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| 2. |
- Borg, Sabina, et al.
(author)
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Effectiveness of a behavioral medicine intervention in physical therapy on secondary psychological outcomes and health-related quality of life in exercise-based cardiac rehabilitation : a randomized, controlled trial
- 2023
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In: BMC Sports Science, Medicine and Rehabilitation. - : BioMed Central Ltd. - 2052-1847. ; 15:1
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Journal article (peer-reviewed)abstract
- Background: Interventions promoting adherence to exercise-based cardiac rehabilitation (exCR) are important to achieve positive physical and psychological outcomes, but knowledge of the added value of behavioral medicine interventions for these measures is limited. The aim of the study was to investigate the added value of a behavioral medicine intervention in physical therapy (BMIP) in routine exCR on psychological outcomes and health-related quality of life (HRQoL) versus routine exCR alone (RC). Methods: A total of 170 patients with coronary artery disease (136 men), mean age 62.3 ± 7.9 years, were randomized at a Swedish university hospital to a BMIP plus routine exCR or to RC for four months. The outcome assessments included HRQoL (SF-36, EQ-5D), anxiety and depression (HADS), patient enablement and self-efficacy and was performed at baseline, four and 12 months. Between-group differences were tested with an independent samples t-test and, for comparisons within groups, a paired t-test was used. An intention-to-treat and a per-protocol analysis were performed. Results: No significant differences in outcomes between the groups were shown between baseline and four months or between four and 12 months. Both groups improved in most SF-36 domains, EQ-VAS and HADS anxiety at the four-month follow-up and sufficient enablement remained at the 12-months follow-up. Conclusion: A BMIP added to routine exCR care had no significant effect on psychological outcomes and HRQoL compared with RC, but significant improvements in several measures were shown in both groups at the four-month follow-up. Since recruited participants showed a better psychological profile than the general coronary artery disease population, further studies on BMIP in exCR, tailored to meet individual needs in broader patient groups, are needed. Trial registration number NCT02895451, 09/09/2016, retrospectively registered.
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- Borg, Sabina, 1982-
(author)
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Exercise-Based Cardiac Rehabilitation in Patients with Coronary Artery Disease : Attendance, Adherence and the Added Value of a Behavioural Medicine Intervention
- 2021
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Doctoral thesis (other academic/artistic)abstract
- Background: Coronary artery disease (CAD) is the leading global cause of death. After an index event related to CAD, exercise-based cardiac rehabilitation (exCR) is strongly recommended as part of the secondary prevention. Despite the well-established beneficial effects of exCR in patients with CAD, attendance at and adherence to the programme are low, and remain a matter of major concern. One strategy that may increase adherence and rehabilitation outcomes in patients with CAD is to add a behavioural medicine intervention to routine exCR care. The added value of such interventions needs to be further explored. Although several factors associated with non-attendance at exCR appear to be similar between different countries, patterns of attendance may differ due to differences in contextual aspects. The factors that affect attendance at exCR in a Swedish context remain to be explored.Overall aim: To investigate barriers for exCR attendance and to evaluate the added value of a behavioural medicine intervention in physiotherapy on exercise adherence and rehabilitation outcomes in patients with CAD.Methods: The three papers in this thesis are based on two studies of patients with CAD, one registrybased cohort study of 31,297 patients included from the SWEDEHEART registry (Paper I), and one randomised controlled trial of 170 patients included at a Swedish university hospital (Papers II and III). In the first paper, several individual and structural variables were compared for attenders and nonattenders, using multivariable analysis in a logistic regression model. In Papers II and III, patients were randomised 1:1 either to a behavioural medicine intervention in physiotherapy in addition to routine exCR care or to routine exCR care alone for four months. The behaviour change techniques used in the