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Telephone Support Oriented by Accelerometric Measurements Enhances Adherence to Physical Activity Recommendations in Noncompliant Patients After a Cardiac Rehabilitation Program
Correspondence to Thibaut Guiraud, PhD, Clinic of Saint-Orens, Cardiovascular and Pulmonary Rehabilitation Centre, 12, avenue de Revel, 31650 Saint-Orens-de-Gameville, France
Clinic of Saint-Orens, Cardiovascular and Pulmonary Rehabilitation Centre, Saint-Orens-de-Gameville, FranceNational Institute of Health and Medical Research (INSERM), UMR-1048, Institut des maladies métaboliques et cardiovasculaires, Toulouse, France
Guiraud T, Granger R, Gremeaux V, Bousquet M, Richard L, Soukarié L, Babin T, Labrunée M, Sanguignol F, Bosquet L, Golay A, Pathak A. Telephone support oriented by accelerometric measurements enhances adherence to physical activity recommendations in noncompliant patients after a cardiac rehabilitation program.
Objective
To assess the efficacy of a strategy, based on telephone support oriented by accelerometer measurements, on the adherence to physical activity (PA) recommendations in cardiac patients not achieving PA recommendations.
Design
Prospective and randomized study.
Setting
A cardiac rehabilitation program (CRP) at a clinic.
Participants
Stable, noncompliant cardiac (coronary artery disease, heart failure, post–cardiovascular surgery) patients (weekly moderate-intensity PA <150min) were randomly assigned to an intervention group (n=19) or a control group (n=10).
Interventions
The intervention group wore an accelerometer for 8 weeks. Every 15 days, feedback and support were provided by telephone. The control group wore the accelerometer during the 8th week of the intervention only.
Main Outcome Measures
Active energy expenditure (EE) (in kilocalories) and the time spent doing light, moderate, or intense PA (minutes per week).
Results
In the intervention group, the time spent at moderate-intensity PA increased from 95.6±80.7 to 137.2±87.5min/wk between the 1st and 8th week (P=.002), with 36.8% of the sample achieving the target amount of moderate-intensity PA. During the 8th week, the EE averaged 543.7±144.1kcal and 266.7±107.4kcal in the intervention group and control group, respectively (P=.004).
Conclusions
Telephone support based on accelerometer recordings appeared to be an effective strategy to improve adherence to PA in noncompliant patients. This intervention could be implemented after a CRP as an inexpensive, modern, and easy-to-use strategy.
ONE OF THE MAIN challenges of a cardiac rehabilitation program (CRP) is to obtain sustained modifications in lifestyle habits. Thus, one of the main objectives of a phase II CRP is to allow patients to become autonomous in their practice of physical activity (PA) with a target of 150min/wk of moderate-intensity exercise (3–6 metabolic equivalents [METs]) or more, according to recent recommendations.
Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation.
Exercise training in heart failure: from theory to practice A consensus document of the Heart Failure Association and the European Association for Cardiovascular Prevention and Rehabilitation.
We recently demonstrated that among patients who had completed a comprehensive CRP, about half resumed a sedentary lifestyle (ie, weekly moderate-intensity PA <150min) in the short- and long-term (2mo and 1y after CRP).
Indeed, noncompliant patients experience many barriers to PA, such as comorbidities, age, exercise intolerance, anxiety-depression, and social and ethnic origin norms.
Determinants of physical activity after hospitalization for coronary artery disease: the Tracking Exercise After Cardiac Hospitalization (Teach) Study.
This probably explains to a large extent the low adherence to PA regimens even after cardiac rehabilitation. Thus, it appears important to examine new strategies for the follow-up of patients postdischarge in order to allow them to reach target levels recommended by physicians. Regular telephone contact has been shown to be an effective evidence-based strategy to improve cardiovascular health-related behavior.
To our knowledge, the efficacy of a support strategy (associating accelerometer feedback and telephone calls) with PA in noncompliant patients who participated as outpatients in a comprehensive phase II CRP has never been assessed. The objectives of this study were thus to assess, in noncompliant, stable cardiac patients who had completed a CRP, the efficacy of telephone calls with feedback and support based on accelerometer recordings to help them reach target levels of PA.
