Efficacy of exercise programs in pa2ents with chronic cardiovascular and pulmonary disease.

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1 Efficacité des programmes d ac2vité physique chez les pa2ents souffrant de maladies chroniques d origine cardio- vasculaire ou respiratoire. Efficacy of exercise programs in pa2ents with chronic cardiovascular and pulmonary disease. Dr. Simon L. Bacon Professeur.tulaire, sciences de l exercice, Université Concordia Co- Directeur, Centre de Médecine Comportementale de Montréal, HSCM Directeur, CRJJG, Hôpital du Sacré- Cœur de Montréal Président, Associa.on canadienne de préven.on et de réadapta.on cardiovasculaires Efficacy of exercise programs in pa2ents with chronic cardiovascular and pulmonary disease. Simon L. Bacon, PhD Professeur.tulaire, sciences de l exercice, Université Concordia Co- Directeur, Centre de Médecine Comportementale de Montréal, Hôpital du Sacré- Cœur de Montréal Directeur, CRJJG, Hôpital du Sacré- Cœur de Montréal Président, Associa.on canadienne de préven.on et de réadapta.on cardiovasculaires iceps 2015, Montpellier 1

2 Disclosures Grants/Research Support: GSK, Abbvie Inves.gator- ini.ated Consul2ng Fees: Schering- Plough, Merck, Kataka Medical Communica.on Behaviour change related CME Overview Efficacy of exercise for clinical outcomes in: Chronic Obstruc.ve Pulmonary Disease Cardiovascular disease Type, frequency, and intensity of exercise Hypertension as an example Future direc.ons Adherence and maintenance of exercise 2

3 COPD CVD Efficacy of exercise for clinical outcomes Chronic Obstruc.ve Pulmonary Disease (COPD) Cardiovascular disease 3

4 Pulmonary Rehab: COPD McCarthy et al. Cochrane Review RCTs 3,822 par.cipants Interven.ons Pulmonary rehab Usual care or medical advice (no educa.on) Outcomes Health- related quality of life Func.onal and maximal exercise capacity Outcomes CRQ (dyspnea) is beeer, MCID=0.5 SGRQ (total) is beeer, MCID=4 Usual care (Med. chge) Treatment (Mean (95%CIs) Par2cipants Quality (GRADE) 0 units (0.56, 1.03) 1,283 (19 studies) 0.42 units (9.26, 4.52) 1,146 (19 studies) 3 / 4 3 / 4 CRQ = Chronic Respiratory Ques.onnaire; SGRQ = St. George Respiratory Ques.onniare; MCID = Minimal clinically important difference 4

5 Outcomes CRQ (dyspnea) is beeer, MCID=0.5 SGRQ (total) is beeer, MCID=4 Incremental Shuele Walk Test (ISWT) Usual care (Med. chge) Treatment (Mean (95%CIs) Par2cipants Quality (GRADE) 0 units (0.56, 1.03) 1,283 (19 studies) 0.42 units (9.26, 4.52) 1,146 (19 studies) 1 metre (22.4, 57.2) 694 (8 studies) 6Min Walk test (6MWT) 3.4 metres (32.6, 55.2) 1,879 (38 studies) Cycle ergometer waes (1.9, 11.7) 779 (16 studies) 3 / 4 3 / 4 3 / 4 1 / 4 2 / 4 CRQ = Chronic Respiratory Ques.onnaire; SGRQ = St. George Respiratory Ques.onniare; MCID = Minimal clinically important difference Pulmonary Rehab: Post COPD exacerb. Hospitalisa.on (OR) Mean FU = 25 wk Mortality (OR) Mean FU = 107 wk OR/MD (95% CIs) NNT (95% CIs) Studies (n) 0.22 (0.08, 0.58) 4 (3, 8) 5 (250) 0.28 (0.10, 0.84) 6 (5, 30) 3 (110) The number needed to treat (NNT) is the average number of pa.ents who need to be treated to prevent one addi.onal bad outcome. Puhan et al. (2011). Cochrane Database of Systema.c Reviews 5

