in Victoria (Australia) between April 2013 and September 2014. Thematic analysis was used to derive important themes. Case studies provided quantitative information to enhance the information gained via interviews.Results: Thirteen rehabilitation consultants, eight consultant surgeons and 13 allied health clinicians were interviewed. Key themes that emerged included the importance of financial considerations as drivers of decision making and the perceived lack of involvement of medical staff in decisions regarding discharge destination following trauma. Other themes included the lack of consistency of factors thought to be important drivers of discharge and the difficulty in acting on trauma patients’ requests in terms of discharge destination. Importantly, as the complexity of the patient increases in terms of acquired brain injury, the options for rehabilitation become scarcer.Conclusions: The information gained in the present study highlights the large variation in discharge practises between and within clinical groups. Further consultation with stakeholders involved in the care of trauma patients, as well as government bodies involved in hospital funding, is needed to derive a more consistent approach to discharge destination decision making.