Motivating Patients in Cardiac Rehabilitation Programs: A Multicenter Randomized Controlled Trial
Concerns have been raised about motivation and psychological distress when implementing telerehabilitation in patients with heart failure. The current study compared conventional and telerehabilitation in two groups (n=67; n=70) of patients with heart failure at 0, 6, and 12 months on measures of motivation (Self-Determination Theory measures) and psychological distress (Hospital Anxiety and Depression scale). We found no significant changes in motivation across groups, although our telerehabilitation group had a slightly lower level of controlled motivation and higher levels of relatedness. In addition, there were no differences between groups with regard to psychological distress. This study demonstrates that telerehabilitation motivates patients with heart failure to the same degree as conventional rehabilitation, and that telerehabilitation is not associated with increased psychological distress. As such, telerehabilitation offers an alternative to conventional rehabilitation and addresses some of the barriers for participating in rehabilitation identified in the literature.
Anderson, L., Sharp, G. A., Norton, R. J., Dalal, H., Dean, S. G., Jolly, K., Cowie, A., Zawada, A., & Taylor, R. S. (2017). Home‐based versus centre‐based cardiac rehabilitation. Cochrane database of systematic reviews, (6). https://doi.org/10.1002/14651858.CD007130.pub4
Balady, G. J., Ades, P. A., Bittner, V. A., Franklin, B. A., Gordon, N. F., Thomas, R. J., Tomaselli, G.F., & Yancy, C. W. (2011). Referral, enrollment, and delivery of cardiac rehabilitation/secondary prevention programs at clinical centers and beyond: A presidential advisory from the American Heart Association. Circulation, 124(25), 2951-2960. https://doi.org/10.1161/CIR.0b013e31823b21e2
Batten, S. (2011). Essentials of acceptance and commitment therapy. Sage Publications.
Bjelland, I., Dahl, A. A., Haug, T. T., & Neckelmann, D. (2002). The validity of the Hospital Anxiety and Depression Scale: An updated literature review. Journal of psychosomatic research, 52(2), 69-77. https://doi.org/10.1016/s0022-3999(01)00296-3
Brennan, D., Tindall, L., Theodoros, D., Brown, J., Campbell, M., Christiana, D., Smith, D., Cason, J., & Lee, A. (2010). A blueprint for telerehabilitation guidelines. International Journal of Telerehabilitation, 2(2), 31. https://doi.org/10.5195/ijt.2010.6063
Brouwers, R. W. M., van Exel, H. J., van Hal, J. M. C., Jorstad, H. T., de Kluiver, E. P., Kraaijenhagen, R. A., Kuijpers, M.J.C., van der Linde, M.R., Spee, R.F., Sunamura, M., Uszko-Lencer, N.H.M., Vromen, T., Wittekoek, M. E., & Kemps, H.M..C., on behalf of the Committee for Cardiovascular Prevention and Cardiac Rehabilitation of the Netherlands Society of Cardiology. (2020). Cardiac telerehabilitation as an alternative to centre-based cardiac rehabilitation. Netherlands Heart Journal, 28, 443-451. https://doi.org/10.1007/s12471-020-01432-y
Buck, H. G., Lee, C. S., Moser, D. K., Albert, N. M., Lennie, T., Bentley, B., Worrall-Carter, L., & Riegel, B. (2012). Relationship between self-care and health-related quality of life in older adults with moderate to advanced heart failure. Journal of Cardiovascular Nursing, 27(1), 8-15. https://doi.org/10.1097/jcn.0b013e3182106299
Burns, A., Höfer, S., Curry, P., Sexton, E., & Doyle, F. (2014). Revisiting the dimensionality of the Hospital Anxiety and Depression Scale in an international sample of patients with ischaemic heart disease. Journal of Psychosomatic Research, 77(2), 116-121. https://doi.org/10.1097/jcn.0b013e3182106299
Cho, Y. M., Lee, S., Islam, S. M. S., & Kim, S. Y. (2018). Theories applied to m-health interventions for behavior change in low-and middle-income countries: A systematic review. Telemedicine and e-Health, 24(10), 727-741. https://doi.org/10.1089/tmj.2017.0249