6 Pulmonary Rehab: Post COPD exacerb. Hospitalisa.on (OR) Mean FU = 25 wk Mortality (OR) Mean FU = 107 wk OR/MD (95% CIs) NNT (95% CIs) Studies (n) 0.22 (0.08, 0.58) 4 (3, 8) 5 (250) 0.28 (0.10, 0.84) 6 (5, 30) 3 (110) CRQ fa.gue (MD) 0.81 (0.16, 1.45) 5 (259) CRQ dyspnea (MD) 0.97 (0.35, 1.58) 5 (259) CRQ mastery (MD) 0.93 (- 0.13, 1.99) 5 (259) SGRQ total (MD) ( , ) 3 (128) SGRQ ac.vity (MD) ( , ) 3 (128) SGRQ impact (MD) ( , ) 3 (128) SGRQ symptoms (MD) 0.85 (- 6.82, 8.52) 3 (128) 6MWT (MD) (12.21, ) 6 (300) Puhan et al. (2011). Cochrane Database of Systema.c Reviews Pulmonary Rehab: Post COPD exacerb. Hospitalisa.on (OR) Mean FU = 25 wk Mortality (OR) Mean FU = 107 wk OR/MD (95% CIs) NNT (95% CIs) Studies (n) 0.22 (0.08, 0.58) 4 (3, 8) 5 (250) 0.28 (0.10, 0.84) 6 (5, 30) 3 (110) CRQ fa.gue (MD) 0.81 (0.16, 1.45) 5 (259) CRQ dyspnea (MD) 0.97 (0.35, 1.58) 5 (259) CRQ mastery (MD) 0.93 (- 0.13, 1.99) 5 (259) SGRQ total (MD) ( , ) 3 (128) SGRQ ac.vity (MD) ( , ) 3 (128) SGRQ impact (MD) ( , ) 3 (128) SGRQ symptoms (MD) 0.85 (- 6.82, 8.52) 3 (128) 6MWT (MD) (12.21, ) 6 (300) Puhan et al. (2011). Cochrane Database of Systema.c Reviews 6

7 Exercise- rehabilita.on and heart disease Anderson and Taylor, 2014, Cochrane review of reviews 6 Cochrane systema.c reviews Post myocardial infarc.on or percutaneous coronary interven.on or heart failure 148 RCTs 98,093 par.cipants Exercise for CHD (Heran 2011) Exercise for HF (Taylor 2014b) Home vs. centre (Taylor 2014a) RCTs (par.cipants) 47 RCTs (10,794) 33 RCTs (4,740) 17 RCTs (2,172) Nature of int. Exercise only Exercise + 29* Median sample size (range) 142 (28 to 2304) 54 (19 to 2331) 104 (20 to 525) Median dura.on mths (range) 3 (1 to 30) 6 (1 to 120) 3 (1.5 to 6) Median follow- up mths (range) 24 (6 to 120) 6 (6 to 120) 6 (2 to 72) *1 study assigned to exercise or exercise + 7

8 Exercise for CHD (Heran 2011) Exercise for HF (Taylor 2014b) Home vs. centre (Taylor 2014a) RCTs (par.cipants) 47 RCTs (10,794) 33 RCTs (4,740) 17 RCTs (2,172) Nature of int. Exercise only Exercise + 29* Median sample size (range) 142 (28 to 2304) 54 (19 to 2331) 104 (20 to 525) Median dura.on mths (range) 3 (1 to 30) 6 (1 to 120) 3 (1.5 to 6) Median follow- up mths (range) 24 (6 to 120) 6 (6 to 120) 6 (2 to 72) Hard outcomes [RR (95% CIs)] Mortality (<1 yr FU) 0.82 ( ) 0.93 ( ) 0.79 ( ) Mortality (>1 yr FU) 0.87 ( ) 0.88 ( ) 1.99 ( ) *1 study assigned to exercise or exercise + Exercise for CHD (Heran 2011) Exercise for HF (Taylor 2014b) Home vs. centre (Taylor 2014a) RCTs (par.cipants) 47 RCTs (10,794) 33 RCTs (4,740) 17 RCTs (2,172) Nature of int. Exercise only Exercise + 29* Median sample size (range) 142 (28 to 2304) 54 (19 to 2331) 104 (20 to 525) Median dura.on mths (range) 3 (1 to 30) 6 (1 to 120) 3 (1.5 to 6) Median follow- up mths (range) 24 (6 to 120) 6 (6 to 120) 6 (2 to 72) Hard outcomes [RR (95% CIs)] Mortality (<1 yr FU) 0.82 ( ) 0.93 ( ) 0.79 ( ) Mortality (>1 yr FU) 0.87 ( ) 0.88 ( ) 1.99 ( ) Hospitalisa.ons (<1 yr FU) 0.69 ( ) 0.75 ( ) 1 RCT no diff Hospitalisa.ons (>1 yr FU) 0.98 ( ) 0.92 ( ) N/A *1 study assigned to exercise or exercise + 8

