Reading this research project from Europe, I want to focus on 3 important but relatively obvious findings. First, I want to highlight the central premise of this journal: the importance of conducting good randomized controlled research and reporting the findings honestly. Many people in the field would assume that a comprehensive program aimed at helping patients adjust to coronary artery disease (CAD) would be helpful. It takes courage on the parts of the researchers to admit they failed to change what is likely the most critical aspect of lifestyle risk for CAD, the absence of regular and sustained moderate exercise. The patients who were put into the intervention group showed up on average to almost 80% of the sessions, and only 7/207 patients failed to complete the study. Thus, these research participants liked what they were receiving from the CR program. Therefore, it is important to state the conclusion of the study baldly: The intervention as practiced did not do good in this critical domain. In fact, sedentary people showed over time a tendency to give up the limited exercise they were already doing.

Regarding research methodology, the use of intention to treat as the criteria for selection of reportable data is to be commended. This means that everyone who enrolled in the study was counted pre and post, not just people who stayed or showed particular interest in the project. This allows us to see the limitations of some studies that use more restrictive criteria for using subject data as well as augments the power of the null findings of this project. The use of self-report data as well as hard data from exercise monitors allows us to establish that the CAD patients did not develop any form of exercise adherence as a result of this intervention. Noting that participants tended to overestimate their exertion when compared with the exercise monitor shows that the researchers clearly understand the problem they are facing.

The second obvious issue, and the real problem for the field of cardiovascular rehabilitation, is too many people do not choose to exercise, and often those who do so are sporadic and inconsistent in their practice. Considering the health benefits and the enjoyment expressed by people who enjoy exercise, it is a cultural black eye that so many people in the first world are sedentary. Besides the mushrooming incidence of obesity and the cost of exercise indolence in healthcare utilization, it is interesting to reflect on what this study's findings suggest: that even people who have a serious illness, are given education by caring professionals, and are young enough (mean age = 59) to make lasting life style change choose not to do so. That these patients are willing to suffer a greater likelihood of continued CAD, are comfortable allowing the healthcare system to expend resources on their care without their active participation, and are capable of ignoring the well-intentioned hospital staff who tried to make a difference is remarkable. Because the issue is not education, we are left unaware as to whether the problem is one of self-efficacy, or whether indifference to movement is in itself the overarching problem. Another way of saying that is whether failure to exercise is a part of the disease process of CAD, or do people with a tendency to not move much develop CAD, in part, because they are temperamentally or biologically predisposed to a sedentary life? This might be one reason a problem-based learning approach failed for these patients as their passivity regarding exercise needed more directed attention and more of a system of specific reinforcement to have any impact.

Finally, all research has its flaws, and this intervention study is not unique. The most obvious issue is the suggestion that something as refractory to intervention as exercise adherence could be impacted through a multifactorial intervention that was aimed at a whole gamut of patient lifestyle issues. The participants may not have understood that a lifestyle program aimed to improve their response to CAD was clearly focused on a need to exercise more. The researchers may have bitten off a bit too much when they designed their study and did not put enough emphasis on this critical variable. A second and corollary problem is having a limited number of sessions (13) that stretched out over a full year. A year is a long time to create change in participants without front loading the sessions with intensive training or education. In addition, this project did not appear to create sufficient mechanisms for improving adherence such as selecting an exercise buddy or providing ongoing communication with patients through e-mail or phone. There is no suggestion that the researchers used positive modeling to provide an impetus for successful participation. One wonders if self-efficacy was an issue and not only habits of sedentary life. If that is so, ways should have been offered to allow participants the ability to create short-term goals for success and/ or develop a climate where even small gains were noted and acknowledged. If there was failure at early points, the researchers could have used backup strategies to enhance adherence.

The bottom line is we all have a lot of work to do to get CAD patients to take better care of themselves. In the rehabilitation field, we are still struggling with how to do this important task. Besides needing more exercise, our patients tend to eat too much and choose the wrong food. They struggle to take their medications when indicated. They do not practice stress management in sufficient dosage to help their blood pressure or reduce the strain on their sympathetic nervous systems. More to the point, they fail to realize the preciousness of this life they are given and abuse their bodies. That is the real tragedy for us all: for patients, providers, and families. Each of the human beings aggregated in this research study presents a minor tragedy. Each of them struggles with the inevitable illness, disability, and imminent death of old age that face us all. However, too many of us, through our lifestyle choices, hasten the process of decay and too often do not change our choices to arrest that decay process once it has begun. As professionals, our ability to change people's ingrained habits is modest at best. The authors of this study quote the data which show that CR programs by themselves are insufficient to create long-term habits of exercise adherence. Bad and self-destructive habits are hard to change, and it is incumbent that we all submit our attempts, both successful and unsuccessful, to scrutiny as these researchers have.