TY - JOUR
AU1 - Reid, Robert D
AU2 - Morrin, Louise I
AU3 - Higginson, Lyall A J
AU4 - Wielgosz, Andreas
AU5 - Blanchard, Chris
AU6 - Beaton, Louise J
AU7 - Nelson, Chantal
AU8 - McDonnell, Lisa
AU9 - Oldridge, Neil
AU1 - Wells, George A
AU1 - Pipe, Andrew L
AB - Abstract Background Many patients with coronary artery disease (CAD) fail to attend cardiac rehabilitation following acute coronary events because they lack motivation to exercise. Theory-based approaches to promote physical activity among non-participants in cardiac rehabilitation are required. Design A randomized trial comparing physical activity levels at baseline, 6, and 12 months between a motivational counselling (MC) intervention group and a usual care (UC) control group. Method One hundred and forty-one participants hospitalized with acute coronary syndromes not planning to attend cardiac rehabilitation were recruited at a single centre and randomized to either MC (n = 69) or UC (n = 72). The MC intervention, designed from an ecological perspective, included one face-to-face contact and eight telephone contacts with a trained physiotherapist over a 52-week period. The UC group received written information about starting a walking programme and brief physical activity advice from their attending cardiologist. Physical activity was measured by: 7-day physical activity recall interview; self-report questionnaire; and pedometer at baseline, 6, and 12 months after randomization. Results Latent growth curve analyses, which combined all three outcome measures into a single latent construct, showed that physical activity increased more over time in the MC versus the UC group (µadd = 0.69, p < 0.05). Conclusion Patients with CAD not participating in cardiac rehabilitation receiving a theory-based motivational counselling intervention were more physically active at follow-up than those receiving usual care. This intervention may extend the reach of cardiac rehabilitation by increasing physical activity in those disinclined to participate in structured programmes. Behavioural counselling, coronary artery disease, physical activity Introduction Physical activity moderates the impact of coronary artery disease (CAD); patients with CAD who are regularly physical active have a mortality rate one-third lower than those who are inactive.1 Physical activity counselling and exercise training are core components of cardiac rehabilitation; however, most patients with CAD (70–85%) do not participate.2 Lack of motivation to exercise is as a key barrier to participating in cardiac rehabilitation.3 New interventions to increase physical activity among non-participants are needed. A recent review identified nine studies of behavioural interventions for physical activity in CAD patients not attending cardiac rehabilitation.4 Interventions involved counselling for 8–12 weeks and employed various behaviour-change techniques (e.g. goal setting, self-monitoring, and physical activity prescription). Most follow-ups lasted less than 12 weeks, adequate to address adoption of physical activity but too brief to assess maintenance. Only one intervention5 was theory-based (i.e., self-efficacy). Most studies relied on self-reported physical activity. Physical activity interventions examining adoption and maintenance of physical activity (i.e. ≥ 1 year), that are theoretically-guided, and use both self-reported and objective physical activity outcome measures are required. We report findings of a randomized controlled trial comparing long-term physical activity levels between a theoretically guided motivational counselling (MC) intervention group and a usual care (UC) control group. We hypothesized the MC group would show greater increases in physical activity over 1 year compared to the UC group. Methods Settings and participants Participants were identified by a research coordinator during an index hospitalization at a single cardiac centre in Ottawa, Canada (University of Ottawa Heart Institute) between September 2005 and November 2008. Patients with acute coronary syndromes who underwent successful percutaneous coronary revascularization and were not planning on enrolling in cardiac rehabilitation (after having