9 Exercise for CHD (Heran 2011) Exercise for HF (Taylor 2014b) Home vs. centre (Taylor 2014a) RCTs (par.cipants) 47 RCTs (10,794) 33 RCTs (4,740) 17 RCTs (2,172) Nature of int. Exercise only Exercise + 29* Median sample size (range) 142 (28 to 2304) 54 (19 to 2331) 104 (20 to 525) Median dura.on mths (range) 3 (1 to 30) 6 (1 to 120) 3 (1.5 to 6) Median follow- up mths (range) 24 (6 to 120) 6 (6 to 120) 6 (2 to 72) Hard outcomes [RR (95% CIs)] Mortality (<1 yr FU) 0.82 ( ) 0.93 ( ) 0.79 ( ) Mortality (>1 yr FU) 0.87 ( ) 0.88 ( ) 1.99 ( ) Hospitalisa.ons (<1 yr FU) 0.69 ( ) 0.75 ( ) 1 RCT no diff Hospitalisa.ons (>1 yr FU) 0.98 ( ) 0.92 ( ) N/A HF- specific admissions (>1 yr FU) N/A 0.61 ( ) N/A *1 study assigned to exercise or exercise + Exercise for CHD (Heran 2011) Exercise for HF (Taylor 2014b) Home vs. centre (Taylor 2014a) RCTs (par.cipants) 47 RCTs (10,794) 33 RCTs (4,740) 17 RCTs (2,172) Nature of int. Exercise only Exercise + 29* Median sample size (range) 142 (28 to 2304) 54 (19 to 2331) 104 (20 to 525) Median dura.on mths (range) 3 (1 to 30) 6 (1 to 120) 3 (1.5 to 6) Median follow- up mths (range) 24 (6 to 120) 6 (6 to 120) 6 (2 to 72) Hard outcomes [RR (95% CIs)] Mortality (<1 yr FU) 0.82 ( ) 0.93 ( ) 0.79 ( ) Mortality (>1 yr FU) 0.87 ( ) 0.88 ( ) 1.99 ( ) Hospitalisa.ons (<1 yr FU) 0.69 ( ) 0.75 ( ) 1 RCT no diff Hospitalisa.ons (>1 yr FU) 0.98 ( ) 0.92 ( ) N/A HF- specific admissions (>1 yr FU) N/A 0.61 ( ) N/A HRQoL [SMD (95% CIs)] *1 study assigned to exercise or exercise + 7/10 RCTs sig 3/10 no diff (- 0.7, - 0.3) Overall no gp diff 9

10 Exercise- based cardiac rehab Risk factors Variable Studies Treatment (n) Control (n) WMD (95% CIs) Cholesterol (- 0.63, ) LDL (- 0.43, 0.12) HDL (- 0.03, 0.14) Trigs (- 0.39, ) SBP (- 5.44, ) DBP (- 2.68, 0.32) Taylor et al. (2004). Am J Med, 116: Clinical efficacy of exercise COPD mortality (mt) hospit (st) fitness quality of life CHD and HF mortality (mt) hospit (st) HF hospit. (mt) fitness quality of life 10

