Exercise Exercise

Despite well established evidence and guidelines, exercise adherence remains a significant challenge for many people with cardiovascular disease. Estimated participation rates for cardiac rehabilitation are as low as 10-30% [#clark-ra-conway-a-poulsen-v-et-al]. Completion rates and ongoing exercise participation following centre based rehabilitation is equally poor. In the HF ACTION trial, a large scale study of patients with HF, only 30% of participants in the exercise intervention group, achieved the target of 120 minutes of exercise per week at 12 month follow up [#oconnor-c-whellan-d-lee-k-et-al.-2009].

Strategies to improve exercise adherence should be a significant focus for all clinicians who work with patients with cardiovascular disease. Fundamental to this, is to provide a flexible approach so that patients are able to access exercise information and support, irrespective of working situation, age, functional level or distance from health care services [#clark-ra-conway-a-poulsen-v-et-al]. The model of delivery of the exercise  program will depend upon staffing and available resources. Examples of settings and formats include structured centre based programs, supported home based training, and technology assisted approaches such as telerehabilitation and smartphone apps.

Group exercise programs may be disease specific or have a more generic format (e.g., chronic disease programs) the program should be tailored to individual needs.

Location

Programs are often conducted in hospital or community health centre gymnasiums, but if unavailable, other venues such as community halls or local gymnasiums can be considered. The environment should be safe (e.g., in terms of space and floor surface) and preferably air-conditioned. Patient access to the venue should be assessed (e.g., to ensure logistical access into the building/room, as well as availability of lifts, parking access and public transport).

Frequency and duration of exercise session

For group programs, it is recommended that patients attend twice a week for approximately 1 hour. Home based exercise and regular physical activity are essential adjuncts to all group programs. If patient frailty and co-morbid disease precludes attending twice weekly or if resources are limited, less frequent attendance may be an option with greater emphasis placed upon the home program.

Duration of program

Programs may be time-limited or ongoing in the case of patients wait-listed for cardiac transplantation.  Cardiac rehabilitation exercise groups are usually for 4-12 weeks whereas patients with HF usually require at least 8-12 weeks as longer duration may elicit greater physiological effects and slow down decline post program.[#chen-ym-li-zb-zhu-m-et-al.-2012,#collins-e-langbein-we-dilan-koetje-j-et-al.-2004,#willenheimer-r-rydberg-e-cline-c-et-al.-2001]

Entry and exit of a group exercise program

All patients should attend an individual assessment prior to attending any group program.  Rolling format allow patients to enter at any week according to availability with patients beginning and ending at different times.  A 'stop-start' format has set commencement dates.

  • The ‘rolling program’ offers more flexibility for patients who, for example, need to return to work early, and reduces the waiting time for participation in the program.
  • The ‘stop-start’ format offers a fixed time limit and strong social interconnection, but limits new membership until the next cycle of sessions commences.

Communication with all health care providers is essential to optimise patient outcomes. Sample letters/templates are available in the Resources section.

Group exercise staffing & ratios

All exercise programs should be run by an exercise specialist such as a physiotherapist or exercise physiologist. Additional support staff may include nurses, allied health professionals or lay people. It is crucial that all staff members are trained in cardiopulmonary resuscitation (CPR) and are familiar with local emergency procedures.

There is no standard ratio of staff to patients. Staffing will depend on the access to medical services, disease severity and numbers in the group. Usually, patients with HF need a staff-to-patient ratio of 1:5. A greater ratio will be required for larger numbers of patients, higher-risk participants or for programs with moderate-intensity exercises. Frail and high-risk patients may require a 1:1 ratio.

Patient education is a vital component of any centre-based rehabilitation program and is usually provided by members of the multidisciplinary team either to a group of patients or individually.

Group education scheduled after an exercise session allows time to monitor patients prior to them going home. However, education can be delivered before or after the group exercise sessions, and can be scheduled so that patients from different groups can attend a mutual education component.

For further information see the education topics section of this website.

Maintenance exercise is a fundamental component of all exercise rehabilitation programs and should be considered early in the rehabilitation period. Physical activity should be ongoing unless clinical deterioration necessitates a temporary reduction in activity and patients should be encouraged to participate in 150 minutes of moderate intensity exercise per week to maintain physical improvements.