options explained by the research coordinator) were eligible. Patients were excluded if they: underwent bypass surgery; had Class III or IV heart failure; had contraindications to physical activity; did not speak and read English; or were unable to provide informed consent. The protocol was approved by the institutional Research Ethics Committee and all participants provided written consent. All acute coronary syndrome patients treated at the centre received a Cardiology Discharge Book which included information on how to initiate a walking programme. Each patient engaged in a discussion with the attending cardiologist concerning heart disease and its treatment. Advice about the importance of physical activity was provided (Supplementary Appendix A). Procedure Baseline assessment The research coordinator extracted information from the patient chart regarding cardiac history, medications, smoking status, and body mass index. Participants completed questionnaires regarding comorbidities and physical activity levels prior to hospitalization. They were fitted with a pedometer which they wore for a 9-day period; a logbook was provided to record the distance in kilometres measured by the pedometer each day. Randomization and blinding Before randomization, participants were placed into strata based on physical activity level before hospitalization measured by the Godin Leisure Score Index6 (<20 or ≥20). Participants were randomized to MC or UC using a random sequence generated by a statistician. Sequences were concealed until after baseline assessment. The research coordinator then allocated the next available number and notified participants of their intervention immediately. Research assistants, blinded to treatment assignment, conducted follow-up assessments. Interventions The motivational counselling intervention consisted of nine contacts between the participant and one of three specially trained physiotherapists over a 52-week intervention period (Supplementary Appendix A). The first contact was face-to-face (time 0) and the remaining contacts were via telephone (at weeks 2, 4, 8, 14, 20, 24, 40, and 52). The intervention was designed from an ecological perspective, i.e. it assumed that there are ‘individual’ (e.g. motivation, self-efficacy, self-monitoring, and action planning skills), ‘social-environmental’ (e.g. family and social networks), and ‘physical-environmental (e.g. access to home exercise equipment, walking routes, community facilities, and programmes; weather) factors that influence physical activity behaviour.7,8 The behavioural objective was to have the patient engage in ≥30 minutes of physical activity at a moderate or vigorous intensity 5 or more days per week. Intervention elements included gaining commitment, identifying valued outcomes, setting goals, making choices, action planning, self-monitoring, identifying opportunities for physical activity at home, in the neighbourhood, and in the community, problem solving to overcome barriers, feedback and encouragement, symptoms and intensity management, and links to medical care. Physiotherapists providing the intervention received 2 days of training and had regular case discussions to maintain skills over time. They used scripts/checklists to ensure intervention fidelity. The usual care group received no additional intervention concerning physical activity following hospital discharge. Follow-up assessments Participants returned to the centre at 26 and 52 weeks to complete: an interview about physical activity over the past week; a questionnaire concerning physical activity over the past 6 months; and to be fitted with a pedometer they wore for a 9-day period. A logbook was provided to record the distance measured by the pedometer each day. Measures Seven-day physical activity recall interview A structured physical activity recall interview9 ascertained estimates of time spent in activities of moderate (3.0–4.9 metabolic equivalents, METS), hard (5.0–6.9 METS), and very hard intensity (≥7.0 METS) over the past 7 days. Minutes of physical activity were summed across the three intensities to create a 7-day total. Self-reported physical activity questionnaire A modified and validated version10 of the Godin Leisure Time Exercise Questionnaire6 was used to gather data concerning average weekly physical activity. Participants were asked ‘How many days in a typical week in the past 6 months did you do moderate (e.g., fast walking, easy bicycling, easy swimming, dancing) physical activity for at least 10 minutes at a time?’ and, ‘On the days when you did moderate physical activity, how many minutes on average did you spend per day doing this activity?’ The same two questions assessed the frequency and duration of vigorous (e.g., running, jogging) activities. Minutes of moderate and vigorous physical activity per week were summed. Pedometer-measured physical activity Daily physical activity was measured using the Yamax DIGI-WALKERTM (Yamasa Tokei Keiki, Tokyo, Japan) pedometer. This pedometer has accuracy within 1% at walking speeds of 80 m/min.11 The pedometer was worn for a 9-day period and data from the first and last days were discarded. Analytical plan Baseline characteristics were compared between groups using ANOVAs and χ2 analyses. The pattern of missing physical activity data was assessed and missing data were imputed using a Markov Chain Monte Carlo method. Descriptive statistics were generated and standardized effect sizes were calculated.12 Since physical activity was measured in three different ways (i.e., self-reported minutes over the past week, ‘typical’ minutes per week over the past 6 months, and pedometer-measured distance travelled over a 7-day period), a second-order latent growth curve analysis was conducted in LISREL 8.8 using maximum-likelihood estimation.13 Activity measures were aggregated into one second-order construct at each time point. A multi-group analysis strategy was used,14 whereby the second-order intercept (i.e. baseline physical activity) and slope (i.e. change in physical activity) were constrained to be equal between groups in terms of the means, variances, and co-variances (Figure 1). The mean for the treatment slope (i.e. the change in physical activity across time for the MC group above and beyond the UC change) was freely estimated,14 whereas its associated variance was fixed to 0 to reflect group change.15 In terms of the first-order physical activity constructs, the factor loadings for baseline physical activity were constrained to be equal with their associated factor loadings at 6 and 12 months to ensure a comparable definition of physical activity across time. Secondary sensitivity analyses were conducted with complete cases. Figure 1. Open in new tabDownload slide Results from the latent growth curve analysis. Ped: pedometer, Godin: godin leisure time exercise questionnaire, PAR: physical activity recall. Study power A model where µadd was freely estimated was compared to a model where µadd was fixed to 0 to calculate the χ2 non-centrality parameter used to calculate study power at α = 0.05 and df = 1.14 Study power was 0.82. Results Patient flow and baseline characteristics A total of 868 patients were screened, of which 355 (40.8%) met study eligibility criteria and 141 (39.7% of those eligible) agreed to participate (Supplementary Appendix B). Among consenting participants, 69 were randomized to MC and 72 to UC with a total of 141, 110, and 96 completing the baseline, 6-month, and 12-month assessments, respectively. Outcome data were missing at random after controlling for age and employment status and missing values were imputed using a Markov Chain Monte Carlo method. The two groups were similar when baseline factors were compared (Table 1). Table 1. Baseline characteristics of participants in a randomized trial of motivational counselling for physical activity Variable . Overall (n = 141) . Usual care (n = 72) . Motivational counselling (n = 69) . Demographic characteristics  Age (years) 60.5 ± 9.8 61.4 ± 9.7 59.5 ± 9.9  Men/women 103/38 56/16 47/22  Education (years) 12.0 ± 3.1 11.6 ± 3.0 12.3 ± 3.1  Married or common law/not married or common-law 111/30 55/17 56/13  Employed/not employed 65/76 33/39 32/37 Clinical characteristics  Smoker/non-smoker 20/121 11/61 9/60  Body mass index (kg/m2) 29.4 ± 5.6 29.0 ± 4.6 29.7 ± 6.6  Diabetes/no diabetes 22/119 10/62 12/57  