11 Type of exercise Hypertension and exercise as an example Effects of type of exercise on BP: aerobic 11

12 Effects of type of exercise on BP: aerobic Year Author Studies (n) SBP DBP Aerobic 1988 Hagberg Effects of type of exercise on BP: aerobic Year Author Studies (n) SBP DBP Aerobic 1988 Hagberg Fagard 44 (2,674) (- 4.5, - 2.3) (- 3.2, - 1.6) 2002 Whelton 54 (2,419) (- 5.0, - 2.7) (- 3.4, - 1.8) 2005 Cornelissen 72 (3,936) (- 4.0, - 2.0) (- 3.1, - 1.7) 12

13 Effects of type of exercise on BP: aerobic Year Author Studies (n) SBP DBP Aerobic 1988 Hagberg Fagard 44 (2,674) (- 4.5, - 2.3) (- 3.2, - 1.6) 2002 Whelton 54 (2,419) (- 5.0, - 2.7) (- 3.4, - 1.8) 2005 Cornelissen 72 (3,936) (- 4.0, - 2.0) (- 3.1, - 1.7) 2013 Cornelissen 69 (4,220) (- 4.6, - 2.3) (- 3.2, - 1.7) Frequency, dura2on, intensity 13

14 Wallace, Sports Med 2003: 33; RCT s from Whelton et al s 2002 Meta- analysis So what is the best combina.on of dura.on and intensity to reduce BP? Op.mal dura.on and intensity? If exercising 3.mes a week should you do a) 15 min at 50% VO2 (low dura.on, low intensity) b) 45 min at 50% VO2 (high, low) c) 15 min at 70% VO2 (low, high) d) 45 min at 70% VO2 (high, high) 14

15 Wallace, Sports Med 2003: 33; 585 Resistance exercise: dynamic vs. isometric 15

16 Effects of type of exercise on BP: resistance Year Author Studies (n) SBP DBP Dynamic 2005 Cornelissen 12 (341) (- 7.1, 0.7) (- 6.1, - 0.9) 2011 Cornelissen 30 (1024) (- 4.3, - 1.3) (- 3.8, - 1.7) Effects of type of exercise on BP: resistance Year Author Studies (n) SBP DBP Dynamic 2005 Cornelissen 12 (341) (- 7.1, 0.7) (- 6.1, - 0.9) 2011 Cornelissen 30 (1024) (- 4.3, - 1.3) (- 3.8, - 1.7) 2013 Cornelissen 25 (734) (- 3.7, ) (- 4.5, - 2.0) 16

17 Effects of type of exercise on BP: resistance Year Author Studies (n) SBP DBP Dynamic 2005 Cornelissen 12 (341) (- 7.1, 0.7) (- 6.1, - 0.9) 2011 Cornelissen 30 (1024) (- 4.3, - 1.3) (- 3.8, - 1.7) 2013 Cornelissen 25 (734) (- 3.7, ) (- 4.5, - 2.0) 2013 Rossi 9 (452) (- 3.4, 1.0) (- 3.9, - 0.5) Effects of type of exercise on BP: resistance Year Author Studies (n) SBP DBP Dynamic 2005 Cornelissen 12 (341) (- 7.1, 0.7) (- 6.1, - 0.9) 2011 Cornelissen 30 (1024) (- 4.3, - 1.3) (- 3.8, - 1.7) 2013 Cornelissen 25 (734) (- 3.7, ) (- 4.5, - 2.0) 2013 Rossi 9 (452) (- 3.4, 1.0) (- 3.9, - 0.5) Isometric 2011 Cornelissen 3 (71) ( ) (- 8.3, - 3.9) 2013 Cornelissen 4 (114) (- 14.5, - 7.4) (- 10.3, - 2.0) 17

18 Effects of type of exercise on BP: resistance Year Author Studies (n) SBP DBP Dynamic 2005 Cornelissen 12 (341) (- 7.1, 0.7) (- 6.1, - 0.9) 2011 Cornelissen 30 (1024) (- 4.3, - 1.3) (- 3.8, - 1.7) 2013 Cornelissen 25 (734) (- 3.7, ) (- 4.5, - 2.0) 2013 Rossi 9 (452) (- 3.4, 1.0) (- 3.9, - 0.5) Isometric 2011 Cornelissen 3 (71) ( ) (- 8.3, - 3.9) 2013 Cornelissen 4 (114) (- 14.5, - 7.4) (- 10.3, - 2.0) Aerobic 2013 Cornelissen 69 (4,220) (- 4.6, - 2.3) (- 3.2, - 1.7) Type of exercise: Summary Not all exercise is created equal Different disease states may have different op.mal paeerns 18