Methods
Participants
The results herein represent the final analysis phase of a prospective study on PA maintenance after a CRP. This protocol was proposed to all patients referred to our cardiac rehabilitation unit at the end of their outpatient phase II CRP after an acute event. The inclusion criteria were noncompliance to PA, participation in a CRP, and the presence of a computer at home. The exclusion criteria were unstable angina, uncontrolled hypertension, severe arrhythmia, or any neuro-orthopedic diseases that could have a major impact on exercise capacity. Patients who resumed a sedentary lifestyle were defined as noncompliant patients (table 1).
All patients gave their written informed consent to participate in this protocol (fig 1), which was revised and approved by the local ethics committee. The enrollment was based on a previous study conducted by our group that assessed the amount of PA after CRP in patients contacted either 2 months or 1 year after discharge.
We considered this PA level assessed during our previous study as baseline PA. For the present study, we identified noncompliant patients to PA recommendations, defined as patients performing <150 minutes of moderate-intensity PA per week based on accelerometer recordings. The study was thus designed as a prospective randomized trial. Among the cohort of 29 noncompliant patients who had taken part in a CRP either 2 months or 1 year earlier, the patients were randomly assigned to an intervention group (n=19) or a control group (n=10).
Fig 1Flow chart of the study design. The part in white color represents the study design of Guiraud et al
All the subjects had completed the same CRP as outpatients in the Clinic of Saint Orens, Cardiovascular Rehabilitation Centre, after a cardiac event. The CRP (3h/d, 21 nonconsecutive days) included a 45-minute session on an ergocycle or treadmill and a 1-hour outdoor walking session at the target heart rate determined during the stress test (60%–80% of the heart rate reserve).
Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation.
Furthermore, the patients participated in 45-minute fitness, gymnastics, relaxation, Qi Gong, or aquatic training sessions. Each session was monitored by a physiotherapist or kinesiologist and supervised by a cardiologist. In addition to the exercise protocol, the patients were involved in therapeutic education sessions conducted by a multidisciplinary team with interactive workshops on cardiovascular risk factors and treatment knowledge (3–4h/wk), and a minimum of 5 hours of basic knowledge about PA
Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation.
Exercise training in heart failure: from theory to practice A consensus document of the Heart Failure Association and the European Association for Cardiovascular Prevention and Rehabilitation.
(duration, volume, intensity, and type of exercise according to their disease), in order to help the patients achieve autonomy in their PA. Throughout their stay, all the patients received advice on the importance of adhering to the exercise prescription based on the maximal stress test performed at admission and then at discharge.
Measurements and Intervention
In the intervention group, PA measurements were recorded during a period of 2 months. The kinesiologist insisted on the importance of wearing the accelerometer from first thing in the morning to last thing at night. To motivate the patients, the kinesiologist called them every 15 days. During the telephone interview, the kinesiologist gave standard feedback on the amount of PA performed and counseled patients to identify potential barriers encountered to achieve PA recommendations, and to implement strategies to increase the daily amount of moderate-intensity PA (table 2).
Table 2Content of the Telephone Intervention
Telephone Call Phases
Behavior Change Techniques
Duration (min)
General exchange
General feedback on the 2 previous weeks
Did you experience any problems with using the device or uploading data?
3
Verbal persuasion
Provide instructions
To give feedback and to discuss the success or failure in reaching the PA target
To discuss how to perform exercise based on PA recommendations (intensity, duration, frequency)
5
Experience with other persons
To motivate the patient to exercise with other persons
3
Performance accomplishments
Identification of obstacles
To identify obstacles to PA encountered by patients, and to discuss solutions to overcome these obstacles
5
Specific goal setting for the next 2 weeks
To set new targets with EE above or at least identical to the previous PA results
To avoid any Hawthorne effect (ie, a form of reactivity whereby subjects improve or modify an aspect of their behavior being experimentally measured simply in response to the fact that they are being studied
), we chose not to telephone patients in the control group. To compare the 2 groups, PA was measured with the accelerometer during the 8th week of the testing period in the control group.
