Archives of Physical Medicine and Rehabilitation

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Archives of Physical Medicine and Rehabilitation 2020;101:1835-8

SPECIAL COMMUNICATION

Cardiac Rehabilitation During Quarantine in COVID-19

Pandemic: Challenges for Center-Based Programs
Florent Besnier, PhD,a,b Mathieu Gayda, PhD,a,b Anil Nigam, MD,a,b Martin Juneau, MD,a,b
Louis Bherer, PhDa,b,c
From the aPreventive Medicine and Physical Activity Centre and Research Center, Montreal Heart Institute, Université de Montréal, Montreal,
QC; bDepartment of Medicine, Université de Montréal, Montreal, QC; and cResearch Centre, Institut Universitaire de Gériatrie de Montréal,
Montreal, QC, Canada.

Abstract
Because of the coronavirus disease 2019 (COVID-19) epidemic, many cardiac rehabilitation (CR) services and programs are stopped. Because CR
is a class I level A recommendation with clinical benefits that are now well documented, the cessation of CR programs can lead to dramatic
consequences in terms of public health. We propose here a viewpoint of significant interest about the sudden need to develop remote home-based
CR programs both in clinical research and in clinical care routine. This last decade, the literature on remote home-based CR programs has been
increasing, but to date only clinical research experiences have been implemented. Benefits are numerous and the relevance of this approach has
obviously increased with the actual health emergency. The COVID-19 crisis, the important prevalence of smartphones, and high-speed Internet
during confinement should be viewed as an opportunity to promote a major shift in CR programs with the use of telemedicine to advance the
health of a larger number of individuals with cardiac disease.
Archives of Physical Medicine and Rehabilitation 2020;101:1835-8
ª 2020 by the American Congress of Rehabilitation Medicine

Coronavirus disease 2019 (COVID-19) is a highly contagious To date, there is no treatment and to slow the rapid spread of the
respiratory disease caused by a new respiratory virus, the severe virus, most epidemiologist experts and public health authorities
acute respiratory syndrome coronavirus 2. In mid-June 2020, the recommend quarantine and frequent handwashing. Most govern-
World Health Organization reported that more than 7.4 million ments have therefore imposed exceptionally drastic measures, such
cases of COVID-19 were confirmed worldwide with more than as social distancing, quarantine, and restricting movement for basic
418,000 deaths. Among infected patients, 15% develop a much necessities, such as going to the grocery store and/or pharmacy. All
more severe form of the disease,1 including acute respiratory hospitals and clinics have to reorganize to receive patients with
distress syndrome. COVID-19 while limiting contact between people. Ambulatory
Elderly individuals and patients with cardiovascular diseases visits and nonessential services are closed. The closure of cardio-
are particularly at risk of developing severe complications. The vascular rehabilitation (CR) programs were among the first clinical
mortality rate increases sharply with age and reaches 3.6% in services closed and would be the last to open.4
people aged 60 years, 8% in people aged 70 years, and 14.8% in
people older than 80 years1,2; these data depend on the country
and are constantly changing. High blood pressure, type 2 diabetes, Center-based CR
or cardiovascular diseases are the most common comorbidities in
people affected by COVID-19,3 with mortality rates particularly Cardiovascular rehabilitation is a class I level A recommendation,5,6
high from 5.6%-10.5%.1 and it is generally provided in specialized centers. Programs involve
multidomain therapeutic education (nutrition, lifestyle, stress
management), individualized exercise training, cardiovascular risk
factors management, pharmacologic treatment optimization, and
Funding: Mirella and Lino Saputo Research Chair in Cardiovascular Diseases and the Pre-
vention of Cognitive Decline from Université de Montréal at the Montreal Heart Institute.
return to home management.5 More recently, cognitive training
Disclosures: none. programs have also been proposed.7 Individualized exercise

0003-9993/20/$36 - see front matter ª 2020 by the American Congress of Rehabilitation Medicine
https://doi.org/10.1016/j.apmr.2020.06.004
1836 F. Besnier et al