Clemensen, J., Rothmann, M. J., Smith, A. C., Caffery, L. J., & Danbjorg, D. B. (2017). Participatory design methods in telemedicine research. Journal of telemedicine and telecare, 23(9), 780-785. https://doi.org/10.1177/1357633x16686747
Cook, C., Cole, G., Asaria, P., Jabbour, R., & Francis, D. P. (2014). The annual global economic burden of heart failure. International Journal of Cardiology, 171(3), 368-376. https://doi.org/10.1016/j.ijcard.2013.12.028
Cranen, K., Drossaert, C. H., Brinkman, E. S., Braakman‐Jansen, A. L., IJzerman, M. J., & Vollenbroek‐Hutten, M. M. (2012). An exploration of chronic pain patients’ perceptions of home telerehabilitation services. Health Expectations, 15(4), 339-350. https://doi.org/10.1111/j.1369-7625.2011.00668.x
Dalleck, L. C., Schmidt, L. K., & Lueker, R. (2011). Cardiac rehabilitation outcomes in a conventional versus telemedicine-based programme. Journal of Telemedicine and Telecare, 17(5), 217-221. https://doi.org/10.1258/jtt.2010.100407
Dinesen, B., Dittmann, L., Gade, J. D., Jørgensen, C. K., Hollingdal, M., Leth, S., Melholt, C., Spindler, H., & Refsgaard, J. (2019). “Future patient” telerehabilitation for patients with heart failure: Protocol for a randomized controlled trial. JMIR Research Protocols, 8(9), e14517. https://doi.org/10.2196/14517
Dinesen, B., Nonnecke, B,; Lindeman, D., Toft, E., Kidholm, K., Jethwani, K., Young, H.M., Spindler, H., Oestergaard, C.U., Southard, J.A., Gutierrez, M., Anderson, N., Albert, N.M., Han, J.J., & Nesbitt, T. (2016) Personalized telehealth in the future: A global research agenda. Journal of Medical Internet Research. 18, e53. https://doi.org/10.2196/jmir.5257
Egede, L. E., & Osborn, C. Y. (2010). Role of motivation in the relationship between depression, self-care, and glycemic control in adults with type 2 diabetes. Diabetes Educator, 36(2), 276-283. https://doi.org/10.1177/0145721710361389
Emons, W. H., Sijtsma, K., & Pedersen, S. S. (2012). Dimensionality of the Hospital Anxiety and Depression Scale (HADS) in cardiac patients: Comparison of Mokken scale analysis and factor analysis. Assessment, 19(3), 337-353. https://doi.org/10.1177/1073191110384951
Frederix, I., Vanhees, L., Dendale, P., & Goetschalckx, K. (2015). A review of telerehabilitation for cardiac patients. Journal of Telemedicine and Telecare, 21(1), 45-53. https://doi.org/10.1177/1357633x14562732
Gillison, F. B., Rouse, P., Standage, M., Sebire, S. J., & Ryan, R. M. (2019). A meta-analysis of techniques to promote motivation for health behaviour change from a self-determination theory perspective. Health Psychology Review, 13(1), 110-130. https://doi.org/10.1080/17437199.2018.1534071
Herrmann, C. (1997). International experiences with the Hospital Anxiety and Depression Scale-a review of validation data and clinical results. Journal of Psychosomatic Research, 42(1), 17-41. https://doi.org/10.1016/S0022-3999(96)00216-4
Jaarsma, T., Cameron, J., Riegel, B., & Stromberg, A. (2017). Factors related to self-care in heart failure patients according to the middle-range theory of self-care of chronic illness: A literature update. Current Heart Failure Reports, 14(2), 71-77. https://doi.org/10.1007/s11897-017-0324-1
Jaarsma, T., Strömberg, A., Mårtensson, J., & Dracup, K. (2003). Development and testing of the European heart failure self‐care behaviour scale. European Journal of Heart Failure, 5(3), 363-370. https://doi.org/10.1016/s1388-9842(02)00253-2
Joensson, K., Melholt, C., Hansen, J., Leth, S., Spindler, H., Olsen, M. V., & Dinesen, B. (2019). Listening to the patients: Using participatory design in the development of a cardiac telerehabilitation web portal. mHealth, 5, . https://doi.org/10.21037/mhealth.2019.08.06