Physical Activity
PA was assessed using a small, lightweight single-axis accelerometera worn on the waistband every day throughout the waking period for a full week. The 19 patients included in this study were taught by the kinesiologist how to download and install a simple computer program on their own computers. The use of the software required no specific skills. At the end of each week, the patient plugged the accelerometer into his own computer, and the data were automatically transferred to a web portal that the kinesiologist could access.
The validity of this device has been demonstrated.
It provides a measurement of PA and time spent at different intensity levels: light, 1.8 to 2.9 METs; moderate, 3 to 5.9 METs; and vigorous, ≥6 METs. The number of minutes spent at each intensity level was averaged over the 7 days. To convert the data into total weekly active energy expenditure (EE),
Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity).
we used the following methodology: the duration recorded by the accelerometer was multiplied by the mean EE of the corresponding zone (2.5 METs for light, 4.5 METs for moderate, and 7.5 METs for vigorous). These 3 values were added to obtain the total active weekly EE in METs, which was then converted to mL O2·kg−1·min−1 (1 MET = 3.5mL O2·kg−1·min−1). Finally, EE was converted into kilocalories according to the energy cost of 1L of O2 (1L=5kcal).
Statistical Analyses
Continuous variables were described as mean ± SD. We compared the proportions (in percentages) of pathologies using the chi-square test with Yates correction. Normal Gaussian distribution of the data was verified by the Shapiro-Wilk test. When distribution was normal, we used repeated-measures analysis of variance (ANOVA) to test the null hypothesis that there was no difference between baseline values (measured in our previous study) and the first and the 8th week of intervention. Then, a paired t test was performed to verify the differences between 2 variables. When distribution was not normal, a nonparametric procedure was used. A Friedman ANOVA by ranks was performed to test the null hypothesis that there was no difference between baseline values and the first and the 8th week of intervention. Multiple comparisons were made with a Wilcoxon matched-pairs test. Total active EE and the time spent at light and moderate-intensity PA in the 2 groups were compared using repeated-measures ANOVA during the 8th week. The threshold for significance was set at P<.05. The analyses were performed using Statview 5.1 software.b
Results
Participants' Characteristics
Twenty-nine noncompliant patients were included. Briefly, most were middle-aged men (57.4±12.4y) who were overweight when they left the rehabilitation program (body mass index, 27±4kg/m2), and were receiving optimal medical treatment according to the latest recommendations (ie, β-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, antiplatelet agents, and statins). They all had a high exercise capacity at the end of the CRP (peak power output, 146.7±36.7W).
Measurement of PA
The time spent at moderate-intensity PA increased from 95.6±80.7 to 137.2±87.5 minutes between the 1st and the 8th week (P=.002) (tables 3 and 4) , with a peak close to PA recommendations during the 6th week (140±99.4min). At the 8th week, 36.8% of the sample performed more than 150 minutes of moderate-intensity PA. In contrast, no change was observed for the time spent at light intensity during the same period (respectively, 271.3±112.3min vs 301.3±116.3min).
Table 3Comparison of PA Level in Intervention and Control Group During the 8th Week
Variable
Intervention Group
Control Group
P
Time spent at different intensities (min/wk)
Light
301.3±116.3
259.4±112.8
NS
Moderate
137.2±87.5
45.7±43.4
.002
Active EE (kcal/wk)
Light
302.5±129.4
203.3±98.4
.004
Moderate
241.2±154.7
63.4±56.1
.04
Total
543.7±144.1
266.7±107.4
.004
NOTE. Values are mean ± SD or as otherwise indicated.
Total weekly EE increased between the 1st and the last week (respectively, 430.8±128.4kcal/wk vs 543.7±144.1kcal/wk; not significant). EE at light intensity remained unchanged between the 1st and 8th week (263.3±101.4kcal/wk and 302.5±129.4kcal/wk, respectively), while EE at moderate intensity increased significantly (167.5±136.9kcal/wk and 241.2±154.7kcal/wk, respectively; P=.013). When compared with the PA values of the control group, the intervention group had a significantly higher total active EE (respectively, 266.7±107.4kcal/wk vs 543.7±144.1kcal/wk; P=.004). When compared with baseline values measured after CRP during a 1-week period,
the duration of moderate-intensity PA had increased significantly at the 8th week in the intervention group only, from 70.1±32.4 to 137.2±87.5 minutes (P<.0004), whereas the PA duration remained unchanged in the control group.
