Barriers to cardiac rehabilitation and patient perceptions on the usage of technologies in cardiac rehabilitation: A cross-sectional study.

AIMS AND OBJECTIVES: The study aimed to identify factors associated with participation in Phase II cardiac rehabilitation and to assess patient perceptions towards the usage of technologies in cardiac rehabilitation. BACKGROUND: Despite efforts to promote utilisation of cardiac rehabilitation (CR), participation among patients remains unsatisfactory. Little is known of patient decision to participate Phase II CR in a multi-ethnic country. DESIGN: A cross-sectional study design. METHODS: A consecutive sampling of 240 patients with coronary heart disease completed Coronary Artery Disease Education Questionnaire (CADE-Q) II, Hospital Anxiety and Depression Scale (HADS), Multidimensional Scale of Perceived Social Support (MSPSS) and Cardiac Rehabilitation Barriers Scale (CRBS). RESULTS: Seventy per cent of patients (mean age 60.5 [SD = 10.6] years, 80.8% male) participated in phase II cardiac rehabilitation. Self-driving to cardiac rehabilitation centres, higher barriers in perceived need/health care and logistical factors were significantly associated with decreased odds of participation. Patients with more barriers from comorbidities/functional status, higher perceived social support from friends, and anxiety were more likely to participate. Chinese and Indians were less likely to participate when compared with Malays. More than 80% of patients used both home and mobile broadband internet, and 72.9% of them would accept the usage of technologies, especially educational videos, instant messenger, and video calls to partially replace the face-to-face, centre-based cardiac rehabilitation approach. CONCLUSION: Several barriers were associated with non-participation in phase II cardiac rehabilitation. With the high perceived acceptance of technology usage in cardiac rehabilitation, home-based and hybrid cardiac rehabilitation may represent potential solutions to improve participation. RELEVANCE TO CLINICAL PRACTICE: By addressing the barriers to cardiac rehabilitation, patients are more likely to be ready to adopt health behaviour changes and adhere to the cardiac rehabilitation programme. The high perceived acceptance of using technologies in cardiac rehabilitation may provide insights into new delivery models that can improve and overcome barriers to participation.

Evaluation of an electronic clinical decision support system (DeSSBack) to improve low back pain management: a pilot cluster randomized controlled trial.

BACKGROUND: Low back pain (LBP) is a common reason for primary care consultation; yet doctors often find managing it challenging. An electronic decision support system for LBP (DeSSBack) was developed based on an evidence-based risk stratification tool to improve the management of patients with LBP in a Malaysian primary care setting. This pilot study aimed to assess the feasibility, acceptability, and preliminary effectiveness of DeSSBack for the conduct of a future definitive trial. METHODS: A pilot cluster randomized controlled trial (cRCT) with qualitative interviews was conducted. Each primary care doctor was considered a cluster and randomized to either the control (usual practice) or intervention (DeSSBack) group. Patient outcomes including Roland-Morris Disability Questionnaire (RMDQ), Hospital Anxiety and Depression Scale, and a 10-point pain rating scale were measured at baseline and 2-month postintervention. The doctors in the intervention group were interviewed to explore feasibility and acceptability of using DeSSBack. RESULTS: Thirty-six patients with nonspecific LBP participated in this study (intervention n = 23; control n = 13). Fidelity was poor among patients but good among doctors. The RMDQ and anxiety score had medium effect sizes of 0.718 and 0.480, respectively. The effect sizes for pain score (0.070) and depression score were small (0.087). There was appreciable acceptability and satisfaction with use of DeSSBack, as it was helpful in facilitating thorough and standardized management, providing appropriate treatment plans based on risk stratification, improving consultation time, empowering patient-centred care, and easy to use. CONCLUSIONS: A future cRCT to evaluate the effectiveness of DeSSBack is feasible to be conducted in a primary care setting with minor modifications. DeSSBack was found useful by doctors and can be improved to enhance efficiency. TRIAL REGISTRATION: The protocol of the cluster randomized controlled trial was registered at ClinicalTrials.gov (NCT04959669).

Evaluation of Wrist-Worn Photoplethysmography Trackers with an Electrocardiogram in Patients with Ischemic Heart Disease: A Validation Study.