Kessing, D., Denollet, J., Widdershoven, J., & Kupper, N. (2016). Psychological determinants of heart failure self-care: Systematic review and meta-analysis. Psychosomatic Medicine, 78(4), 412-431. https://doi.org/10.1097/psy.0000000000000270
Knudsen, M. V., Laustsen, S., Petersen, A. K., Hjortdal, V. E., & Angel, S. (2019). Experience of cardiac tele-rehabilitation: Analysis of patient narratives. Disability and Rehabilitation, 1-8. https://doi.org/10.1080/09638288.2019.1625450
Lee, C. S., Moser, D. K., Lennie, T. A., & Riegel, B. (2011). Event-free survival in adults with heart failure who engage in self-care management. Heart & Lung, 40(1), 12-20. https://doi.org/10.1016/j.hrtlng.2009.12.003
Martin, C. R., Thompson, D. R., & Barth, J. (2008). Factor structure of the Hospital Anxiety and Depression Scale in coronary heart disease patients in three countries. Journal of Evaluation in Clinical Practice, 14(2), 281-287. https://doi.org/10.1111/j.1365-2753.2007.00850.x
McAlister, F. A., Stewart, S., Ferrua, S., & McMurray, J. J (2004). Multidisciplinary strategies for the management of heart failure patients at high risk for admission: A systematic review of randomized trials. Journal of the American College of Cardiology, 44, 810–819. https://doi.org/10.1016/j. jacc.2004.05.055
McLean, S., Protti, D., & Sheikh, A. (2011). Telehealthcare for long term conditions. Bmj, 342. https://doi.org/10.1136/bmj.d120
Pâquet, M., Bolduc, N., Xhignesse, M., & Vanasse, A. (2005). Re‐engineering cardiac rehabilitation programmes: Considering the patient's point of view. Journal of Advanced Nursing, 51(6), 567-576. https://doi.org/10.1111/j.1365-2648.2005.03544.x
Piotrowicz, E. (2017). The management of patients with chronic heart failure: The growing role of e-Health. Expert Review of Medical Devices, 14(4), 271-277. https://doi.org/10.1080/17434440.2017.1314181
Piotrowicz, E., Baranowski, R., Bilinska, M., Stepnowska, M., Piotrowska, M., Wójcik, A., Korewicki, J., Chojnowska, L., Malek, L., Klopotowski, M., Piotrowski, W., & Piotrowicz, R. (2010). A new model of home‐based telemonitored cardiac rehabilitation in patients with heart failure: Effectiveness, quality of life, and adherence. European Journal of Heart Failure, 12(2), 164-171. https://doi.org/10.1093/eurjhf/hfp181
Piotrowicz, E., Piepoli, M. F., Jaarsma, T., Lambrinou, E., Coats, A. J., Schmid, J. P., Corrà, U., Agostoni, P., Dickstein, K., Seferović, P.M., Adamopoulos, S., & Ponikowski, P. P. (2016). Telerehabilitation in heart failure patients: The evidence and the pitfalls. International Journal of Cardiology, 220, 408-413. https://doi.org/10.1016/j.ijcard.2016.06.277
Rahman, R. J., Hudson, J., Thøgersen-Ntoumani, C., & Doust, J. H. (2015). Motivational processes and well-being in cardiac rehabilitation: A self-determination theory perspective. Psychology, Health & Medicine, 20(5), 518-529. https://doi.org/10.1080/13548506.2015.1017509
Ryan, R. M., Patrick, H., Deci, E. L., & Williams, G. C. (2008). Facilitating health behaviour change and its maintenance: Interventions based on self-determination theory. The European Health Psychologist, 10(1), 2-5. https://doi.org/10.1186/1479-5868-9-18
Savarese, G., & Lund, L. H. (2017). Global public health burden of heart failure. Cardiac Failure Review, 3(1), 7.
Schafer, J. L., & Graham, J. W. (2002). Missing data: Our view of the state of the art. Psychological methods, 7(2), 147.https://doi.org/10.15420/cfr.2016:25:2
Scherer, M., Himmel, W., Stanske, B., Scherer, F., Koschack, J., Kochen, M. M., & Herrmann-Lingen, C. (2007). Psychological distress in primary care patients with heart failure: A longitudinal study. British Journal of General Practice, 57(543), 801-807.
Schumi, J., & Wittes, J. T. (2011). Through the looking glass: Understanding non-inferiority. Trials, 12(1), 1-12.