Patient Compliance
No patients experienced any difficulties with the accelerometer procedure, and there were no dysfunctions of the web portal. The use of telephone calls, feedback, and accelerometers showed a positive effect. The percentage of patients reaching >150 minutes of moderate PA per week increased from 15.7% to 36.8% between the 1st and 8th week of follow-up. The results also doubled for those who completed a level close to the recommendations for PA (>120min), from 26.3% (1st week) to 57.9% (8th week). Moreover, we also observed an increase in those who performed >90 minutes of moderate PA per week from 47.3% (1st week) to 68.5% (8th week). In contrast, there was a decrease in the number of patients engaged in moderate PA lasting <90 minutes, from 52.7% (1st week) to 31.5% (8th week).
Discussion
The main result of this work was that, in this population of patients with stable coronary artery disease, including 2 patients with heart failure, who completed a CRP and were noncompliant to regular exercise after discharge, a simple intervention associating telephone calls and accelerometers effectively increased weekly active EE. The strength of this study was its randomized design in a selected sample of patients who were noncompliant to PA—that is, a subgroup of patients who would be more likely to experience a rapid decline in cardiovascular health and a recurrent cardiac event.
The problem of nonadherence to drug treatment in coronary patients is well documented in EUROASPIRE studies. Exercise training is an effective nonpharmacologic method to improve risk factors control, but as it is initially demanding for patients, it seems obvious that they experience difficulties in maintaining an active lifestyle in the long-term. Indeed, these EUROASPIRE registries showed that the control of risk factors 1 year after the acute event remained poor.
The increasing prevalence of obesity, particularly abdominal obesity, reflects the insufficient respect of behavior to foster a healthy lifestyle particularly in terms of nutrition and PA. Therefore, PA should remain one of the main objectives of therapeutic observance, in the same way as drugs.
To our knowledge, this is the first study to assess the adherence to PA measured with an objective tool in noncompliant patients who had taken part in a CRP. It is well known that the amount of PA declines significantly after hospitalization irrespective of attendance during cardiac rehabilitation.
Cardiac rehabilitation and secondary prevention of coronary heart disease: an American Heart Association scientific statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in collaboration with the American Association of Cardiovascular and Pulmonary Rehabilitation.
we observed that only 41% of patients who had completed a comprehensive multidisciplinary CRP remained active (ie, performing >150min of moderate-intensity PA per week) 1 year after discharge. Given the improvements at the acute phase of cardiac events, thanks to more effective interventions and medication, adherence to PA is a great challenge in tertiary cardiac prevention. Learned societies have thus highlighted the need to assess the effectiveness of non–hospital-based interventions in secondary and tertiary prevention, and the optimal mode to deliver these services.
Cardiac rehabilitation and secondary prevention of coronary heart disease: an American Heart Association scientific statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in collaboration with the American Association of Cardiovascular and Pulmonary Rehabilitation.
recently showed that the use of a personal digital assistant with or without daily feedback messages led to improved adherence to PA in a weight-loss program. Our results concerning the time spent in moderate-intensity PA every week are in line with previous works that studied various interventions aiming to increase PA in cardiac patients, but did not specifically select low-compliance patients. Pinto et al
found that a telephone-based intervention helped patients to maintain exercise (measured at baseline, and at 6 and 12mo using an accelerometer), to prevent regression in motivational readiness for exercise, and to improve exercise tolerance. Other recent works have studied the effects of associating objective measurements of PA and behavioral support. In a 6-week intervention using pedometer-based self-monitoring of PA, associated with 2 behavioral counseling and goal-setting sessions, Butler et al
reported a 112-minute increase in total weekly PA at 6 months, which was significantly greater than that observed in the control group. This was associated with a greater improvement in oxygen uptake at the anaerobic threshold. Houle et al
studied the effects of the association of an intervention associating the use of a pedometer and behavioral support in the form of 5 face-to-face consultations led by a specialized nurse. They found a positive and significant impact on average steps per day and waist circumference at the 1-year follow-up. Moore et al
studied the effects of an intervention based on 5 sessions (3 during the CRP, and the 2 others 1 and 2mo after discharge) based on a theoretic cognitive-behavioral framework (social problem-solving model, self-efficacy theory, expectancy-value theory, and relapse-prevention theory). They reported that participants in the usual-care group were 76% more likely than the intervention group to stop exercising 1 year after discharge. This intervention was made possible thanks to 1.5-hour sessions led by an experienced cardiac nurse. Additionally, Hughes et al
reported that an exercise consultation (a 30-min one-to-one discussion) was effective in maintaining self-reported PA, but not peak oxygen uptake, for 12 months after completion of phase III. Our reports are in keeping with this sample of patients, suggesting that counseling, exercise consultations, telephone calls, and accelerometers may help patients to remain active. This intervention is a promising and inexpensive alternative to supervised exercise in the maintenance phase.
