The Effectiveness of Exercise Interventions Supported by Telerehabilitation For Recently Hospitalized Adult Medical Patients: A Systematic Review

Objective: To evaluate the effectiveness of exercise interventions delivered via telerehabilitation (via videoconference) for recently hospitalized adult medical patients. Data sources: A search was undertaken across six databases for English language publications from inception to May 2020. Methods: Studies were selected if they included an exercise intervention for recently hospitalized adults, delivered by a physiotherapist via videoconference. Two reviewers independently screened 1,122 articles (21 full text screening) and assessed methodological quality using the Downs and Black Checklist. A narrative synthesis of the included studies was undertaken. Results: Three studies met eligibility criteria involving 201 participants with chronic heart failure or chronic obstructive pulmonary disease. Findings demonstrated limited evidence supporting the effectiveness of exercise delivered via telerehabilitation in improving physical function and patient reported quality of life outcomes in recently hospitalized medical patients. Telerehabilitation in this setting was also associated with high attendance rates and patient satisfaction. Conclusions: Findings provide preliminary support for the benefits of exercise interventions delivered via telerehabilitation for recently hospitalized medical patients. Results do need to be interpreted with caution as further high-quality studies specific to this method of exercise intervention delivery are needed

Predictors of Exercise Training and Physical Activity Adherence in People Recently Hospitalized with Heart Failure: A BRIEF REPORT

For individuals with heart failure (HF), frequent attendance at exercise training programs and meeting physical activity (PA) guidelines are significantly associated with improvements in 6-min walk distance. Despite the evidence, adherence to exercise interventions remains poor. The aim of this study was to identify predictors of these 2 variables in patients recently hospitalized with HF. Methods: In this substudy of the Exercise Joins Education: Combined Therapy to Improve Outcomes in Newly-discharged Heart Failure (EJECTION-HF) trial, all participants were enrolled in a HF disease management program, including weekly review of a home exercise program for 12 wk. Intervention group participants additionally undertook twice weekly supervised exercise training. Primary outcomes were frequent exercise training program attendance (≥12 sessions) and attainment of PA guidelines (150 min/wk of moderate intensity exercise) at 12 wk. Participant and clinical characteristics were analyzed using a logistic regression model to identify significant predictors of each outcome. Results: A total of 278 participants provided PA data and 140 contributed attendance data. New diagnosis of HF was a significant predictor of frequent program attendance (OR = 2.3; 95% CI, 1.1-4.7; P =.03). Predictors of meeting PA guidelines at follow-up included new HF diagnosis (OR = 2.4; 95% CI, 1.2-4.8, P =.013), and being physically active at baseline (OR = 2.7; 95% CI, 1.3-5.6; P =.007). Gender, symptom severity, multimorbidity, and disability were not significantly associated with either outcome in multivariate analysis. Conclusion: To improve adherence, specific strategies may be required for patients with decompensated HF and those physically inactive at time of referral

Impact of exercise training program attendance and physical activity participation on six minute walk distance in patients with heart failure

Background: Exercise training is recommended for all people with stable heart failure (HF) however adherence is poor. This study sought to describe exercise participation in recently hospitalized HF patients who participated in a 12-week exercise training program. The association between exercise training variables and improvement in 6-min walk distance (6MWD) was also investigated. Methods: This study is a secondary analysis of results from the intervention arm of the EJECTION-HF trial (ACTRN12608000263392), (n = 140). Exercise program attendance was defined according to session frequency (= 12 sessions) and attendance duration (= 6 weeks) over the 12 weeks. Physical activity at baseline and follow up were reported according to self-report of 150 min of moderate intensity exercise per week. Primary outcome was change in 6MWD at 12 weeks. Results: Being physically active (OR 3.8, CI 1.3-11.5) and frequent program attendance (OR 2.7, CI 1.2-5.9) were associated with significant improvements in 6MWD. Program duration and baseline physical activity were not significantly associated with the outcome. Conclusions: Attainment of 150 min of moderate intensity exercise per week and at least weekly attendance at the program, were associated with significant improvements in 6MWD at follow up. Efforts should be made to assist patients with HF to achieve these targets