training is the cornerstone of these programs prescribed by a technological tools to personalize prevention care, help patients in
physician after a cardiopulmonary exercise test or a field test, such their recovery, and prevent recurrent events.15 The optimal pro-
as 6-minute walk test. In general, CR services offer a length of stay gram would include several modules dedicated to online coaching
ranging from 3 weeks to 3 months (depending on the country) with and learning, social interaction, and bilateral communication with
exercise training sessions that are done in groups or individually, the health care team. To date only clinical research experiences
3-5 times per week under the supervision of a health professional have been implemented, and no long-term follow-up is available.
(physiotherapist, exercise specialist, nurse). Virtual home-based CR could be an alternative to rehabilitation
Although the proportion of eligible cardiac patients partici- carried out in a specialized center, especially for low-risk pa-
pating in CR programs is generally low (range, 14%-55% in North tients.15-17 These innovative virtual home-based CR programs are
America8,9), its effects on individual health outcomes and the multiplying with remote monitoring trackers that can help cardiac
benefits for the health care system are paramount. In fact, clinical patients to manage their heart disease and medication (therapeutic
benefits of CR programs are now well documented: CR reduces education) and promote healthy diet and increased physical ac-
total and cardiovascular mortality (by 25%-30%) and the risk of tivity. The use of trackers to quantify physical activity may lead
rehospitalization in the 12 months following rehabilitation by 30% patients to adopt an active lifestyle while ensuring safety. More-
compared with the usual care treatment without CR.10 These over, patients should be able to contact the health care team at any
programs also have a beneficial effect on depressive symptoms, time. The interface should be able to record and send variables
stress, and cognitive functions in cardiac patients.11 The cessation (energy expenditure, body mass, glycemia, blood pressure, heart
of cardiovascular rehabilitation programs is therefore dramatic in rate, electrocardiogram [ECG], etc) measured via sensors to a web
terms of public health. platform accessible to the physician, cardiologist, exercise spe-
cialists, and nurses. Virtual home-based CR trials have been done
in a number of countries. Some experiences described below
Need to maintain physical activity during (nonexhaustive) have shown convincing data both in terms of
feasibility, safety, and improvement of cardiovascular risk factors.
confinement However, some challenges remain, such as the issues of privacy
Because of the COVID-19 epidemic, many CR services and data and the ability to engage older patients. Real-time moni-
programs have closed (eg, gyms for the general public) to limit toring, such as ECG and blood pressure measurement during ex-
contact between people, especially those most at risk (elderly ercise, is also an issue. It may add some safety but is challenging
persons with cardiovascular disease), and the issue of aerosolizing in terms of technology resources as bandwidth.
of secretions with exercise training. Isolation and quarantine are In a randomized controlled trial (RCT), Frederix et al have
certainly the best solution to stem the pandemic. However, these evaluated the effects of telerehabilitation (after a period of con-
exceptional measures also might have negative effects and create ventional CR) compared with center-based CR.18 The program
collateral damage to health, especially in frail people.12 First, the involved semiautomatic e-mails or text messages, encouraging
psychological effects of quarantine have been discussed subjects to achieve their predefined physical activity goals. Results
recently.13 It seems that most of the negative effects (stress, of the cost-effectiveness analysis and the readmission rate show a
confusion, anxiety) come from the imposition of a restriction of positive effect in favor of telerehabilitation.19 In another RCT Reid
liberty, while voluntary confinement is associated with less et al have demonstrated the effectiveness of a strategy including an
distress and fewer long-term complications.13 Confinement im- individual interview and 8 telephone contacts to increase the vol-
plies a radical change in our lifestyle, and in cardiac patients who ume of physical activity over a period of 52 weeks in patients
already have a sedentary and/or inactive profile, these measures recovering from an acute coronary syndrome who did not plan to
excessively increase the level of physical inactivity and sedentary undergo standard CR.20 Moreover, the European Study on Effec-
lifestyle, which can increase the risk of acute events, depressive tiveness and Sustainability of Current Cardiac Rehabilitation Pro-
syndromes, and anxiety. Maintaining a minimum of physical grammes in the Elderly21 is designed to evaluate the effectiveness
activity during the COVID-19 crisis is essential14 for cardiac of telerehabilitation via a mobile application in elderly cardiac
patients with the advice of the medical team who can offer remote patients who have refused to participate in a center-based CR. This
home-based supervised exercise training. study combines 2 clinical studies: the first is observational
(nZ1760 patients) and plans to assess the cardiorespiratory fitness,
measured as peak oxygen consumption (V_O2peak), at the beginning
and the end of the center-based CR program and at 12 months of
Remote home-based CR program follow-up. The second study is prospective and plans to include 248
Recent developments in telemedicine with telecommunications patients who refused to participate in a conventional CR program.
(eg, virtual consultations, remote patient monitoring) and the They will be offered to participate in a telerehabilitation program
multiple smartphone applications have led to the emergence of (or in a control group without specific advice). The duration of
new strategies supplementing the conventional services offered in follow-up (12mo) and the variables of interest are the same as the
rehabilitation centers. There is an urgent need to validate these observational study (VO _ 2peak, adhesion, cost, barriers, cardiovas-
cular risk factors, acute events, rehospitalizations).
Home-based programs have also been used in patients with
List of abbreviations: chronic heart failure. For instance, Piotrowicz et al22 evaluated the
COVID-19 coronavirus disease 2019 effect of an 8-week Nordic walking program at home (5 sessions/wk
CR cardiovascular rehabilitation at 40%-70% of maximum heart rate) in 78 patients (New York Heart
ECG electrocardiogram
Association II-III, left ventricular ejection fraction<40%); another
RCT randomized controlled trial
_ 2peak 34 patients were part of a sedentary control group. Patients in the
VO peak oxygen consumption
training group received a monitoring kit connected to a smartphone

