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Patient-Selected Strategies for Post Cardiac Rehabilitation Exercise Adherence in Heart Failure

Nielsen, Jessica, DNP, APRN-NP1; Duncan, Kathleen, PhD, RN2; Pozehl, Bunny, PhD, APRN-NP, FAHA, FAAN2

doi: 10.1097/rnj.0000000000000127

Purpose The aim of this study was to evaluate the use of patient-selected exercise adherence strategies following cardiac rehabilitation (CR).

Design Twenty patients with heart failure (HF) were recruited and randomly assigned to the intervention or control group at completion of CR.

Methods The intervention included the use of six adherence strategies (logs, graphs, pedometers, phone follow-up, education, and a letter from CR staff), which were provided for 6 weeks post CR and during home-based exercise. After 6 weeks, the intervention group selected strategies to continue, and only those were provided for the last 6 weeks. At 12 weeks, patients were retested.

Findings Patients with HF demonstrated improvement in distance walked and less HF symptoms and adhered to exercise at levels recommended during CR.

Conclusion Inclusion of patient-selected adherence strategies supports continued exercise and helps to sustain physiological improvements.

Clinical Relevance Results from this study have implications for CR programs serving HF patients and provide insight into adherence strategies.

1 College of Nursing-Omaha Division, University of Nebraska Medical Center, Omaha, NE, USA

2 College of Nursing-Lincoln Division, University of Nebraska Medical Center, Omaha, NE, USA

Correspondence: Jessica Nielsen, College of Nursing-Omaha Division, University of Nebraska Medical Center, 985330 Nebraska Medical Center, 4111 Dewey Avenue, Omaha, NE 68198–5330, USA. E-mail:

Funding for his study was received from University of Nebraska Medical Center, College of Nursing, Dean’s Grant. The authors declare no conflicts of interest.

All authors have read and approved submission of the manuscript and the manuscript has not been published and is not being considered for publication elsewhere in whole or part in any language except as an abstract.

Cite this article as: Nielsen, J., Duncan, K., & Pozehl, B. (2019). Patient-selected strategies for post cardiac rehabilitation exercise adherence in heart failure. Rehabilitation Nursing, 44(3), 181–185. doi:10.1097/rnj.0000000000000127

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Exercise is a recommended adjunctive treatment for heart failure (HF), and considerable research demonstrates that exercise improves clinical outcomes and quality of life in HF patients (van der Wal & Jaarsma, 2008). Exercise is difficult for patients with HF. The chronic nature of the disease and the commonly reported symptoms of dyspnea and fatigue decrease exercise tolerance. Patients report that adherence to exercise is the most difficult of all HF treatments (van der Wal & Jaarsma, 2008).

Cardiac rehabilitation (CR) is an established program designed to teach patients to safely exercise and to adhere to exercise long term. A considerable barrier to the enrollment of HF patients in CR has been the lack of reimbursement. Expanded coverage by Medicare in 2014 to patients with chronic stable HF is projected to increase the demands for exercise programs for HF patients (Keteyian, Squires, Ades, & Thomas, 2014).

To respond to this demand, CR programs may benefit from new strategies to meet the unique needs of HF patients. Regular and sustained exercise is needed to maintain the benefits of exercise, and HF patients may need support for a longer time period than is currently provided by CR. The post CR period may be a critical time for patients to learn to self-manage exercise (Hwang & Marwick, 2009). Unfortunately, there are few tested strategies that are available to support post CR exercise for patients with HF.

Ultimately, exercise is an individually controlled activity, and patients continue using only those strategies they perceive as helpful. There is a lack of studies that address ways to include patient’s preferences in the design of exercise programs. Patient choice in selection of exercise strategies may offer a way to provide an individualized approach to adherence more suited to the post CR period when exercise is self-managed. Allowing patient choice in HF patients may increase confidence for independent exercise and support long-term adherence and, thereby, sustain the benefits of CR.

The primary aim of this pilot study was to evaluate feasibility of the use of patient-selected exercise adherence strategies following completion of CR on physiological outcomes (6-minute walk test, symptoms of dyspnea and fatigue) and exercise adherence. Patients’ perceptions of strategies (helpfulness and use) post CR were also assessed.

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Twenty patients were recruited from a CR program associated with a mid-western hospital. Approval was obtained from the researchers’ and study site’s institutional review board prior to recruitment. Patients were recruited during the first 3 weeks of CR participation. Inclusion criteria were as follows: a diagnosis of HF with an ejection fraction of 40% or less, 21 years of age or greater, access to a telephone, and willingness to return to the CR facility for follow-up testing. A total of 20 patients met the inclusion criteria and consented to participate.