PURPOSE: Photoplethysmography measurement of heart rate with wrist-worn trackers has been introduced in healthy individuals. However, additional consideration is necessary for patients with ischemic heart disease, and the available evidence is limited. The study aims to evaluate the validity and reliability of heart rate measures by a wrist-worn photoplethysmography (PPG) tracker compared to an electrocardiogram (ECG) during incremental treadmill exercise among patients with ischemic heart disease. METHODS: Fifty-one participants performed the standard incremental treadmill exercise in a controlled laboratory setting with 12-lead ECG attached to the patient's body and wearing wrist-worn PPG trackers. RESULTS: At each stage, the absolute percentage error of the PPG was within 10% of the standard acceptable range. Further analysis using a linear mixed model, which accounts for individual variations, revealed that PPG yielded the best performance at the baseline low-intensity exercise. As the stages progressed, heart rate validity decreased but was regained during recovery. The reliability was moderate to excellent. CONCLUSIONS: Low-cost trackers AMAZFIT Cor and Bip validity and reliability were within acceptable ranges, especially during low-intensity exercise among patients with ischemic heart disease recovering from cardiac procedures. Though using the tracker as part of the diagnosis tool still requires more supporting studies, it can potentially be used as a self-monitoring tool with precautions.

Predicting Return to Work after Cardiac Rehabilitation using Machine Learning Models.

OBJECTIVE: To explore machine learning models for predicting return to work after cardiac rehabilitation. SUBJECTS: Patients who were admitted to the University of Malaya Medical Centre due to cardiac events. METHODS: Eight different machine learning models were evaluated. The models included 3 different sets of features: full features; significant features from multiple logistic regression; and features selected from recursive feature extraction technique. The performance of the prediction models with each set of features was compared. RESULTS: The AdaBoost model with the top 20 features obtained the highest performance score of 92.4% (area under the curve; AUC) compared with other prediction models. CONCLUSION: The findings showed the potential of using machine learning models to predict return to work after cardiac rehabilitation.

A Theory-Based, Technology-Assisted Intervention in a Hybrid Cardiac Rehabilitation Program for Patients with Coronary Heart Disease: A Feasibility Study.

PURPOSE: To assess the feasibility of a technology-assisted intervention in a hybrid cardiac rehabilitation program among patients with coronary heart disease. METHODS: This study was a two-arm parallel randomized controlled trial. Twenty-eight patients with coronary heart disease were randomly assigned to either the intervention group, receiving a 12-week technology-assisted intervention (n = 14), or the control group (n = 14), receiving usual care. Guided by the Health Belief Model, the intervention group received three center-based, supervised exercise training sessions, a fitness watch that served as a cue to action, six educational videos, and a weekly video call. The Self-efficacy for Exercise, exercise capacity, and Health Promoting Lifestyle Profile II were assessed at baseline and immediately post-intervention (12-weeks). RESULTS: Among the 28 patients who participated in this study, 85.7% completed the program, with a relatively low attrition rate (14.3%). The number of exercise training sessions accomplished by the participants in the intervention group was 51.27 ± 19.41 out of 60 sessions (85.5%) compared to 36.46 ± 23.05 (60.8%) in the control group. No cardiac adverse events or hospitalizations were reported throughout the study. Participants in the intervention group showed greater improvement in health-promoting behaviors when compared with the control group at 12 weeks. Within-group effects demonstrated improvement in exercise self-efficacy and exercise capacity among participants in the intervention group. A participant satisfaction survey conducted immediately post-intervention revealed that participants were "very satisfied" (23.1%) and "satisfied" (76.9%) with the technology-assisted intervention. CONCLUSIONS: The findings demonstrated that technology-assisted intervention in a hybrid cardiac rehabilitation program was feasible and suggested to be beneficial in improving exercise self-efficacy, exercise capacity, and health promoting behavior among patients with coronary heart disease. A full-scale study is needed to determine its effectiveness in the long term. TRIAL AND PROTOCOL REGISTRATION: ClinicalTrials.gov NCT04862351. https://clinicaltrials.gov/ct2/show/NCT04862351.

Changes in Perception of Illness during Cardiac Rehabilitation Programme among Patients with Acute Coronary Syndrome: A Longitudinal Study.