Heart failure/no heart failure 38/102 17/55 21/48  First cardiac event/previous cardiac events 98/43 51/21 47/22  AMI + PCI/PCI only 15/126 8/64 7/62 Variable . Overall (n = 141) . Usual care (n = 72) . Motivational counselling (n = 69) . Demographic characteristics  Age (years) 60.5 ± 9.8 61.4 ± 9.7 59.5 ± 9.9  Men/women 103/38 56/16 47/22  Education (years) 12.0 ± 3.1 11.6 ± 3.0 12.3 ± 3.1  Married or common law/not married or common-law 111/30 55/17 56/13  Employed/not employed 65/76 33/39 32/37 Clinical characteristics  Smoker/non-smoker 20/121 11/61 9/60  Body mass index (kg/m2) 29.4 ± 5.6 29.0 ± 4.6 29.7 ± 6.6  Diabetes/no diabetes 22/119 10/62 12/57  Heart failure/no heart failure 38/102 17/55 21/48  First cardiac event/previous cardiac events 98/43 51/21 47/22  AMI + PCI/PCI only 15/126 8/64 7/62 Values are mean ± standard deviation or n/n. AMI, acute myocardial infarction; PCI, percutaneous coronary intervention. Open in new tab Table 1. Baseline characteristics of participants in a randomized trial of motivational counselling for physical activity Variable . Overall (n = 141) . Usual care (n = 72) . Motivational counselling (n = 69) . Demographic characteristics  Age (years) 60.5 ± 9.8 61.4 ± 9.7 59.5 ± 9.9  Men/women 103/38 56/16 47/22  Education (years) 12.0 ± 3.1 11.6 ± 3.0 12.3 ± 3.1  Married or common law/not married or common-law 111/30 55/17 56/13  Employed/not employed 65/76 33/39 32/37 Clinical characteristics  Smoker/non-smoker 20/121 11/61 9/60  Body mass index (kg/m2) 29.4 ± 5.6 29.0 ± 4.6 29.7 ± 6.6  Diabetes/no diabetes 22/119 10/62 12/57  Heart failure/no heart failure 38/102 17/55 21/48  First cardiac event/previous cardiac events 98/43 51/21 47/22  AMI + PCI/PCI only 15/126 8/64 7/62 Variable . Overall (n = 141) . Usual care (n = 72) . Motivational counselling (n = 69) . Demographic characteristics  Age (years) 60.5 ± 9.8 61.4 ± 9.7 59.5 ± 9.9  Men/women 103/38 56/16 47/22  Education (years) 12.0 ± 3.1 11.6 ± 3.0 12.3 ± 3.1  Married or common law/not married or common-law 111/30 55/17 56/13  Employed/not employed 65/76 33/39 32/37 Clinical characteristics  Smoker/non-smoker 20/121 11/61 9/60  Body mass index (kg/m2) 29.4 ± 5.6 29.0 ± 4.6 29.7 ± 6.6  Diabetes/no diabetes 22/119 10/62 12/57  Heart failure/no heart failure 38/102 17/55 21/48  First cardiac event/previous cardiac events 98/43 51/21 47/22  AMI + PCI/PCI only 15/126 8/64 7/62 Values are mean ± standard deviation or n/n. AMI, acute myocardial infarction; PCI, percutaneous coronary intervention. Open in new tab Adherence to motivational counselling intervention Completion rates for scheduled sessions at time 0 and 2, 4, 8, 14, 20, 24, 40, and 52 weeks were 100, 94, 91, 91, 90, 87, 88, 86, and 83%, respectively. Effectiveness of the motivational counselling intervention Descriptive statistics for physical activity variables are shown in Table 2. Effect sizes were small to moderate for the 7-day physical activity recall and Godin at both 6 and 12 months; they were small at 12 months for the pedometer data. The treatment slope coefficient of the latent growth curve analysis (Figure 1) showed the MC group had a larger increase in physical activity across time compared to the UC group (µadd = 0.69, t = 2.44, p < 0.05). Table 2. Means, standard deviations, and effect sizes for physical activity measures at baseline, 6, and 12 months by group Group . Baseline . 6 months . 12 months . Pedometer (kilometres travelled over 7 days)  Usual care 20.9 ± 17.0 29.8 ± 19.0 34.5 ± 24.5  Motivational counselling 21.2 ± 13.9 30.6 ± 16.7 38.3 ± 25.9  Cohen’s d −0.02 −0.05 -0.15 Godin Leisure Time Exercise Questionnaire (minutes of moderate and vigorous physical activity in typical week in past 6 months)  Usual care 102.6 ± 207.1 124.9 ± 145.1 168.8 ± 176.6  Motivational counselling 80.5 ± 150.2 192.8 ± 163.0 233.8 ± 189.5  Cohen’s d 0.12 −0.44 −0.36 7-day physical activity recall (minutes of moderate, hard, and very hard physical activity in the past 7 days)  Usual care 132.1 ± 164.5 224.0 ± 201.9 261.5 ± 269.7  Motivational counselling 148.5 ± 151.3 310.1 ± 224.3 328.8 ± 226.4  Cohen’s d −0.10 −0.40 −0.27 Group . Baseline . 6 months . 