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Cardiac rehabilitation during COVID-19 1837

for remote data transmission (measuring heart rate, ECG, and blood strict confinement. However, a precise individualized prescription
pressure). Daily telephone coaching was set up by a nurse and an (movement description, contraindications, duration of the exercises,
exercise specialist to ensure that the sessions were carried out number of repetitions, series, and recovery) for each patient is
correctly. Symptoms and adherence to treatments were also evalu- necessary to ensure safety aspects. Moreover, telephone coaching is
ated. At the end of the training period, the authors report an seen as a good strategy to increase adherence and reduce isolation,
improvement in VO _ 2peak and depression scores measured by Beck’s which is known for having detrimental effects on psychological and
questionnaire. The usual care group only reported an improvement in physical health, even more so in the elderly population.36
depression scores. Nevertheless, in a large RCT of 850 patients with
chronic heart failure, the clinical benefits of a 9-week tele-
rehabilitation program did not confirm the superiority of usual care vs eHealth, confinement, and perspective
telerehabilitation on mortality and rehospitalization rate over a
follow-up period of 14-26 months without ongoing exercise.23 This The debate on connected health is taking an increasingly impor-
study showed that without encouragement, patients fail to continue tant place in our society. More than 3.4 billion people are currently
exercise, and strategies are needed to maintain exercise adherence. confined to different degrees in an attempt to temper the
pandemic. Social networks, online eHealth platforms, exercise
training mobile applications, and home gym workouts videos have
Exergames in CR never been so popular.37 The actual health emergency and the
massive use of smartphones and internet during confinement could
In patients with chronic heart failure, video games such as the become an important tool of prevention methods in CR programs.
Nintendo Wii Fit have also been proposed in CR.24 These tools Digital teleworking, trackers, and connected tools allow regular
combining physical exercises and video games called exergames and individualized remote monitoring by exercise specialists,
are promising, but more studies are needed. The HF-Wii study25 nurses, and cardiologists to promote healthy behavior. Within the
evaluated the effectiveness of this new type of CR in a multi- framework of COVID-19, some countries use smartphones on a
center and international RCT of 605 patients with chronic heart large scale to compel individuals to communicate their tempera-
failure (6712y). At 1 year of follow-up the Wii intervention group ture, identify the movements of infected patients, identify their
reported mitigated results on the 6-minute walk test compared with contacts, etc. The modernization of CR services with digital tools
the control group without intervention. However, the authors would allow better promotion of telerehabilitation programs. One
underlined that this type of program is feasible and safe.25 In challenge of these coming years will be to legislate and propose
addition, because 36% of the patients report being inactive at remote home-based CR for cardiac patients at low risk and clin-
baseline and this proportion did not change after the follow-up, the ically stable.6,31,38 Older and disabled patients have less access
authors emphasize the importance of remote coaching and the ne- and comfort with eHealth, devices, applications, and data collec-
cessity to study specifically remote motivational strategies.25 tion devices, and these challenge need to be address.
To summarize, compared with conventional center-based CR, In sum, evidence supports the use of home-based CR. Benefits
recent studies and meta-analyses suggest that telerehabilitation are numerous and relevance is obviously suddenly increased with
could be (1) as effective on improving the VO _ 2peak, (2) less the COVID-19 crisis. This should be viewed as an opportunity to
costly, (3) safe, and (4) more effective in terms of maintenance of promote a major shift in CR programs for good and for the health
an active lifestyle in the medium-term.19,26-31 Regarding mortality, of a larger number of individuals. Furthermore, the severe acute
cardiovascular risk factors, and physical activity volume, Dalal respiratory syndrome coronavirus 2 can lead to cardiac compli-
et al demonstrated in 1938 cardiac patients that there was no cations that could be addressed by CR. Nevertheless, while the
difference between home-based and center-based CR programs.32 Centers for Medicare and Medicaid Services recently agreed to
Studies with longer follow-up are still needed in the subpopulation cover additional types of telehealth services during the COVID-19
of cardiac patients with heart failure.23 pandemic, home-based CR services were not among them.

Physical activity at home during Keywords

confinement Cardiac rehabilitation; Coronavirus; Exercise; Rehabilitation

Currently, the US Department of Health and Human Services and

the American College of Sports Medicine have published new
recommendations of physical activity during the COVID-19
Corresponding author
period.33,34 In CR, teams can propose workouts at home without Florent Besnier, PhD, Montreal Heart Institute, 5055 Rue St
equipment material, such as gymnastic movements of muscular Zotique Est, Montréal, QC, H1T 1N6, Canada. E-mail address:
strengthening (squat, sit-to-stand, push-ups against a wall, 1-L florent.besnier@umontreal.ca.
water bottles for weights to exercise the upper body, etc), balance
or stretching exercises, and online relaxation sessions. These ex-
ercises do not require any equipment and can be described and References
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