Exercise adherence remains a significant challenge for many people with cardiovascular disease and HF, with participation rates ranging from 10-30% worldwide.

To improve exercise adherence service delivery should be flexible so that patients are able to take advantage of a program whether they are working, are elderly or live a long way from health care services.

As demonstrated in the figure below, cardiac rehabilitation and heart failure disease management programs can be delivered in a variety of ways. Services may be offered via group programs or individual appointments, delivered in the hospital or community setting, or in the individual’s home environment. Technology assisted approaches such as telerehabilitation and smartphone apps are now common in clinical practice. Patients and staff may interact through more than one delivery mode and whilst new models may change how services are delivered, core components of services should always remain.

Local staffing capacity and capability will determine which modes of delivery are offered, but services should strive to provide the most comprehensive care within the resources available.

Figure to come

Education

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

Group education can be delivered before or after the group exercise sessions, in-person or remotely, and can be scheduled so that patients from different groups can attend a mutual education component. Group education scheduled after an exercise session allows opportunity to monitor patients for a period of time after the exercise to ensure stability of symptoms. 

Setting

While group exercise programs may be disease specific or have a more generic format (e.g., chronic disease programs) the program should always be tailored to individual needs and should include education. See Patient education.

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

Format

Evidence recommends that people commence a cardiac rehabilitation program as soon as practical after discharge from hospital.

With a rolling format, which allows attendees to enter at any week according to availability, patients will begin and end at different times.  This type of program offers flexibility for patients who, for example, need to return to work early, and reduces the waiting time for commencement of the program.

By comparison, a 'stop-start' format has set commencement and completion dates limits new membership until the next cycle of sessions commences.  Stop – start programs foster strong social connections and group dynamics which may encourage attendance.

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 programs may elicit greater physiological effects.

Program frequency and duration

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

Staffing

All exercise programs should be run by an exercise specialist such as a physiotherapist or clinical 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 number of patients in the group. Usually, patients with HF need a staff-to-patient ratio of 1:5. Additional staff may be required for larger group sizes and for patients who have a high symptom burden, are considered high risk or those who are frail.

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 [#anderson-l-sharp-ga-norton-rj-et-al].

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 able to carry out the exercises independently
• Telerehabilitation, in which exercise is conducted in the individual's home; with the exercise specialist and participants linked via telehealth [#cavalheiro-ah-carddoso-js-azevedo-lf-et-al]
• A combination of the above, such as independent home-based exercise in combination with group education sessions. For those in rural or remote centres, education sessions can be attended 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 [#varnfield-m-karunanithi-m-lee-c-k-et-al]

Clinic appointments may be useful for reassessment, redefining of goals and modification of the intervention. These can also be undertaken within a centre, or remotely via telemedicine.

For home-based / telehealth exercise models, staff should consider the patients:

• physical environment in which the exercise will be taking place (consider space and privacy). Staff attending the patient’s home should always carry a mobile phone.
• cognition, vision and hearing which may impact upon use of technology
• functional level and balance (consider safety)
• access to and familiarity with technology (for telerehabilitation and smart phone apps)
• access to a support person to be present during the exercise session
• access to home monitoring such as HR, BP and SpO2 machines

Regardless of the mode, regular contact is essential to ensure that the exercise training program is progressed throughout and that the exercise program consist of endurance and strength training.

Specific information such as the Physical activity, exercise and heart failure and Physical activity and heart failure for Australian Aboriginals and Torres Strait Islanders booklets provide an excellent guide for patients.

Deconditioning occurs within weeks of ceasing exercise training, and benefits of a structured rehabilitation program are often lost within 6 months. 

Maintenance exercise is therefore 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. Regular reassessment is recommended for some patients to optimise adherence.

Maintenance exercise may include:

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

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.