Little is known about the changes in perception of illness among patients with the acute coronary syndrome (ACS) during cardiac rehabilitation programme (CRP). The purpose of this study is to determine changes in perception of illness with ACS patients during CRP to evaluate the association of patients' characteristics with the perception of illness at the end of Phase II of CRP. A descriptive longitudinal study was conducted among 450 patients who attended 8-weeks of Phase II CRP at 2 public hospitals in Malaysia and perception of illness was assessed using Brief Illness Perception Questionnaire (BIPQ). The assessment was conducted before Phase II (T0), during the 4th session (T1), and at the end of right after the 8th session (T2). One-way repeated measures of ANOVA analysed the changes of perception at T1 and T2 while logistic regression analysis evaluated the association of patients' characteristics with the perception of illness at T2. Perception of illness changed during and after CRP from T0 to T1, and T1 to T2 (p < 0.001). The patient viewed ACS as an illness that changed from being more acute to a chronic condition as the sessions progressed. Previous history of acute myocardial infarction (OR = 2.380, 95% CI 1.46, 5.49) and angioplasty intervention were both found to be associated with the perception of illness (OR = 3.857, 95% CI 1.55, 9.61). Perception of illness changed during CRP and these changes are associated with patients' previous history of cardiac events. Phase II can be viewed as the second window of opportunity for healthcare professionals to intervene early in modifying the perception of illness.

Developing a home-based pulmonary rehabilitation programme for patients with chronic respiratory diseases in Malaysia: A mixed-method feasibility study.

Background: The COVID-19 pandemic has underscored the importance of remote healthcare and home-based interventions, including pulmonary rehabilitation, for patients with chronic respiratory diseases (CRDs). It has also heightened the vulnerability of individuals with underlying respiratory conditions to severe illness from COVID-19, necessitating exploration and assessment of the feasibility of delivering home - pulmonary rehabilitation (home-PR) programmes for CRD management in Malaysia and other countries. Home-based programmes offer a safer alternative to in-person rehabilitation during outbreaks like COVID-19 and can serve as a valuable resource for patients who may be hesitant to visit healthcare facilities during such times. We aimed to assess the feasibility of delivering a home-PR programme for patients with CRDs in Malaysia. Methods: We recruited patients with CRDs from two hospitals in Klang Valley, Malaysia to a home-PR programme. Following centre-based assessment, patients performed the exercises at home (five sessions/week for eight weeks (total 40 sessions)). We monitored the patients via weekly telephone calls and asked about adherence to the programme. We measured functional exercise capacity (6-Minutes Walking Test (6MWT) and Health-Related Quality-of-Life (HRQoL) (COPD Assessment Test (CAT)) at baseline and post-PR at nine weeks. We conducted semi-structured interviews with 12 purposively sampled participants to explore views and feedback on the home-PR programme. The interviews were audio recorded, transcribed verbatim, and analysed thematically. Results: We included 30 participants; two withdrew due to hospitalisation. Although 28 (93%) adhered to the full programme, only 11 (37%) attended the post-PR assessment because COVID-19 movement restrictions in Malaysia at that time prevented attendance at the centre. Four themes emerged from the qualitative analysis: involvement of family and caregivers, barriers to home-PR programme, interactions with peers and health care professionals, and programme enhancement. Conclusion: Despite the COVID-19 pandemic, the home-PR programme proved feasible for remote delivery, although centre-based post-PR assessments were not possible. Family involvement played an important role in the home-PR programme. The delivery of this programme can be further improved to maximise the benefit for patients.

Gelam honey scavenges peroxynitrite during the immune response.