behavioural medicine intervention – specific goal-setting, re-evaluation of the goals, and selfmonitoring and feedback – were based on control theory. Outcome assessment took place at baseline, four and 12 months, and included physical fitness, psychological outcomes and health-related quality of life. Exercise adherence was evaluated at the end of the four-month intervention. An intention-to-treat and a per-protocol analysis were performed.Results: Individual and structural factors associated with non-attendance at exCR in a Swedish context were identified as having a distance greater than 16 km to the hospital, belonging to a county hospital, having a higher burden of comorbidities, being male, and being retired. Exercise adherence was higher for patients who received the behavioural medicine intervention in physiotherapy together with routine exCR (31%) than it was for those who received routine exCR care alone (19%). Rehabilitation outcomes did not differ significantly between the two groups, either between baseline and four months or between four and 12 months. Both groups improved significantly in all measures of physical fitness, and in several measures of health-related quality of life and anxiety at the four-month follow-up. Sufficient enablement remained for patients in both groups at the 12-months follow-up.Conclusions: Distance to the hospital was the strongest predictor for non-attendance at exCR in a Swedish context. The individual factors associated with non-attendance at exCR identified in this thesis confirm previous results, with the exception that female gender was associated with a higher attendance at exCR. The results of this thesis confirm what others have pointed out: it is challenging to achieve behavioural change in patients with the aim to improve rehabilitation outcomes. Even though adherence was higher when a behavioural medicine intervention was added, it was low in both groups. The current behavioural medicine intervention in physiotherapy did not give any improvements over routine exCR care alone in physical fitness, psychological outcomes or health-related quality of life. As such, there is still room for further development and evaluation of behavioural medicine interventions within the context of exCR. A greater tailoring of these interventions to individual needs in a broader population of patients with CAD is suggested.
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| 4. |
- Borg, Sabina, et al.
(author)
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Factors associated with non-attendance at exercise-based cardiac rehabilitation
- 2019
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In: BMC Sports Science, Medicine and Rehabilitation. - : BMC. - 2052-1847. ; 11
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Journal article (peer-reviewed)abstract
- BackgroundDespite its well-established positive effects, exercise-based cardiac rehabilitation (exCR) is underused in patients following an acute myocardial infarction (AMI). The aim of the study was to identify factors associated with non-attendance at exCR in patients post-AMI in a large Swedish cohort.MethodsA total of 31,297 patients who have suffered an AMI, mean age 62.4 ± 4 years, were included from the SWEDEHEART registry during the years 2010–2016. Comparisons between attenders and non-attenders at exCR were done at baseline for the following variables: age, sex, body mass index, occupational status, smoking, previous diseases, type of index cardiac event and intervention, and left ventricular function. Distance of residence from the hospital and type of hospital were added as structural variables in logistic regression analyses, with non-attendance at exCR at one-year follow-up as dependent, and with individual and structural variables as independent variables.ResultsIn total, 16,214 (52%) of the patients did not attend exCR. The strongest predictor for non-attendance was distance to the exCR centre (OR 1.75 [95% CI: 1.64–1.86]). Other predictors for non-attendance included smoking, history of stroke, percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), AMI or diabetes, male sex, being retired vs. being employed, and being followed-up at a county hospital. Patients with ST-elevation myocardial infarction (STEMI) and those intervened with PCI or CABG were more likely to attend exCR.ConclusionsA distance greater than 16 km was associated with increased probability of non-attendance at exCR, as were smoking, a higher burden of comorbidities, and male sex. A better understanding of individual and structural factors can support the development of future rehabilitation services.
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| 5. |
- Borg, Sabina, et al.