Following the completion of the CR program, patients were randomly assigned to either an intervention (INV) group (n = 10) or an attention control (AC) group (n = 10). All patients were baseline-tested and asked to continue to exercise at home for the following 12 weeks at the same goals set during CR. Exercise goals were frequency of five sessions per week and duration of 30 minutes (plus warm-up and cool-down) at a rating of perceived exertion (RPE) intensity of 12–13.

Intervention. The intervention included the use of six adherence strategies. Several of these strategies have been previously tested with HF patients during self-managed, home-based exercise (Duncan & Pozehl, 2003). These strategies were: exercise logs (using the same format as CR), bar graphs of past weeks’ exercise participation (compared to exercise goals for frequency, duration, RPE), a half-page educational handout on exercise benefits, a pedometer (demonstrated during baseline testing), phone contact provided by study nurses (included review of graph data, feedback on completed exercise, problem-solving), and a letter from a personally selected CR nurse or professional. At completion of CR, all patients were asked to identify a CR staff member they would like to have informed of their progress following CR. A letter was composed by study personnel using a standardized format. It consisted of a brief summary of the patient’s recent exercise participation (obtained from logs), positive feedback on exercise participation and a note of encouragement for future exercise. The letter was signed by the CR member who was identified by patients. Subjects in the intervention (INV) group received all of the adherence strategies during the initial six weeks following completion of CR.

Procedure. Exercise logs, graphs, and education information were mailed to patients in the INV group 3 weeks post baseline testing. Phone calls occurred 5–7 days post mailing. The letter from the CR professional was mailed during the sixth week to allow for CR staff to review recent exercise data and for signing of the letter. All strategies were provided to the INV group during the first 6 weeks of the study period.

During the initial 6 weeks of the study, similar time and attention was provided to the AC group through phone contact, which occurred at the same 3-week interval as for the INV group. The context of the phone contact for the AC group was discussion of recent dietary intake of high-fat and cholesterol foods and education on ways to reduce intake.

After 6 weeks, the INV group was asked to select which strategies they wished to continue, and only those strategies were provided for the last 6 weeks. No further contact occurred with the AC group. Outcome testing was conducted at 12 weeks by a research nurse blinded to group and different from the intervention nurse.

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Outcomes Measures

Dyspnea/fatigue index. The dyspnea/fatigue index measures impairment caused by symptoms of dyspnea or fatigue. Reliability and validity of this instrument have been established with HF patients (Feinstein, Fisher, & Pigeon, 1989). The scale ranges from the worst score of 0 to the best score of 12 for no impairment. Higher scores reflect fewer symptoms.

Six-minute walk test. The 6-minute walk test is a submaximal measure of subjects’ functional ability to walk a number of feet during a 6-minute period of time. The 6-minute walk is routinely performed at completion of CR at the study site (Forman et al., 2012).

Exercise adherence. All subjects were asked to monitor their exercise participation, but only the INV group was asked to record exercise in the logs. Adherence to exercise was also assessed by asking patients to rate their exercise participation during the past 12-week study period, in comparison to the goals set during CR (five times a week, 30 minutes duration, 12–13 RPE), on a scale of 0–10, indicating how closely they adhered to goals.

Strategy preference. The number of patients in the INV group requesting to continue each strategy was compiled after 6 weeks. Perception of strategy helpfulness was determined at 12 weeks by asking patients to rate on a scale of 0–10 how helpful each of the six adherence strategies were to continued exercise.

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All patients in both groups completed the CR program, and all patients completed the 12-week study period. There were no significant baseline differences (p < .05) between groups for demographics (age, gender, and ejection fraction). There were equal number of men (n = 8) and women (n = 2) in each group. All subjects were Caucasian, except for one Asian patient in the INV group. The INV group was younger (INV M = 66.6 ± 10.4, AC M = 69.8 ± 9.9 years) and had a slightly higher ejection fraction (INV M = 35.00 ± 5.3, AC M = 34.3 ± 4.7) than the AC group. There were no group baseline differences (p < .05) for the 6-minute walk test or for the dyspnea fatigue index (DFI).