Monocytes and macrophages are part of the first-line defense against bacterial, fungal, and viral infections during host immune responses; they express high levels of proinflammatory cytokines and cytotoxic molecules, including nitric oxide, reactive oxygen species, and their reaction product peroxynitrite. Peroxynitrite is a short-lived oxidant and a potent inducer of cell death. Honey, in addition to its well-known sweetening properties, is a natural antioxidant that has been used since ancient times in traditional medicine. We examined the ability of Gelam honey, derived from the Gelam tree (Melaleuca spp.), to scavenge peroxynitrite during immune responses mounted in the murine macrophage cell line RAW 264.7 when stimulated with lipopolysaccharide/interferon-γ (LPS/IFN-γ) and in LPS-treated rats. Gelam honey significantly improved the viability of LPS/IFN-γ-treated RAW 264.7 cells and inhibited nitric oxide production-similar to the effects observed with an inhibitor of inducible nitric oxide synthase (1400W). Furthermore, honey, but not 1400W, inhibited peroxynitrite production from the synthetic substrate 3-morpholinosydnonimine (SIN-1) and prevented the peroxynitrite-mediated conversion of dihydrorhodamine 123 to its fluorescent oxidation product rhodamine 123. Honey inhibited peroxynitrite synthesis in LPS-treated rats. Thus, honey may attenuate inflammatory responses that lead to cell damage and death, suggesting its therapeutic uses for several inflammatory disorders.

A randomized control trial on retro-walking improves symptoms, pain, and function in primary knee osteoarthritis.

BACKGROUND: Primary knee osteoarthritis is the leading cause of chronic disability and pain among adults worldwide. Retro-walking has been shown to reduce patellofemoral pain, increases functional capability while strengthening the lower limbs and improving proprioception and balance. We aim to examine the effects of retro-walking on symptoms, pain, and perceived ability to perform daily activities in comparison to forward-walking in subjects with primary knee osteoarthritis. METHODS: This was a single-blinded, randomized control trial involving 34 subjects between the age of 45-70 years (58.41±5.93) comparing retro-walking (RW) to forward-walking (FW). Subjects were randomly allocated to receive either RW with structured resistance training (SRT) or FW with SRT; 3 times a week for 12 weeks. The symptoms, pain, and function of daily living sub scores of the Knee Injury and Osteoarthritis Outcome Score (KOOS) along with Timed up and go (TUG) and Chair stand test (CST) were assessed at baseline and after 12 weeks. The outcomes were analyzed with two-way repeated measure analysis of variance. RESULTS: Significant improvements for all outcomes were observed intra-group (P value <0.05) after 12 weeks. The KOOS sub scores, TUG and CST times was not statistically significant between study groups (P value >0.05). However, the partial eta squared scores for all outcomes were better in the RW group compared to FW except for CST. CONCLUSIONS: It can be concluded that RW is a feasible and non-inferior option to FW in the rehabilitation of subjects with bilateral knee OA.

Adductor canal block versus intra-articular steroid and lidocaine injection for knee osteoarthritis: a randomized controlled study.

Background: This study aimed to assess the efficacy of the adductor canal block (ACB) in comparison to intra-articular steroid-lidocaine injection (IASLI) to control chronic knee osteoarthritis (KOA) pain. Methods: A randomized, single-blinded trial in an outpatient rehabilitation clinic recruiting chronic KOA with pain ≥ 6 months over one year. Following randomization, subjects received either a single ACB or IASLI under ultrasound guidance. Numerical rating scale (NRS) scores for pain, and Knee Injury and Osteoarthritis Outcome Scores (KOOS) were recorded at baseline, 1 hour, 1 month, and 3 months postinjection. Results: Sixty-six knees were recruited; 2 were lost to follow-up. Age was normally distributed (P = 0.463), with more female subjects in both arms (P = 0.564). NRS scores improved significantly for both arms at 1 hour, with better pain scores for the IASLI arm (P = 0.416) at 1st month and ACB arm at 3rd month (P = 0.077) with larger effect size (Cohen's d = 1.085). Lower limb function improved significantly in the IASLI arm at 1 month; the ACB subjects showed greater functional improvement at 3 months (Cohen's d = 0.3, P = 0.346). Quality of life (QoL) improvement mirrored the functional scores whereby the IASLI group fared better at the 1st month (P = 0.071) but at the 3rd month the ACB group scored better (Cohen's d = 0.08, P = 0.710). Conclusions: ACB provides longer lasting analgesia which improves function and QoL in chronic KOA patients up to 3 months without any significant side effects.

Exploring Social Support for Women Coping with a Cardiac Rehabilitation Programme after Acute Coronary Syndrome: A Systematic Review of Qualitative Studies.