The second phase of the study also highlighted the importance of lifestyle changes. Indeed, we found no true changes in EE related to daily life during the 8 weeks, but it appeared to be significant in total active EE, suggesting that our intervention motivated patients to increase the amount of moderate PA rather than light PA. This is noteworthy because it seems that sports and active leisure activities correlate best with the physical aptitude of the individual and are thus more likely to reduce the risk of cardiovascular disease.
The MyWellness Key accelerometer provided a daily reminder of the amount of PA accomplished and therefore allowed patients to reach the objective proposed by the kinesiologist. Moreover, the telephone calls were also used to provide feedback and better understanding of the results, leading to better control of the tool. We could assume that this control led to both greater autonomy and greater motivation to manage the amount of PA required every week. This intervention could be implemented in phase III because it is a modern, easy-to-use strategy that could optimize cost-effectiveness. Even though we did not perform any cost-benefit evaluation, it could be assumed that this strategy will reduce the number and therefore the cost of consultations. Pedometers are much cheaper and possibly easier to use, but the miniaturization and decrease in the cost of simple tools such as the MyWellness Key accelerometera should soon make it possible to use objective measures more frequently, especially when there is a need for a more precise evaluation of adherence to PA recommendations, or to assess the effects of therapeutic interventions that involve PA. Indeed, accelerometers provide a more qualitative assessment of PA, and give the opportunity to record activity within the light-, moderate-, or high-intensity range. Moreover, even though it is more difficult to distinguish between a range of random everyday movements like do-it-yourself, gardening, and other activities such as cycling or water-based activities (most devices are not waterproof), accelerometers do provide a relatively good representation of true PA, whereas pedometers only record activities involving the lower limbs.
Study Limitations
There are limitations inherent to the study design. First, we chose to associate the telephone calls with accelerometers systematically in the intervention group; therefore, it is impossible to assess the part of each strategy on PA levels. Second, most of our subjects were men, which is a frequently encountered referral bias in CRPs.
Third, our sample was quite small, but this was because of the design of the study, as we voluntarily chose to select a subsample of noncompliant patients. Nonetheless, these results seem particularly relevant from a clinical viewpoint, as we considered patients who are the most difficult to take care of. Finally, we only studied the immediate effects of the intervention—that is, during the period of accelerometer recordings. Further studies are now necessary to assess the long-term effects of such interventions and to define the optimal duration.
Conclusions
Our results showed the efficacy of a simple, easy-to-implement intervention to improve PA adherence in low-compliance patients after a CRP program, thus improving lifestyle habits with regard to exercise. Further studies are needed to explain how such interventions positively affect PA behavior, and to determine their cost-effectiveness.
Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation.
Determinants of physical activity after hospitalization for coronary artery disease: the Tracking Exercise After Cardiac Hospitalization (Teach) Study.
Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity).
Cardiac rehabilitation and secondary prevention of coronary heart disease: an American Heart Association scientific statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in collaboration with the American Association of Cardiovascular and Pulmonary Rehabilitation.
No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.
Reprints are not available from the author.
In-press corrected proof published online on Sep 11, 2012, at www.archives-pmr.org.
Others: valvulopathy, intermittent claudication.
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