12 months . Pedometer (kilometres travelled over 7 days)  Usual care 20.9 ± 17.0 29.8 ± 19.0 34.5 ± 24.5  Motivational counselling 21.2 ± 13.9 30.6 ± 16.7 38.3 ± 25.9  Cohen’s d −0.02 −0.05 -0.15 Godin Leisure Time Exercise Questionnaire (minutes of moderate and vigorous physical activity in typical week in past 6 months)  Usual care 102.6 ± 207.1 124.9 ± 145.1 168.8 ± 176.6  Motivational counselling 80.5 ± 150.2 192.8 ± 163.0 233.8 ± 189.5  Cohen’s d 0.12 −0.44 −0.36 7-day physical activity recall (minutes of moderate, hard, and very hard physical activity in the past 7 days)  Usual care 132.1 ± 164.5 224.0 ± 201.9 261.5 ± 269.7  Motivational counselling 148.5 ± 151.3 310.1 ± 224.3 328.8 ± 226.4  Cohen’s d −0.10 −0.40 −0.27 Values are mean ± standard deviation unless otherwise indicated. Cohen’s d = mean1–mean2/SDpooled. Open in new tab Table 2. Means, standard deviations, and effect sizes for physical activity measures at baseline, 6, and 12 months by group Group . Baseline . 6 months . 12 months . Pedometer (kilometres travelled over 7 days)  Usual care 20.9 ± 17.0 29.8 ± 19.0 34.5 ± 24.5  Motivational counselling 21.2 ± 13.9 30.6 ± 16.7 38.3 ± 25.9  Cohen’s d −0.02 −0.05 -0.15 Godin Leisure Time Exercise Questionnaire (minutes of moderate and vigorous physical activity in typical week in past 6 months)  Usual care 102.6 ± 207.1 124.9 ± 145.1 168.8 ± 176.6  Motivational counselling 80.5 ± 150.2 192.8 ± 163.0 233.8 ± 189.5  Cohen’s d 0.12 −0.44 −0.36 7-day physical activity recall (minutes of moderate, hard, and very hard physical activity in the past 7 days)  Usual care 132.1 ± 164.5 224.0 ± 201.9 261.5 ± 269.7  Motivational counselling 148.5 ± 151.3 310.1 ± 224.3 328.8 ± 226.4  Cohen’s d −0.10 −0.40 −0.27 Group . Baseline . 6 months . 12 months . Pedometer (kilometres travelled over 7 days)  Usual care 20.9 ± 17.0 29.8 ± 19.0 34.5 ± 24.5  Motivational counselling 21.2 ± 13.9 30.6 ± 16.7 38.3 ± 25.9  Cohen’s d −0.02 −0.05 -0.15 Godin Leisure Time Exercise Questionnaire (minutes of moderate and vigorous physical activity in typical week in past 6 months)  Usual care 102.6 ± 207.1 124.9 ± 145.1 168.8 ± 176.6  Motivational counselling 80.5 ± 150.2 192.8 ± 163.0 233.8 ± 189.5  Cohen’s d 0.12 −0.44 −0.36 7-day physical activity recall (minutes of moderate, hard, and very hard physical activity in the past 7 days)  Usual care 132.1 ± 164.5 224.0 ± 201.9 261.5 ± 269.7  Motivational counselling 148.5 ± 151.3 310.1 ± 224.3 328.8 ± 226.4  Cohen’s d −0.10 −0.40 −0.27 Values are mean ± standard deviation unless otherwise indicated. Cohen’s d = mean1–mean2/SDpooled. Open in new tab Sensitivity analyses conducted with complete cases showed similar effects of the intervention on self-reported and pedometer-measured physical activity at 6 months, and only slightly weaker effects of the intervention at 12 months (Supplementary Appendix C); data imputation had little impact on the effects seen in the primary analysis. Discussion Patients with CAD not participating in cardiac rehabilitation who received a theory-based motivational counselling intervention were more physically active at follow-up compared to usual care. The long-term impact of the motivational counselling intervention was superior to that observed in the only other theory-based intervention study in this population.5 We used a different theoretical approach (ecological versus self-efficacy), a longer intervention period (52 versus 12 weeks), more contacts (nine versus six), and combined face-to-face and telephone contacts (versus telephone contacts alone). Our results are consistent with a recent review of behavioural interventions to increase physical activity in cardiac patients;4 home-based interventions are effective for increasing physical activity in those not attending cardiac rehabilitation if they included follow-up prompts, encouragement, specific goals set by care providers, and self-monitoring. These behaviour change techniques were key elements of the MC intervention. Participants in the MC group reported engaging in moderate to vigorous intensity physical activity 86 and 67 minutes more per week at 6 and 12 months, respectively. Increases of this magnitude are clinically important because higher levels of leisure time energy