OBJECTIVE: Female sex is a major barrier to completing a programme of cardiac rehabilitation (CR) after acute coronary syndrome (ACS). Women require significant social support to promote compliance and the ability to cope with CR programme attendance. The aim of this systematic review of qualitative studies was to explore social support among women coping with CR programme attendance at phase II CRP is 3 months after their cardiac event. METHODS: Articles were searched through CINAHL (Cumulative Index and Allied Health Literature), Science Direct and PubMed databases using the following terms: "women", "acute coronary syndrome", "coping", "social support" and "cardiac rehabilitation". RESULTS: A total of 6 articles were selected based on eligibility criteria. Thematic analysis was used to analyse the data using line to line coding into descriptive themes, interpreting further to generate new insights. The 3 most common themes regarding social support for women attending the CR programme were: family support, female as the primary caregiver in the family, and peer support. For most women who perceived themselves as the primary caregiver in the family there was a negative impact on their ability to cope fully with CR programme attendance. On the other hand, encouraging support from family and peers positively improved their coping mechanism for attending the CR programme, leading to improved compliance. CONCLUSION: Women with ACS consider that support from their family plays a vital role as a coping mechanism in their attendance at a CR programme. Healthcare providers should teach the importance of social support among women after discharge to help them cope with CR programme attendance.

Systematic Review on COVID-19 Readmission and Risk Factors: Future of Machine Learning in COVID-19 Readmission Studies.

In this review, current studies on hospital readmission due to infection of COVID-19 were discussed, compared, and further evaluated in order to understand the current trends and progress in mitigation of hospital readmissions due to COVID-19. Boolean expression of ("COVID-19" OR "covid19" OR "covid" OR "coronavirus" OR "Sars-CoV-2") AND ("readmission" OR "re-admission" OR "rehospitalization" OR "rehospitalization") were used in five databases, namely Web of Science, Medline, Science Direct, Google Scholar and Scopus. From the search, a total of 253 articles were screened down to 26 articles. In overall, most of the research focus on readmission rates than mortality rate. On the readmission rate, the lowest is 4.2% by Ramos-Martínez et al. from Spain, and the highest is 19.9% by Donnelly et al. from the United States. Most of the research (n = 13) uses an inferential statistical approach in their studies, while only one uses a machine learning approach. The data size ranges from 79 to 126,137. However, there is no specific guide to set the most suitable data size for one research, and all results cannot be compared in terms of accuracy, as all research is regional studies and do not involve data from the multi region. The logistic regression is prevalent in the research on risk factors of readmission post-COVID-19 admission, despite each of the research coming out with different outcomes. From the word cloud, age is the most dominant risk factor of readmission, followed by diabetes, high length of stay, COPD, CKD, liver disease, metastatic disease, and CAD. A few future research directions has been proposed, including the utilization of machine learning in statistical analysis, investigation on dominant risk factors, experimental design on interventions to curb dominant risk factors and increase the scale of data collection from single centered to multi centered.

Unilateral neglect or alien hand syndrome? A diagnostic challenge.

Alien hand syndrome (AHS) is a rare post-stroke complication. Although the occurrence of AHS after stroke is rare, it can have a disabling impact on the lifestyle and career of the patients post stroke. It is difficult to distinguish AHS from the non-dominant hemispheric infarction with symptoms of hemianopia and left hemineglect, as patients with AHS can also have neglect as well as behaviour symptoms if the frontal lobe is involved. We report the case of a 62-year-old gentleman who was admitted to the rehabilitation ward and was treated for neglect and apraxia following right middle cerebral artery stroke. After further re-evaluation, the patient was diagnosed with AHS. Functionally, he improved and the symptoms disappeared four months after the stroke. In this case report, we highlight the features of AHS and provide a unique management approach.

Charcot osteoarthropathy of the foot.

BACKGROUND: One of the most devastating complications of diabetes is Charcot osteoarthropathy. It can lead to gross structural deformities of the foot and ankle, and subsequent skin ulceration and lower limb amputation from soft tissue or bony infection. However, it is often unrecognised, with deleterious consequences. OBJECTIVE: This article describes the case of a man with type 1 diabetes who presented with Charcot osteoarthropathy of both feet, with a 3 month delay in diagnosis between the two presentations. DISCUSSION: Treatment, patient comorbidities and risk management were similar for both feet, with a marked difference in outcome, demonstrating the importance of the timely diagnosis of Charcot osteoarthropathy.