19 Future direc2ons Adherence and maintenance of exercise Cardiac rehab adherence and maintenance % pa.ents comple.ng rehab 1 58% (range = 34-80%) Mean % sessions aeended 1 79% (range 75-86%) Post- rehab exercise maintenance (18 months) 2 47% exercise maintainers 24% irregular exercisers 29% inac.ve 1 Taylor et al. J CV Nurs, 2011: 26; 202-9: 2 Leung et al. J Behav Med, 2007: 30;

20 Adherence Great adherence = beeer outcomes Mul.ple predictors of poor adherence Age (both younger and older!) Sex (mainly being female but inconsistent) Smoking High BMI High CVD risk Low illness percep.on Low self- efficacy High depressive symptoms (most consistent predictor) Taylor et al. J CV Nurs, 2011: 26; Adherence: Pulmonary rehab Busch et al. Respiratory Medicine, 2014: 108;

21 Promo.ng adherence Karmali et al, 2014 Cochrane Review 8 studies (1,167 par.cipants) Interven.ons u.lised Self monitoring: exercise (4), daily ac.vi.es (2), body weight (1) Problem- solving / coping strategies (5) Goal sezng (3 studies) Feedback (2) Ac.on planning (1) Wrieen and oral commitments (1) Stress management (1) Persuasive wrieen and telephone communica.on (1) Small group interac.on / peer- modeling (1) Promo.ng adherence: results Study n Interven2on Comparison Oldridge % 42% Daltroy % 62% Ashe % 89% Duncan 2002* 13 Ex. Dura.on: 109% Ex. Frequency*: 104% Izawa % 81% Moore Ex. Amount: 29% Ex. Frequency: 8% Sniehoka 2006* 246 Ac.on plan: 44% Ac2on plan + coping*: 71% Ex. Dura.on: 85% Ex. Frequency: 64% Ex. Amount: 27% Ex. Frequency: 8% 42% Arrigo 2008* % 37% * Significant effect 21

22 Promo.ng adherence: results 3 / 8 studies demonstrated improvement Successful interven.ons included: Duncan: goal sezng, feedback, problem- solving, posi.ve reinforcement Sniehoka: ac.on planning and coping strategies Arrigo: self monitoring of ac.vity Hard to determine any par.cular successful paeern Summary Efficacy of exercise for clinical outcomes Cardiovascular disease: Good COPD: Promising Type of exercise Different disease states may have different op.mal paeerns Adherence Generally poor but s.ll efficacious! How best to improve it? 22

23 Montreal Behavioural Medicine Centre Impact of lifestyle and stress on chronic disease cmcm.ca Acknowledgements Collaborators Kim Lavoie, PhD Jean Bourbeau, MD Gregory Ninot, PhD Jean Dioda., MD Catherine Lemiere, MD Lucie Blais, PhD Veronique Pepin, PhD Gregory Moullec, PhD Staff and students Guillaume Lacoste, BA Grant and salary support 23

24 Exercise and asthma 24

25 Project: Ex- Asthma Trial (CIHR ) 2,4 2,2 am [SE] change =.03 [.11] 2 1,8 1,6 1,4 1,2 1 Baseline Post-intervention Control Project: Ex- Asthma Trial (CIHR ) 2,4 2,2 am [SE] change =.03 [.11] 2 1,8 1,6 1,4 1,2 1 Baseline am [SE] change =.59 [.11] Post-intervention Control Exercise 25

26 Exercise- rehabilita.on and heart disease Anderson and Taylor, 2014, Cochrane review of reviews 6 Cochrane systema.c reviews Post myocardial infarc.on or percutaneous coronary interven.on or heart failure 148 RCTs 98,093 par.cipants 6 Cardiac rehab reviews Exercise- based cardiac rehabilita.on for coronary heart disease Heran 2011 Exercise- based rehabilita.on for heart failure Taylor 2014b Psychological interven.ons for coronary heart disease Whalley 2011 Pa.ent educa.on in the management of coronary heart disease Brown 2011 Home- based versus centre- based cardiac rehabilita.on Taylor 2014a Promo.ng pa.ent uptake and adherence in cardiac rehabilita.on Karmali

