ReviewMeasuring Overall Physical Activity for Cardiac Rehabilitation Participants: A Review of the Literature
Introduction
Cardiovascular disease (CVD) is a major cause of death and disability [1]. However, both cardiac and total mortality may be reduced by cardiac rehabilitation (CR) [2] particularly when supervised, structured exercise is included. The benefits of exercise include stabilisation or reversal of the atherosclerotic process and psychological well-being [3], [4], particularly when exercise achieves recommended levels over the whole day, not only during supervised exercise training at CR but also at home [5]. However, non-adherence to PA recommendations remains a major concern in the CR population [6], and methods are needed to accurately quantify overall PA, not just in supervised CR sessions.
Accurate quantification of PA in CR is crucial [7]. Accuracy is important to monitor trajectories of PA, assess the effectiveness of interventions, examine dose-response relationships, and define which PA dimensions (i.e. frequency, duration and intensity) are important for specific health outcomes [7]. Nonetheless, measuring PA in the CR setting is challenging because there are substantial variations in the population including age, diagnoses, disease severity, and stage of recovery [7]. In general, self-reported and direct measures are proposed in the literature on measurement of PA and their strengths, weaknesses, reliability and validity are comprehensively discussed in a number of reviews [7], [8], [9]. Self-reported measures that assess overall PA are the most frequently used approaches in CR due to their practicality and cost-effectiveness [7]. However, most self-reported PA measures for cardiac patients have great variability, low validity and reliability, and are typically suitable for epidemiologic studies rather than CR settings [7].
Direct measures of PA are likely to be superior to indirect measures in minimising over- or under-reporting. Of direct measures, accelerometry technologies have distinct benefits in continuously measuring activities of daily living, metabolic expenditures (METs), and step counts [10], [11]. Use of such measures enables clinicians to monitor the progress of the patients’ activity levels remotely (i.e. outside of CR settings) and intervene in a timely way. For instance, step counts and active minutes tracked per day could be used to evaluate if the patient attains the CR daily PA recommendation (10,000 steps/day or 30 minutes or more of moderate to vigorous physical activity [MVPA]) [10].
To date, there is a substantial body of literature related to the validity and reliability of PA measures in healthy people [8], [9], [12]. There are, however, far fewer validation studies for people with existing CHD in CR settings [13], [14]. Hence, achieving a precise measurement of overall PA in cardiac patients during and following rehabilitation remains a significant clinical and public health issue [7]. The aim of this study is to establish a reliable and valid measure to assess overall PA in CR participants by performing a narrative literature review that compares two or more PA measures with at least one direct measure.
Section snippets
Search Strategy
A search strategy was developed in consultation with the health librarian. The following electronic databases were searched: Embase; CINAHL; MEDLINE; and PubMed. A search of Google Scholar and a hand search of the reference lists in the selected studies were also performed to identify further relevant studies. The key search terms included: (1) “physical activity”, or “exercise”; (2) “cardiac rehabilitation” or “secondary prevention”; (3) “survey”, “measure”, “instrument”, “questionnaire”,
Results
The main characteristics of the eight studies of PA measures in CR are summarised in Table 1, validity outcomes are synthesised in Table 2, and reliability outcomes in Table 3.
Discussion
Overall, direct measures were substantially better than self-reported PA measures in terms of validity and reliability. Physical activity diary and MobilePAL do better than other self-reported measures. Direct measures also had good agreement when the comparison was made with the criterion measures. Moreover, utilising a specific software version for CR enhanced the validity of the PA measure. Self-reported questionnaires had overall poor sensitivity, very poor agreement, and their validity
Conclusion
Overall, the reviewed studies show low validity of self-reported measures as the strength of correlations were only weak to moderate with a poor level of agreement, and were more likely to overestimate the measured PA parameters compared to direct measures. Direct measures are far more precise than self-reported measures in evaluating current and changing overall PA in and following CR. A review of the methodology of these studies reveals several factors that may explain the discrepant
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