Cardiac Rehabilitation
Tailored Cardiac Rehabilitation for Older Patients With Heart Failure ― Will Cybernics Be a New Treatment Option for Cardiac Rehabilitation? ―
2022 Volume 86 Issue 1 Pages 68-69
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2022 Volume 86 Issue 1 Pages 68-69
A rise in the number of patients with heart failure (HF), and its increasing burden on nursing care, is inevitable in the aging society and presents a major social problem. Thus, it is important to improve the functional ability of these patients to promote independent activities of daily living. Exercise-based cardiac rehabilitation (CR) improves exercise tolerance and the quality of life, and reduces readmissions in patients with HF.1,2 Although CR for HF is strongly recommended in guidelines,3,4 the utilization rates of CR, especially for outpatients, are low.5 The presence of comorbidities, such as cognitive impairment, anxiety, depression, and frailty, makes it difficult to participate in hospital-based and outpatient CR.6 To facilitate the use of CR in older patients with HF, well-designed programs are urgently needed.
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Kato et al7 investigated the effect of sit-to-stand exercise with lumbar-type Hybrid Assistive Limb (HAL) in in-patients with chronic HF who have difficulty walking at the usual walking speed of healthy subjects. Patients in the intervention group used lumbar-type HAL to support the sit-to-stand exercises, and patients in the control group performed sit-to-stand exercises without using HAL. Patients in the intervention group had improved knee extensor muscle strength compared to the control group (0.29±0.11 to 0.35±0.11 kgf/kg, P<0.01; 0.35±0.11 to 0.35±0.13 kgf/kg, P=0.40, respectively), with significant differences between the 2 groups (P=0.045). The authors of this study explained this improvement on the basis of the hybrid system, which allows both voluntary and autonomous modes of action to facilitate the sit-to-stand exercise.7,8 HAL-assisted exercises are performed using ‘interactive biofeedback’, which is a fusion of human and HAL through the mutual exchange of neural information, such as motor unit potentials, proprioception, and dynamic mechanical information, such as coordination, velocity, and angular velocity in limb segments between the wearer’s nervous system and HAL.8,9 Therefore, physical training can easily be repeated without excessive load to the neuromuscular system, leading to rapid recovery. Several reports demonstrated the efficacy of cybernic treatment for patients with slowly progressive rare neuromuscular diseases,9 spinal cord injury,10,11 and stroke.12,13 Although a lumbar-type HAL assisted the HF patients in sit-to-stand exercise to improve knee extension muscle strength in the present study,7 further studies are required to assess the recovery of other functions by the interactive biofeedback-based cybernic treatment.
The access to hospital-based CR may be limited due to geographical or psychological barriers, which may reduce the rate of CR participation. Advances in information and communication technology have enabled the use of telecare, telerehabilitation, and remote monitoring of cardiovascular implantable electronic devices. Hybrid comprehensive CR, which use these technologies to administer comprehensive CR, may solve this problem. The hybrid comprehensive Telerehabilitation in Heart Failure Patients (TELEREH-HF) trial was designed to assess whether potential improvements in functional and quality-of-life outcomes after a 9-week training period translate into improvements in clinical outcomes during the extended follow up of 12–24 months compared to usual care.14 Hybrid comprehensive telerehabilitation in patients with HF was effective in improving the functional capacity and quality of life of patients compared to usual care. However, the rates of hospitalization and cardiovascular death were not reduced.
Recently, the Rehabilitation Therapy in Older Acute Heart Failure Patients (REHAB-HF) trial, a multicenter, randomized, single-blind, controlled trial, showed that a tailored CR program resulted in a greater improvement in physical function than usual care in a diverse population of older patients hospitalized with acute HF.15 During or early after hospitalization, patients in the intervention group underwent CR, consisting of 4 exercise domains (strength, balance, mobility, and endurance), tailored to the physical performance of each patient. CR was continued after discharge for 36 sessions. REHAB-HF highlighted the importance of addressing the physical dysfunction from the time of hospitalization or early after discharge using a tailored CR program that includes multiple physical function domains to promote functional recovery.
The development of new technologies and strategies could contribute to greater functional recovery during hospitalization and maintenance of this improvement in older patients with HF after discharge. Further studies are needed to design a tailored CR program that can be administered from hospitalization to late after discharge, using cybernic treatment, hybrid comprehensive telerehabilitation, and other new treatment options (Figure).
Tailored cardiac rehabilitation program with multidisciplinary assessment is needed for a diverse population of older patients with heart failure.
The current evidence has provided a basis for designing a tailored CR model for a diverse population of older patients with HF.
The authors declare no conflicts of interest.
