Exercise consultation improves short-term adherence to exercise during phase IV cardiac rehabilitation: a randomized, controlled trial.

Abstract

The benefits of exercise-based cardiac rehabilitation in patients with established coronary artery disease include a reduction in total and cardiac mortality and improved aerobic capacity and quality of life. 1;2 In the United Kingdom, cardiac rehabilitation is divided into four phases. 1 Phase I occurs during the inpatient stage and involves medical evaluation, information, risk factor assessment, mobilization, and discharge planning. Phase II is the immediate postdischarge period, which includes further medical evaluation and risk factor modification. This outpatient stage lasts approximately 4 weeks following acute myocardial infarction (AMI) and 6 weeks after coronary artery bypass graft (CABG) surgery. In phase III, participants attend an outpatient supervised exercise program and receive education on risk factor modification. The duration of phase III exercise programs ranges from 5 to 13 weeks. 1 Phase IV involves the long-term maintenance of lifestyle changes in the community. However, many patients do not maintain an active lifestyle subsequent to phase III. 3 Stahle et al. 3 reported significant increases in self-reported physical activity and exercise capacity in a group of cardiac patients after 3 months of supervised exercise training compared with usual care. However, physical activity levels and exercise capacity had declined in the intervention group 12 months after program completion. Exercise and physical activity must be sustained for the physiologic and psychological benefits to continue, 1 therefore interventions are required to improve adherence to exercise in phase IV cardiac rehabilitation. Exercise consultation is based on the transtheoretical model of exercise behavior change, 4,5 and uses strategies to increase and maintain physical activity behavior. The model suggests that when changing exercise behavior, individuals progress through five stages 5: 1) precontemplation: not physically active and no intention to change; 2) contemplation: not active but intend to change; 3) preparation: doing some activity but not enough to meet current recommendations; 4) action: regularly active but only began in the last 6 months; and 5) maintenance: regularly active for longer than 6 months. In addition, individuals may relapse to an earlier stage when attempting behavior change. The model proposes that different strategies are used at each stage to change behavior. Therefore, interventions based on this model should be tailored to a particular stage of change. Exercise consultation is a recent development and growing evidence from randomized-controlled trials supports its effectiveness in increasing adherence to physical activity. 6–9 Exercise consultation, compared with standard exercise information, significantly improved short-term physical activity levels in sedentary people with type 1 7 and type 2 diabetes. 8 In community trials, the exercise consultation was more effective than fitness assessments in maintaining increases in physical activity at 6 months 6 and 1 year. 9 This intervention appears to be successful for long-term adherence to physical activity. 6;9 Given that 1) adherence to exercise in cardiac rehabilitation is poor and 2) the potential for the exercise consultation to improve physical activity behavior, this randomized, controlled trial was conducted to examine the short-term effect of the exercise consultation on adherence to exercise and physical activity during phase IV cardiac rehabilitation after completion of phase III supervised exercise. METHODS A total of 31 cardiac patients (n = 20 AMI and n = 11 CABG surgery) were recruited following successful completion of a phase III exercise program based at a district general hospital in Scotland. The phase III program included 11 weeks of supervised exercise (1-hour sessions, twice per week), relaxation, education, and psychological support. Exclusion criteria included failure to complete the phase III exercise program, stable angina without previous AMI, heart failure (New York Heart Association > II), unstable angina, valve repair or replacement surgery, and waiting for further investigation or surgical intervention. The local ethics committee approved the study and written informed consent was obtained from all participants. The study design is depicted in 1. Two weeks after completion of phase III, participants attended visit 1. Baseline physical activity levels were measured using the Scottish Physical Activity Questionnaire. 10 This validated questionnaire assesses the patient’s current stage of exercise behavior change and the time spent in moderate to vigorous intensity activity during occupation and leisure over the previous 7 days. Participants were then randomized to either the experimental or control group. The researcher was unaware of the patient’s group allocation until the baseline physical activity questionnaire had been completed. The experimental group received an exercise consultation and both groups received standard exercise information. The leaflet entitled “Hassle Free Exercise,” published by the Health Education Board for Scotland, included information on the benefits of physical activity, common barriers to activity, activity recommendations, and examples on how to become more active. This is standard management of patients following completion of phase III. Equal contact time was ensured with the control group by discussing topics unrelated to exercise (eg, the patient’s condition, medications, general conversation). Participants completed a second Scottish Physical Activity Questionnaire 4 weeks after visit 1. 10 The exercise consultation involved a 30-minute individualized counseling session between a trained researcher and the patient. 4 The consultation included a description of the participant’s past and present physical activity behavior, a discussion of the patient’s perceived benefits of being physically active and barriers to activity and ways to overcome these barriers, encouraging social support, setting realistic short-term activity goals, and relapse prevention. Strategies used in the exercise consultation depended on the stage of exercise behavior change. Patients were categorized into the preparation, action, or maintenance stages as they had recently completed an exercise program. Therefore, the main focus of the consultation was to ensure patients were meeting current physical activity recommendations 11;12 and to improve adherence to exercise and physical activity using relapse prevention. 