(author)
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The Added Value of a Behavioral Medicine Intervention in Physiotherapy on Adherence and Physical Fitness in Exercise-Based Cardiac Rehabilitation (ECRA): A Randomised, Controlled Trial
- 2020
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In: Patient Preference and Adherence. - : DOVE MEDICAL PRESS LTD. - 1177-889X. ; 14, s. 2517-2529
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Journal article (peer-reviewed)abstract
- Purpose: Despite beneficial effects, adherence to exercise-based cardiac rehabilitation (exCR) is low in patients with coronary artery disease (CAD). The aim of this study was to investigate adherence to and the effects of a behavioral medicine intervention in physiotherapy (BMW) added to routine exCR care on the primary outcome of physical fitness compared with routine exCR care. Patients and Methods: In a randomized, controlled trial, 170 patients with CAD (136 men), mean age 62.3 (7.9) years, were included at a Swedish university hospital. Patients were randomized 1:1 to routine exCR care (RC) or to a BMIP added to routine exCR care for four months, with a long-term follow-up at 12 months. The outcome assessment included submaximal aerobic exercise capacity, muscle endurance and self-reported physical activity and physical capacity. Results: The four-month follow-up showed improvements in all outcomes for both groups, but changes did not differ significantly between the groups. Patients in the BMIP group were more adherent to exCR recommendations compared with the RC group (31% vs 19%) and a non-significant tendency towards the maintenance of submaximal aerobic exercise capacity over time was seen in the BMIP group, whereas patients in the RC group appeared to deteriorate. Conclusion: Both groups improved significantly at the four-month follow-up, while the 12-month follow-up showed a non-significant tendency towards better long-term effects on submaximal aerobic exercise capacity and exercise adherence for a BMIP compared with RC. In spite of this, a better understanding of the role of a BMIP in enhancing adherence is needed.
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| 6. |
- Borg, Sabina, et al.
(author)
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The role of a behavioural medicine intervention in physiotherapy for the effects of rehabilitation outcomes in exercise-based cardiac rehabilitation (ECRA) - the study protocol of a randomised, controlled trial
- 2017
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In: BMC Cardiovascular Disorders. - : BIOMED CENTRAL LTD. - 1471-2261 .- 1471-2261. ; 17
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Journal article (peer-reviewed)abstract
- Background: To help patients with coronary artery disease (CAD) benefit from the positive health effects attained by exercise-based cardiac rehabilitation (CR), adherence to these programmes according to international guidelines is important. Strategies to increase adherence to exercise-based CR are mainly an unexplored area. The objective of this study is to investigate the effects of a behavioural medicine intervention in physiotherapy, containing goal-setting, self-monitoring and feedback, with the aim of improving rehabilitation outcomes for exercise-based CR, compared with usual care. Methods: This is a randomised, controlled trial. A total of 160 patients with CAD will be included consecutively at the Coronary Care Unit at a university hospital in Sweden. Patients are randomised 1:1 using sealed envelopes to usual care or a behavioural medicine intervention in physiotherapy, in addition to usual care for 4 months. Outcome assessment at baseline, 4 and 12 months includes submaximal aerobic capacity (primary outcome), exercise adherence, muscle endurance, level of physical activity, biomarkers, anxiety and depression, health-related quality of life, patient enablement and self-efficacy (secondary outcomes). Discussion: This is the first study to evaluate the role of an integrated behavioural medicine intervention in exercise-based CR in the effects of rehabilitation outcomes. The results of this study will provide valuable information about the effect of these interventions in exercise-based CR and it has the potential to inform and assist in further treatment in secondary prevention for patients with CAD.
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| 7. |
- Freene, Nicole, et al.