Schweitzer, R. D., Head, K., & Dwyer, J. W. (2007). Psychological factors and treatment adherence behavior in patients with chronic heart failure. Journal of Cardiovascular Nursing, 22(1), 76-83. https://doi.org/10.1097/00005082-200701000-00012
Shen, B. J., & Maeda, U. (2018). Psychosocial predictors of self-reported medical adherence in patients with heart failure over 6 months: An examination of the influences of depression, self-efficacy, social support, and their changes. Annals of Behavioral Medicine, 52(7), 613-619. https://doi.org/10.1007/s12529-011-9215-0
Spindler, H., Leerskov, K., Joensson, K., Nielsen, G., Andreasen, J. J., & Dinesen, B. (2019). Conventional rehabilitation therapy versus telerehabilitation in cardiac patients: A comparison of motivation, psychological distress, and quality of life. International Journal of Environmental Research and Public Health, 16(3), 512. https://doi.org/10.3390/ijerph16030512
Sundhedsstyrelsen. (2015). National klinisk retningslinje for hjerterehabilitering. Sundhedsstyrelsen, 3-62. https://www.sst.dk/da/udgivelser/2015/~/media/401919781C684EE9AAE544EB5E76847B.ashx
Sweet, S. N., Tulloch, H., Fortier, M. S., Pipe, A. L., & Reid, R. D. (2011). Patterns of motivation and ongoing exercise activity in cardiac rehabilitation settings: A 24-month exploration from the TEACH Study. Annals of Behavioral Medicine, 42(1), 55-63. https://doi.org/10.1007/s12160-011-9264-2
Tang, H. Y., Sayers, S. L., Weissinger, G., & Riegel, B. (2014). The role of depression in medication adherence among heart failure patients. Clinical Nursing Research, 23(3), 231-244. https://doi.org/10.1177/1054773813481801
Toback, M., & Clark, N. (2017). Strategies to improve self-management in heart failure patients. Contemporary Nurse, 53(1), 105-120. https://doi.org/10.1080/10376178.2017.1290537
Williams, G. C., Ryan, R. M., & Deci, E.L. (2004). Health-care, self-determination theory packet. http://selfdeterminationtheory.org/health-care-self-determination-theory/
Yohannes, A. M., Doherty, P., Bundy, C., & Yalfani, A. (2010). The long‐term benefits of cardiac rehabilitation on depression, anxiety, physical activity and quality of life. Journal of Clinical Nursing, 19(19‐20), 2806-2813. https://doi.org/10.1111/j.1365-2702.2010.03313.x
Zigmond, A. S., & Snaith, R. P. (1983). The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica, 67(6), 361-370. https://doi.org/10.1111/j.1600-0447.1983.tb09716.x
Copyright (c) 2021 Helle Spindler, Malene Hollingdal, Jens Refsgaard, Birthe Dinesen
This work is licensed under a Creative Commons Attribution 4.0 International License.
Authors who publish with this journal agree to the following terms:
- The Author retains copyright in the Work, where the term “Work” shall include all digital objects that may result in subsequent electronic publication or distribution.
- Upon acceptance of the Work, the author shall grant to the Publisher the right of first publication of the Work.
- The Author shall grant to the Publisher and its agents the nonexclusive perpetual right and license to publish, archive, and make accessible the Work in whole or in part in all forms of media now or hereafter known under a Creative Commons Attribution 4.0 International License or its equivalent, which, for the avoidance of doubt, allows others to copy, distribute, and transmit the Work under the following conditions:
- Attribution—other users must attribute the Work in the manner specified by the author as indicated on the journal Web site;
- The Author is able to enter into separate, additional contractual arrangements for the nonexclusive distribution of the journal's published version of the Work (e.g., post it to an institutional repository or publish it in a book), as long as there is provided in the document an acknowledgement of its initial publication in this journal.
- Authors are permitted and encouraged to post online a prepublication manuscript (but not the Publisher’s final formatted PDF version of the Work) in institutional repositories or on their Websites prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work. Any such posting made before acceptance and publication of the Work shall be updated upon publication to include a reference to the Publisher-assigned DOI (Digital Object Identifier) and a link to the online abstract for the final published Work in the Journal.
- Upon Publisher’s request, the Author agrees to furnish promptly to Publisher, at the Author’s own expense, written evidence of the permissions, licenses, and consents for use of third-party material included within the Work, except as determined by Publisher to be covered by the principles of Fair Use.
- The Author represents and warrants that:
- the Work is the Author’s original work;
- the Author has not transferred, and will not transfer, exclusive rights in the Work to any third party;
- the Work is not pending review or under consideration by another publisher;
- the Work has not previously been published;
- the Work contains no misrepresentation or infringement of the Work or property of other authors or third parties; and
- the Work contains no libel, invasion of privacy, or other unlawful matter.
- The Author agrees to indemnify and hold Publisher harmless from Author’s breach of the representations and warranties contained in Paragraph 6 above, as well as any claim or proceeding relating to Publisher’s use and publication of any content contained in the Work, including third-party content.
Revised 7/16/2018. Revision Description: Removed outdated link.