27 Exercise for CHD (Heran 2011) Exercise for HF (Taylor 2014b) Home vs. centre (Taylor 2014a) RCTs (par.cipants) 47 RCTs (10,794) 33 RCTs (4,740) 17 RCTs (2,172) Nature of int. Exercise only Exercise + 29* Median sample size (range) 142 (28 to 2304) 54 (19 to 2331) 104 (20 to 525) Median dura.on mths (range) 3 (1 to 30) 6 (1 to 120) 3 (1.5 to 6) Median follow- up mths (range) 24 (6 to 120) 6 (6 to 120) 6 (2 to 72) Hard outcomes [RR (95% CIs)] Mortality (<1 yr FU) 0.82 ( ) 0.93 ( ) 0.79 ( ) Mortality (>1 yr FU) 0.87 ( ) 0.88 ( ) 1.99 ( ) Hospitalisa.ons (<1 yr FU) 0.69 ( ) 0.75 ( ) 1 RCT no diff Hospitalisa.ons (>1 yr FU) 0.98 ( ) 0.92 ( ) N/A HF- specific admissions (>1 yr FU) N/A 0.61 ( ) N/A HRQoL [SMD (95% CIs)] *1 study assigned to exercise or exercise + 7/10 RCTs sig 3/10 no diff (- 0.7, - 0.3) Overall no gp diff Future recommenda.ons Reviews needs to reflect individually prescribed programme of exercise training with appropriate co- interven.ons Current CR recommenda.ons Reviews need to explore the complexity of CR Associa.on between interven.on characteris.cs and outcomes across trials Reviews need to standardise methods and repor.ng 27

28 Exercise- based cardiac rehab Hard end points Variable Studies Treatment (n) Control (n) OR (95% CIs) All- cause mortality ( ) Cardiac mortality ( ) MI ( ) CABG ( ) PTCA ( ) Taylor et al. (2004). Am J Med, 116: Exercise- based cardiac rehab Risk factors Variable Studies Treatment (n) Control (n) WMD (95% CIs) Cholesterol (- 0.63, ) LDL (- 0.43, 0.12) HDL (- 0.03, 0.14) Trigs (- 0.39, ) SBP (- 5.44, ) DBP (- 2.68, 0.32) Taylor et al. (2004). Am J Med, 116:

29 Frequency, Dura.on, Intensity So what is the best combina.on of dura.on and intensity to reduce BP? Wallace, Sports Med 2003: 33; 585 Wallace, 2003: Frequency 29

30 Wallace, 2003: Dura.on Wallace, 2003: Intensity 30

31 Adherence: Cardiac Rehab McGrady et al., J Cardiopulm Rehabil Prev 2009: 29:

32 Adherence: Pulmonary rehab Busch et al. Respiratory Medicine, 2014: 108;

33 Impact of psych interven.ons in cardiac rehab Routledge et al. Psychosom Med, 2013; 75:

34 Radionuclear Ventriculogaphy (RNV) Mirror trace task Blumenthal et al, 2005, JAMA New Wall Mo.on Abnormali.es: Mental stress 0,3 Change from rest 0,2 0,1 = UC = Ex = SM 0 No WMA WMA Pre-treatment Status Initial Status by Tx interaction, p =

35 Wall Mo.on Abnormali.es: Exercise 1 p =.012 Change from rest = UC = Ex = SM 0,8 0,6 0,4 0,2 0 UC EX SM Treatment Group Facts: physical ac2vity Physical inac.vity is the 4th leading risk factor for death worldwide (3.2 millions deaths/year) Globally, 1/3 adults are not ac.ve enough Physical inac.vity is a key risk factor for chronic diseases such as CVD, cancer and diabetes Physical ac2vity has significant health benefits for respiratory diseases (COPD, asthma, survival) WHO, 2013; Bacon et al, BMJ Open, 2013* 35

36 The ORBIT Model for Behavioural Interven.on Development Czajkowski et al., In press, Health Psychology 36

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