After 3 months, the distance walked by the INV group increased an average of 106.27 feet from baseline, whereas the AC group walked an average of 7.3 feet less than at baseline (p = .06; see Table 1). Scores on the DFI increased slightly for the INV group reflective of improvement in symptoms and decreased for the AC group indicating a worsening for the symptoms of dyspnea and fatigue. The INV group rated their adherence to the CR exercise goals during the 12-week study higher than the AC group. The INV group reported mean exercise sessions completed and duration of exercise at 90% of goals set by CR. Six of the 10 participants in the AC group reported exercise activity during the study period, and mean exercise frequency was 68% of goal. The most requested adherence strategies were exercise logs and phone contact, which were requested by 9 of 10 patients, and these strategies were also rated as most helpful (see Figure 1). Lowest rated for helpfulness was educational information, and the least requested strategy to continue was the letter from the CR staff. Patients rated the letter as moderately helpful. See Figure 1 for helpfulness ratings on the six adherence strategies.

Table 1

Table 1

Figure 1

Figure 1

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Results from this study indicate that patients with HF who completed the intervention demonstrated sustained or improved physiological functioning and adhered to exercise at levels recommended during CR. After 12 weeks, the INV group increased in distance walked and reported symptoms of dyspnea and fatigue similar to study baseline, which was immediately post CR. The INV group reported continuing to exercise as recommended by CR during the 12-week study period. Self-rated adherence was consistent with exercise participation and higher for the INV than for the AC group. These findings suggest that, for patients with HF who complete CR, inclusion of these patient-selected adherence strategies may support continued exercise post CR and may help to sustain physiological improvements realized during CR.

The study findings provide some insight into adherence strategies for HF patients. The most requested and most helpful strategies were exercise logs and phone support. Previous research indicates strategies that include recording exercise and follow-up contact by nurses support continued exercise in HF patients (Tierney et al., 2012). Patient perception of the strategies of educational info, graphs of past exercise, pedometers, and the letter from CR staff indicate these were less helpful. This may reflect differing individual values for the use of these strategies. It may also indicate a need for less frequent use of a strategy. The CR letter was provided one time in 6 weeks and not requested again by participants; yet, it was rated moderately helpful. This may indicate that once is adequate for this strategy or that phone follow-up maybe preferred to written contact. Further study is needed to understand the role of these strategies in supporting post CR exercise.

Results from this study have implications for CR programs serving HF patients. The highest-rated strategies of phone contact and exercise logs could be implemented post CR. Others strategies could be added based on patient preference. This study is one of few to assess the effect of a letter with personalized feedback from a patient-selected CR member. Other studies suggest that personal contact by a nurse and healthcare professionals may increase exercise participation (Forman et al., 2014; Lin et al., 2015; Van Hoye, Boen, & Lefevre, 2015). It may be possible to strengthen this relationship between the patient and the CR nurse by adding phone contact post CR. In this approach, patients would submit recent exercise data and then receive a follow-up phone call from the selected nurses who work in CR who would review exercise progress and problem-solve adherence issues.

Limitations of this pilot study include a small, volunteer sample from one CR program, recruited in the initial 3 weeks of CR. Although all participants in the study completed the CR program and the 12-week study, they may not be representative of patients who do not volunteer for a post CR study and/or do not complete CR. This study evaluated outcomes for 12 weeks only. Because the pilot study was limited to 12 weeks, effects on long-term clinical outcomes were not evaluated. The measures of exercise adherence were self-reported. Strengths of the pilot include random assignment to group following CR, similar group demographics, and inclusion of an AC group to attempt to reduce the influence of researcher interaction and attention.

The study pilot-tested several adherence strategies and included the concept of choice in continuation of those strategies personally preferred. The need for exercise strategies that support adherence is important to HF patients who may need a longer period of time of support due to the chronic nature of the disease. Choice is often suggested as a way to individualize patient care, but there are few models of how to incorporate this approach into an exercise adherence program. Findings from this pilot study support further research on ways to include patient choice in the design of exercise adherence programs for HF patients.

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Key Practice Points

  • Exercise is difficult for patients with heart failure (HF) due to the commonly reported symptoms that decrease exercise tolerance.
  • Cardiac rehabilitation (CR) programs need new strategies to meet the unique needs of HF patients to safely exercise and adhere long term.
  • Patient self-selected exercise adherence strategies following CR demonstrate improvement in symptom impairment and exercise adherence and may support continued exercise post CR.
  • Findings from this pilot study support further research on ways to include patient choice in the design of exercise adherence programs for HF patients.
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Cardiac patients; cardiac rehabilitation; exercise adherence; heart failure; patient compliance

© 2019 Association of Rehabilitation Nurses.