expenditure are associated with improvements in survival, cardio-respiratory fitness, attenuation of symptoms, and less disease progression in patients with known CAD.16,17 The effect sizes for the self-reported physical activity measures ranged from 0.27 to 0.44, which are consistent with the 0.35 effect size recently reported in a meta-analysis of physical activity interventions in heart disease patients.18 Strengths and limitations of this study are evident. Stratification by prior physical activity level and randomization produced groups well balanced on potentially confounding factors. The motivational counselling intervention was planned using a robust framework (ecological theory) and delivered by trained physiotherapists with extensive experience with CAD patients. MC participants completed a high percentage of counselling sessions. Limitations relate to the complexity of measuring physical activity and potential effects of attrition. There are known limitations to self-report and pedometer measures of activity (e.g. social desirability bias causing over-reporting; participant versus investigator understanding of ambiguous terms like ‘physical activity’, ‘moderate intensity’, and ‘leisure time’; inability to capture all forms of activity; alterations of behaviour during observation periods).19 However, our latent growth curve analysis approach, which combined objective measures and self-report into a single construct, helped capture the complexity of the physical activity construct. Loss-to-follow-up was higher than anticipated and required the imputation of 22% and 33% of outcome data at 6 and 12 months, respectively. However, sensitivity analysis using only complete cases showed similar effects of the intervention on self-reported and pedometer-measured physical activity at 6 months, and only slightly weaker effects of the intervention at 12 months. The use of imputed data in our primary analysis did not materially alter our conclusions about the efficacy of the intervention. The trial consisted primarily of male Caucasian patients, which may limit the generalizability of the findings. Overall, CAD patients receiving a behavioural counselling intervention were more physically active than usual care patients 6 and 12 months after hospitalization. This intervention may extend the reach of physical-activity directed rehabilitation and secondary prevention services to patients who are not able or unwilling to attend supervised programmes. Funding This work was supported by Heart and Stroke Foundation of Ontario (grant numbers NA5626 and T6112). Conflicts of interest None Clinical trial identifier NCT00265525 References 1 Moholdt T , Wisloff U, Nilsen T, Slordahl S. Physical activity and mortality in men and women with coronary heart disease: a prospective population-based cohort study in Norway (the HUNT study) . Eur J Cardiovasc Prev Rehabil 2008 ; 15 ( 6 ): 639 – 645 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Suskin N , McDonald S, Swabey T. Cardiac rehabilitation and secondary prevention services in Ontario: recommendations from a consensus panel . Can J Cardiol 2003 ; 19 ( 7 ): 833 – 838 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 3 Jones M , Jolly K, Raftery J, Lip G Y, Greenfield S. ‘DNA’ may not mean ‘did not participate’: a qualitative study of reasons for non-adherence at home- and centre-based cardiac rehabilitation . Fam Pract 2007 ; 24 ( 4 ): 343 – 357 . Google Scholar Crossref Search ADS PubMed WorldCat 4 Ferrier S , Blanchard C, Vallis M, Giacomantonio N. 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Google Scholar Crossref Search ADS PubMed WorldCat © The European Society of Cardiology 2012 This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) © The European Society of Cardiology 2012
TI - Motivational counselling for physical activity in patients with coronary artery disease not participating in cardiac rehabilitation
JF - European Journal of Preventive Cardiology
DO - 10.1177/1741826711400519
DA - 2012-04-01
UR - https://www.deepdyve.com/lp/oxford-university-press/motivational-counselling-for-physical-activity-in-patients-with-Ru8YLojIAk
SP - 161
EP - 166
VL - 19
IS - 2
DP - DeepDyve
ER -