The validity and reliability of the Turkish version of the Seattle Angina Questionnaire.

OBJECTIVE: The purpose of this study was to assess the validity and reliability of a Turkish version of the Seattle Angina Questionnaire (SAQ) in patients with coronary heart disease (CHD) and angina. METHODS: The SAQ was translated from English to Turkish using the back-translation method. It contains 19 questions scored from 1 to either 5 or 6 in 5 domains (physical limitation, angina stability, angina frequency, disease perception, and treatment satisfaction). Cronbach's alpha coefficient was used to evaluate internal consistency. Spearman's rank correlation coefficient was calculated to assess the construct validity. Convergent validity was examined using correlations between the SAQ and the MacNew Heart Disease Health-related Quality of Life Questionnaire (MacNew) and the Nottingham Health Profile. Divergent validity was evaluated using correlations between the SAQ and age, body mass index (BMI), gender, and the marital status of patients. A value of p<0.05 was considered statistically significant. RESULTS: Sixty-seven patients were enrolled in the study. The mean age of the study patients was 58.7 years (SD: 10.2). Cronbach's alpha scores of the SAQ, ranging in value from 0.715 to 0.910, demonstrated that this scale is reliable. All of the SAQ scales had a significant correlation with all of the MacNew scales, which indicated that the scale has convergent validity. Insignificant correlations with age, BMI, gender, and marital status illustrated the good divergent validity of the scale. CONCLUSION: The Turkish version of the SAQ is a valid and reliable instrument. It is a useful and practical tool to evaluate patients with angina and CHD.

Treatment of chronic back pain using indirect vibroacoustic therapy: A pilot study.

BACKGROUND: Low frequency sound wave stimulation therapy has become increasingly popular in the rehabilitation fields, due to its ease, less fatiguing and time efficient application. OBJECTIVE: This 12-week pilot study examines the efficacy of applying low frequency sound wave stimulation (between 16-160 Hz) through both hands and feet on relieving pain and improving functional ability in patients with chronic back pain. METHODS: Twenty-three participants with chronic shoulder (eleven participants) or low back pain (twelve participants) underwent a 12-week vibration therapy program of three sessions per week. A low frequency sound wave device comprising four piezoelectric vibration-type tactile tranducers enclosed in separate 5-cm diameter circular plates, which generate sinusoidal vibratory stimuli at a frequency of 16-160 Hz, was used in this study. Primary outcome measure was pain sensation measured using the Visual Analogue Scale (P-VAS). The secondary outcome measures were pain-related disability measured using the pain disability index (PDI) and quality of life measured using the SF-12. RESULTS: At week 12, significant reductions in pain sensation and pain-related disability were observed, with mean reductions of 3.5 points in P-VAS and 13.5 points in the PDI scores. Sixty-five percent of the participants had a reduction of at least 3 points on the P-VAS score, while 52% participants showed a decrease of at least 10 points in the PDI score. Significant improvement was observed in the SF-12 physical composite score but not the mental composite score. CONCLUSIONS: The preliminary findings showed that passive application of low frequency sound wave stimulation therapy through both hands and feet was effective in alleviating pain and improving functional ability in patients with chronic back pain.

Optimising the Bariatric Patients' Outcome through Cardiac Rehabilitation Approach.

Bariatric surgery offers a therapeutic alternative with favourable weight management, cardiovascular, metabolic and functional outcomes. Bariatric individuals often have functional impairments pre-operatively that can be addressed to improve post-operative results and eventual functional independence. Multidisciplinary team offers the best approach to address peri-operative needs and sustainable weight loss thereafter. We exemplified the application of cardiac rehabilitation therapeutic model in managing two bariatric clients with specific bariatric-related challenges. Our approach focuses on adaptive physical activity, sustainable lifestyle changes to promote post-operative weight loss through education and problem solving as well as secondary prevention of cardiovascular disease. Putting emphasis on addressing physical and psychosocial barriers towards physical activity alongside nutritional aspects potentially confers sustained if not better outcomes on weight reduction and functional improvement.