Incidence of adverse physiological changes in intensive care – a multi-centre audit

There has been some concern in the literature as to whether physiotherapy causes adverse physiological changes (APC) that could be harmful to intensive care patients. A multicentre audit was performed to: investigate the incidence of APC during physiotherapy in critically ill patients over a three-month period; benchmark this against studies which have recorded spontaneous APC; and to investigate whether there were any trends in patient category, demographic characteristics, type of intervention, or seniority of physiotherapist. There were 12 800 physiotherapy treatments completed with 29 treatments resulting in adverse physiological changes (0.22%). This incidence was significantly lower than a previous study of APC (663 events/247 patients over a 24-hour period), that is, the incidence during physiotherapy was lower than during general ICU care. Significant trends in the 29 patients who had an APC during physiotherapy were apparent, with a deterioration in cardiovascular status the major APC noted (i.e. decrease in blood pressure or arrhythmia) in patients on medium to high doses of inotropes/vasopressors, having unstable baseline hemodynamic values, previous cardiac co-morbidities, receiving intervention consisting of positive pressure, and/or with junior physiotherapists completing the intervention. Combinations of incidents in these 29 patients demonstrated that a decrease in blood pressure commonly occurred if a patient on inotropes with unstable baseline values was either turned to right side lying (2 sided Fishers exact test, p = 0.006) or received positive pressure (2-sided Fishers exact test, p = 0.07). This audit has demonstrated that the overwhelming majority of physiotherapy treatments in intensive care are safe. Zeppos, L., Paratz, J., Adsett, J., Berney, S., Bridson, J., & Patman, S. (2006). Incidence of adverse physiological changes in intensive care – a multi-centre audit. Australian Journal of Physiotherapy, 52(1), S35. ISSN: 0004-951

Aquatic exercise training and stable heart failure: A systematic review and meta-analysis

Aim A meta-analysis and review of the evidence was conducted to determine the efficacy of aquatic exercise training for individuals with heart failure compared to traditional land-based programmes. Methods A systematic search was conducted for studies published prior to March 2014, using MEDLINE, PUBMED, Cochrane Library, CINAHL and PEDro databases. Key words and synonyms relating to aquatic exercise and heart failure comprised the search strategy. Interventions included aquatic exercise or a combination of aquatic plus land-based training, whilst comparator protocols included usual care, no exercise or land-based training alone. The primary outcome of interest was exercise performance. Studies reporting on muscle strength, quality of life and a range of haemodynamic and physiological parameters were also reviewed. Results Eight studies met criteria, accounting for 156 participants. Meta-analysis identified studies including aquatic exercise to be superior to comparator protocols for 6 minute walk test (p < 0.004) and peak power (p < 0.044). Compared to land-based training programmes, aquatic exercise training provided similar benefits for VO2peak, muscle strength and quality of life, though was not superior. Cardiac dimensions, left ventricular ejection fraction, cardiac output and BNP were not influenced by aquatic exercise training. Conclusions For those with stable heart failure, aquatic exercise training can improve exercise capacity, muscle strength and quality of life similar to land-based training programmes. This form of exercise may provide a safe and effective alternative for those unable to participate in traditional exercise programmes

Patient perspectives of airway clearance techniques in bronchiectasis

Introduction While airway clearance techniques (ACTs) are recommended for individuals with bronchiectasis, data suggests the use of and adherence to ACTs is poor. Objective This study aimed to identify patient perceptions regarding ACTs, the barriers and facilitators to ACTs, and factors affecting adherence. Methods A multi-center qualitative study using in-depth semi-structured interviews of individuals with bronchiectasis was undertaken. All interviews were audio recorded and transcribed verbatim. Data was analyzed using the thematic framework approach described by Braun and Clark. NVIVO™ 12 software assisted with coding and thematic analysis of the interview transcripts. Data saturation was achieved when no new common themes were identified. Findings were summarized into major conceptual themes. Participant demographic data was also obtained. Results Twenty-four participants participated in semi-structured interviews. The main facilitators to using ACTs included a perceived health and quality of life benefit, a tailored approach to ACTs and the use of self-management strategies. Main barriers included lack of time and motivation, lack of access to resources, and a lack of perceived health benefit. A number of factors were identified by participants that may help promote adherence including combining and trialing different ACTs, receiving regular ACT reviews and education from physiotherapists, and having good social support. Conclusion To assist the personalized prescription of ACTs, these facilitators and barriers should be considered by clinicians to help promote adherence and improve patient outcomes