For patients with HF, deconditioning occurs in as little as 3 weeks following cessation of exercise training, and benefits of a structured rehabilitation program are often lost within 6 months. Regular reassessment is recommended for some patients to optimise adherence.[#willenheimer-r-rydberg-e-cline-c-et-al.-2001,#hansen-d-dendale-p-raskin-a-et-al.-2010,#coorey-m-genevieve-neubeck-lis-mulley-et-al]

Maintenance exercise may include:

  • Supervised exercise sessions for a defined period of time at the hospital, community centre or local gym
  • Referral to a community exercise program such as Lungs In Action
  • Alternative exercise options such as local walking groups or Tai Chi
  • Individualised exercise programs at home or a local gym

Home based exercise training has been found to be as beneficial as centre based training for improving clinical outcomes in patients with CVD and heart failure [#hansen-d-dendale-p-raskin-a-et-al.-2010]

For many people with cardiac conditions, structured centre based programs may not be accessible and alternative, more convenient approaches may be preferred. Alternative modes of delivery may comprise:

  • One-on-one supervised exercise at home for a defined period of time
  • Supervised exercise for 1-2 sessions followed by telephone support once the patient is safe and independent to carry out the exercises
  • Tele-rehabilitation, in which exercise is conducted in the individual's home; however, the exercise specialist and participants are linked via telemedicine
  • A combination of the above, such as independent home exercise in combination with group education sessions. For those in rural or remote centres, education sessions can be attended at a local health facility, via video link to a group education session being delivered at larger metropolitan centres
  • Use of smartphone apps. These can be used in conjunction with traditional centre based programs or can be used by individuals to complete their rehabilitation entirely remotely [#coorey-m-genevieve-neubeck-lis-mulley-et-al]

Clinic appointments may be useful for reassessment, redefining of goals and modification of the intervention.

For delivery in-home, staff should have a good understanding of cardiac disease and its management and should at all times carry a mobile phone. Specific information such as the Physical activity and heart failure and Physical activity and heart failure for Australian Aboriginals and Torrest Strait Islanders booklets provide an excellent guide for patients.

Equipment requirements vary according to the type of program and available resources. Both centre-based and home-based programs can be successfully conducted with minimal or no equipment.

The  Equipment checklist provides a list of suggested equipment to run a program.

  • Clark RA, Conway A, Poulsen V, et al. Alternative models of cardiac rehabilitation: a systematic review. Eur J Prev Cardiol 2013; 0(00), 1–40.

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  • O'Connor C, Whellan D, Lee K, et al. HF-ACTION Investigators. Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomised controlled trial. JAMA 2009;301:1439-1450.

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  • National Heart Foundation of Australia. Multidisciplinary care for people with chronic heart failure. Principles and recommendations for best practice. 2010.

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  • Chen YM, Li ZB, Zhu M et al. Effects of exercise training on left ventricular remodelling in heart failure patients: an updated meta-analysis of randomised controlled trials. Int J Clin Pract 2012;66:782-791.

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  • Collins E, Langbein WE, Dilan-Koetje, J et al. Effects of exercise training on aerobic capacity and quality of life in individuals with heart failure. J Acute Crit Care 2004;33:154-161.

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  • NHFA CSANZ Heart Failure Guidelines Working Group: Atherton JJ, Sindone A, De Pasquale CG, et al. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018. Heart Lung Circ. 2018;27(10):1123-208.

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  • Hansen D, Dendale P, Raskin A, et al. Long-term effect of rehabilitation in coronary artery disease patients: randomized clinical trial of the impact of exercise volume. Clin Rehabil 2010;24:319-327.

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  • Coorey M, Genevieve & Neubeck, Lis & Mulley, et al. (2018) Effectiveness, acceptability and usefulness of mobile applications for cardiovascular disease self-management: Systematic review with meta-synthesis of quantitative and qualitative data. European Journal of Preventive Cardiology. 25. 204748731775091. 10.1177/2047487317750913.

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  • Varnfield M, Karunanithi M, Lee CK, et al. Smartphone-based home care model improved use of cardiac rehabilitation in postmyocardial infarction patients: results from a randomised controlled trial Heart. 2014;100:1770-1779.

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