Cardiovascular disease is the leading cause of death worldwide.1 To optimize cardiovascular risk reduction and promote healthy lifestyle behavior, Phase 2 cardiac rehabilitation (CR) is considered the standard of care for individuals with a qualifying diagnosis. Despite the well-established benefits of reduced morbidity and mortality and improvement in quality of life and fitness, CR remains remarkably underutilized. Studies report that <30% of eligible patients participate in CR.2 Several factors, such as distance, work and family obligations, lack of physician referral, physical disability, depression, and minimal social support, can all serve as barriers for CR engagement.3-5

With the goal of improving participation, alternative models of CR can serve as a unique opportunity to engage with individuals who, otherwise, would not attend traditional CR. In this issue of the Journal of Cardiopulmonary Rehabilitation and Prevention, Platz et al6 provide the results of a systematic review of qualitative studies to capture the patient perspective of alternative forms of CR. Per the authors, an alternative model of CR was defined as a program using nontraditional forms of exercise including Wii (gaming console), tai chi, yoga, stretching, dance, qigong, aquatics, gardening, mind-body, and/or a location such as home-based, telerehabilitation, or community-based setting. The authors are to be commended for undertaking a review focused on the patient perspectives as, oftentimes, this is not prioritized.

The analysis included peer-reviewed, English-only studies published since 2009. A total of 459 studies were identified and considered. After screening and critically appraising the 459 citations, 25 studies from eight different countries were ultimately included in the review. In total, 487 individuals (including patients, caregivers, and professionals) engaged in an alternative model of CR. Many of the studies were home-based models and 12 of the 25 studies included heart failure patients. Additionally, the vast majority (20/25) of studies included individual, semi-structured interviews while five pertained to focus groups.

Platz et al6 identified three central themes regarding the patient perspectives:

1. Exercise benefits, which included increased self-efficacy, physical and psychological improvements, and greater social support

2. Exercise facilitators, included increased program accessibility, convenience, and social support

3. Barriers affecting participation, included fear of exercise, lack of interest in exercise, chronic comorbid medical conditions, lack of transportation, family and work obligations, and weather conditions.

Regarding benefits, self-efficacy and lifestyle change were reported in all 25 studies. The second most prominent category was physical or health benefits followed by psychological improvements. Physical benefits included improvements in balance, flexibility, strength, and coordination. These improvements are crucial for reversing muscle atrophy, which is commonly associated with aging. While older adults are often underreferred to CR, it appears that they have the most to benefit from CR exercise.7 Additionally, exercise self-efficacy co-occurred with psychological benefits. Confidence in exercise allowed patients to try new exercises or train at higher intensity, which, in turn, could contribute to improved mood; interestingly, the six programs, which incorporated tai chi or yoga in a group setting, all reported psychological benefit, suggesting that social support can influence mood.

Among exercise facilitators, convenience and family/peer support were major factors, especially for heart failure patients. For community-based programs, group meetings were a motivating factor; in home-based programs, many caregivers or family members were present, often joining in exercise or providing encouragement. Interestingly, feeling of safety was notably mentioned and seen even with home-based programs. With distance and lack of transportation reported as barriers, a benefit of home-based CR programs is convenience. Importantly, patients report that being held accountable was considered a valuable aspect of alternative CR programming. Additional research is needed to assess whether convenience improves adherence. Furthermore, these facilitators reinforce the challenges seen among heart failure patients and attempts at improving social isolation and mobility should be prioritized.

Finally, regarding barriers to exercise, fear or misconception of exercise was often cited. Many were concerned that engaging in exercise or too much exercise can lead to further damage or precipitate another event. This reinforces similar findings cited by Farris et al,8 who noted that 40-50% of patients in CR feared negative consequences of exercise. This factor can, perhaps, be mitigated if physicians recommend CR as lack of physician recommendation has been seen as a notable predictor for CR nonparticipation.4 Another important barrier was physical limitations. Consistent with other studies, issues such as back pain, arthritis or cardiovascular symptoms can hinder exercise engagement, particularly in older individuals.7,9 Therefore, reassurance and exercise tailoring to focus on other aspects such as balance, coordination, and strength training should be emphasized.10,11

While highlighting the patient perspectives is a primary strength of this article, there are some limitations. Unfortunately, many of the reviewed studies lacked specific demographics and there was lots of heterogenicity, meaning there was no uniformity in type of intervention or qualitative analysis, thus making it more challenging for the results to be generalizable.

Despite the variability in alternative CR models, benefits from a physical, psychological, and social perspective were seen. Key aspects include family/peer support, sense of safety, and convenience. Taken together, the patient insights gleaned from the Platz el al6 systematic review can provide opportunities to develop CR programming that is more accommodating, allowing increased accessibility to more individuals and improve the utilization of CR.

For decades, the approach to providing CR services has been "build it and [hopefully] they will come." This manner of delivering CR services has demonstratively improved the lives of many of those individuals that have been able and willing to participate. Unfortunately, it is clear that the rate of participation in the traditional facility- or center-based model of CR is woefully inadequate. If we are to make progress toward achieving the goal of 70% participation among eligible individuals, we need to critically reconsider how CR services are delivered.10-12 Historically, advances in CR programming have been guided by science. We know, as a result of objective, peer-reviewed research that the traditional model of delivering CR services is enormously effective. Going forward, changes in the way we deliver CR services need to be rooted in science. Critically, as we consider alternatives to the traditional CR model,13,14 we need to consider the patient perspective. More research is needed regarding the effectiveness of alternative models of CR in rural, remote, diverse and, otherwise, underserved populations. Expanding beyond the traditional CR model will require us to develop and integrate alternatives that are tailored to individual factors in order to ensure that we are meeting our patient needs and preferences.

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