Physiotherapist perspectives of airway clearance techniques in bronchiectasis

Introduction Our understanding regarding the personalization of airway clearance techniques (ACTs) in bronchiectasis is limited. Objective This study aimed to determine physiotherapist perceptions regarding the prescription of ACTs in inpatients and outpatients with bronchiectasis. Methods A single-center qualitative study using semi-structured interviews of physiotherapists who treated individuals with bronchiectasis was undertaken. All interviews were audio recorded and transcribed verbatim. Data was analyzed using the thematic framework approach described by Braun and Clark. NVivo 12 software assisted with coding and thematic analysis of the interview transcripts. Findings were summarized into major conceptual themes. Participant demographic data was also obtained. Results Eleven physiotherapists participated in the interviews. Central to all themes was the complexity of physiotherapy clinical decision-making regarding ACT prescription. Main themes included: organizational factors (i.e. workload, scope of service, access to resources/ACTs); patient-related factors (i.e. symptom severity, finances, disease-specific knowledge, social commitments, clinical setting, and perceived benefit); and physiotherapist/profession-related factors (i.e. clinical experience, access to professional support and education, awareness of evidence of ACTs, and evaluating ACT effectiveness). Conclusion Physiotherapists regularly and routinely prescribe ACTs for individuals with bronchiectasis allowing for a multitude of competing factors. These factors should be considered by physiotherapists to enhance the personalized prescription of ACTs and may help promote patient adherence to ACTs to improve outcomes

Motivators and barriers for participation in aquatic and land-based exercise training programs for people with stable heart failure: a mixed methods approach

Background: Aquatic exercise training may be suitable for people with stable heart failure (HF) to engage in physical activity. Objectives: Acceptability, experiences and preferences regarding aquatic and traditional land-based exercise training, were explored in people with HF. Methods: As part of a comparative intervention study, participants completed a questionnaire assessing acceptability, benefits and challenges of aquatic compared to land-based programs. Semi-structured interviews explored participant experiences in greater depth. Results: Forty-eight participants, (mean age 70 + /- 11 years), completed the questionnaire and 14 participated in semi structured interviews. Aquatic exercise was regarded as acceptable and beneficial. Motivators were similar for both programs and included: a skilled and compassionate workforce, tailored care, perceived health benefit, sense of safety and an inclusive and enjoyable environment. Few barriers were identified for either program. Conclusions: Aquatic and land-based exercise training are equally acceptable for people with stable HF and motivators are similar for both programs

Addition of Supervised Exercise Training to a Post-Hospital Disease Management Program for Patients Recently Hospitalized\ua0With Acute Heart Failure: The EJECTION-HF Randomized Phase 4 Trial

This study sought to measure the impact on all-cause death or readmission of adding center-based exercise training (ET) to disease management programs for patients with a recent acute heart failure (HF) hospitalization.ET is recommended for patients with HF, but evidence is based mainly on ET as a single intervention in stable outpatients.A randomized, controlled trial with blinded outcome assessor, enrolling adult participants with HF discharged from 5 hospitals in Queensland, Australia. All participants received HF-disease management program plus supported home exercise program; intervention participants were offered 24 weeks of supervised center-based ET. Primary outcome was all-cause 12-month death or readmission. Pre-planned subgroups included age (40%), and exercise adherence.Between May 2008 and July 2013, 278 participants (140 intervention, 138 control) were enrolled: 98 (35.3%) age\ua0≥70 years, 71 (25.5%) females, and 62 (23.3%) with a left ventricular ejection fraction of >40%. There were no adverse events associated with ET. There was no difference in primary outcome between groups (84 of 140 [60.0%] intervention vs. 90 of 138 [65.2%] control; p\ua0= 0.37), but a trend toward greater benefit in participants age\ua