13 Current activity guidelines were defined as 30 minutes of accumulated moderate intensity activity on most days of the week 11 or 20-minute bouts of moderate to vigorous intensity exercise 3 days per week. 12 Relapse prevention involved identification of situations (eg, bad weather) that can cause a lapse from activity (eg, missing an exercise session). These lapses can accumulate and can lead to a return to a sedentary lifestyle. The researcher helped the patient to acquire coping strategies (eg, having an alternative indoor activity in bad weather), thereby reducing the likelihood of a lapse in activity and a decline in physical activity levels. 13 Data were analyzed using the Statistical Package for the Social Sciences (SPSS, Chicago, Ill) version 8.0. Normally distributed continuous data are presented as mean and standard deviation, and differences between the experimental and control groups were analyzed using two sample Student t tests. Physical activity data were not normally distributed and are presented as median and interquartile (IQ) range. Differences in physical activity between the experimental and control groups were analyzed using Mann-Whitney tests. Wilcoxon signed rank tests were used for within group comparisons. Reported are 95% confidence intervals. Categoric data are reported as proportions and analyzed using Fisher exact test, P <.05 was considered to be significant. RESULTS The 31 cardiac patients were randomized to the experimental (n = 16) and control (n = 15) groups. Of patients, 29 completed the study, 2 participants dropped out for reasons unrelated to the study, 1 patient in the experimental group and 1 patient in the control group (Fig. 1). The characteristics at study entry were similar between the groups (Table 1).Table 1: CHARACTERISTICS OF PATIENTS AT STUDY ENTRYFigure 1.: Study design.At baseline, 75% (12/16) of the experimental group and 86.7% (13/15) of the control group were in the action and maintenance stages, with no significant differences between the groups (P >.05). The Scottish Physical Activity Questionnaire assesses both occupational and leisure physical activity. However, only two patients in each group were working during the study period, therefore, occupational physical activity was not considered. Baseline leisure physical activity in minutes per week and changes in leisure activity from baseline for the experimental and control groups are presented in Table 2. Using Mann-Whitney tests, leisure physical activity at baseline was similar between the experimental and control groups (95% CI −325, 105.1). In the experimental group, leisure physical activity significantly increased from baseline by 29.5% (123/417.5), analyzed using the Wilcoxon signed rank test. A nonsignificant decline of 12% (68/555) was seen in leisure physical activity in the control group. Mann-Whitney tests demonstrated that the change in leisure activity from baseline was significantly different between the groups.Table 2: CHANGE IN LEISURE PHYSICAL ACTIVITY IN MINUTES/WEEK FROM BASELINE TO FOLLOW-UP IN THE EXPERIMENTAL AND CONTROL GROUPSDISCUSSION This study demonstrates that exercise consultation significantly improved short-term adherence to exercise during phase IV cardiac rehabilitation in a group of patients who had completed a phase III exercise program. A significant increase was seen in leisure physical activity from baseline in the experimental group compared with the control group. These findings are consistent with other randomized, controlled trials demonstrating the effectiveness of the exercise consultation on physical activity adoption and maintenance in sedentary healthy individuals 6;9 and people with type 1 7 and type 2 diabetes. 8 Therefore, this study provides further evidence for the efficacy of the exercise consultation process and suggests that the intervention may be applied to cardiac rehabilitation settings to assist with exercise behavior change. Short-term adherence to exercise in phase IV cardiac rehabilitation was satisfactory because baseline physical activity levels of both groups exceeded current guidelines. 11;12 However, many patients have difficulty maintaining physical activity habits and lifestyle changes in the long term, after completion of a supervised exercise programme. 1;3 Therefore, future studies are needed to assess whether the exercise consultation has a long-term effect on physical activity levels during phase IV cardiac rehabilitation. Activity levels were measured using a self-report questionnaire. 10 Self-report methods are susceptible to recall bias, because individuals tend to over report the duration, frequency, and intensity of their activity. 14 Therefore, the proportion of patients meeting current guidelines may be overestimated. An objective measure of physical activity may improve the accuracy of physical activity measurement in future studies. The American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation recommend that physical activity counseling should be incorporated into cardiac rehabilitation programs. 15 Exercise consultation includes strategies similar to those suggested in this guideline, including evaluating stage of change, identifying barriers to increasing physical activity, social support, and goal setting. Presently, patients completing phase III cardiac rehabilitation can attend phase IV community exercise programs. However, these exercise opportunities are not available in all areas. Furthermore, only a few patients attend community programs, because of barriers associated with supervised exercise programs, including transportation problems, high costs, limited access, work, and domestic conflicts. 1 Thus, the exercise consultation may provide an effective alternative to supervised exercise in phase IV. Furthermore, it could be used to facilitate patients’ progression from phase III, hospital-based exercise rehabilitation to independent exercise and community programs. In the United Kingdom, physiotherapists play a central role in the exercise component of cardiac rehabilitation. Physiotherapists have an ideal opportunity to deliver the exercise consultation to patients entering phase IV because they have good insight into the patient’s progress from phases I to III cardiac rehabilitation with regard to their exercise and physical activity and could incorporate the intervention into existing programs. In addition, phase IV exercise staff could use exercise consultation to provide support to patients who are having difficulty remaining active. To train in the exercise consultation, individuals need to understand the exercise behavior change principles embedded in the process. This could be achieved by appropriate in-service training. In conclusion, the findings of this study, along with the results of the other trials using the exercise consultation, justify future studies to evaluate the long-term effect of this intervention on adherence to exercise during phase IV cardiac rehabilitation. A study is currently underway, involving a longer followup and a larger sample size, using an objective physical activity measure and evaluating physiologic and psychological variables associated with exercise participation and secondary prevention.