(author)
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Comparison of device-based physical activity and sedentary behaviour following percutaneous coronary intervention in a cohort from Sweden and Australia: a harmonised, exploratory study
- 2020
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In: BMC Sports Science, Medicine and Rehabilitation. - : BMC. - 2052-1847. ; 12:1
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Journal article (peer-reviewed)abstract
- Background Few studies have measured device-based physical activity and sedentary behaviour following a percutaneous coronary intervention (PCI), with no studies comparing these behaviours between countries using the same methods. The aim of the study was to compare device-based physical activity and sedentary behaviour, using a harmonised approach, following a PCI on-entry into centre-based cardiac rehabilitation in two countries. Methods A cross-sectional study was conducted at two outpatient cardiac rehabilitation centres in Australia and Sweden. Participants were adults following a PCI and commencing cardiac rehabilitation (Australia n = 50, Sweden n = 133). Prior to discharge from hospital, Australian participants received brief physical activity advice (< 5 mins), while Swedish participants received physical activity counselling for 30 min. A triaxial accelerometer (Actigraph GT3X/ActiSleep) was used to objectively assess physical activity (light (LPA), moderate-to-vigorous (MVPA)) and sedentary behaviour. Outcomes included daily minutes of physical activity and sedentary behaviour, and the proportion and distribution of time spent in each behaviour. Results There was no difference in age, gender or relationship status between countries. Swedish (S) participants commenced cardiac rehabilitation later than Australian (A) participants (days post-PCI A 16 vs S 22, p < 0.001). Proportionally, Swedish participants were significantly more physically active and less sedentary than Australian participants (LPA A 27% vs S 30%, p < 0.05; MVPA A 5% vs S 7%, p < 0.01; sedentary behaviour A 68% vs S 63%, p < 0.001). When adjusting for wear-time, Australian participants were doing less MVPA minutes (A 42 vs S 64, p < 0.001) and more sedentary behaviour minutes (A 573 vs S 571, p < 0.001) per day. Both Swedish and Australian participants spent a large part of the day sedentary, accumulating 9.5 h per day in sedentary behaviour. Conclusion Swedish PCI participants when commencing cardiac rehabilitation are more physically active than Australian participants. Potential explanatory factors are differences in post-PCI in-hospital physical activity education between countries and pre-existing physical activity levels. Despite this, sedentary behaviour is high in both countries. Internationally, interventions to address sedentary behaviour are indicated post-PCI, in both the acute setting and cardiac rehabilitation, in addition to traditional physical activity and cardiac rehabilitation recommendations.
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| 8. |
- Hoppe, Sabina, et al.
(author)
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Can natural levels of Al influence Cu speciation and toxicity to Daphnia magna in a Swedish soft water lake?
- 2015
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In: Chemosphere. - : Elsevier BV. - 0045-6535 .- 1879-1298. ; 138, s. 205-210
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Journal article (peer-reviewed)abstract
- It is well known that chemical parameters, such as natural organic matter (NOM), cation content and pH may influence speciation and toxicity of metals in freshwaters. Advanced bioavailability models, e.g. Biotic Ligand Models (BLMs), can use these and other chemical parameters to calculate site specific recommendations for metals in the aquatic environment. However, since Al is not an input parameter in the BLM v.2.2.3, used in this study, there could be a discrepancy between calculated and measured results in Al rich waters. The aim of this study was to evaluate if the presence of Al in a circumneutral (pH similar to 6) soft humic freshwater, Lake St. Envattern, will affect the Cu speciation and thereby the toxicity to the cladoceran Daphnia magna. The results show a statistically significant increase in the free Cu2+ concentration with Al additions and that measured levels of Cu2+ significantly differed from BLM calculated levels of Cu2+. Furthermore, there was also a statistically significant elevated acute toxic response to D. magna at low additions of Al (10 mu g/L). However, since the large difference between calculated and measured Cu2+ resulted in a significant but minor (factor of 2.3) difference between calculated and measured toxicity, further studies should be conducted in Al rich soft waters to evaluate the importance of adding Al as an input parameter into the BLM software.
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| 9. |
- Hoppe, Sabina, et al.
(author)
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Evaluation of current copper bioavailability tools for soft freshwaters in Sweden
- 2015
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In: Ecotoxicology and Environmental Safety. - : Elsevier BV. - 0147-6513 .- 1090-2414. ; 114, s. 143-149
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Journal article (peer-reviewed)abstract
- The Water Framework Directive (WFD) in Europe calls for an improved aquatic ecological status. Biotic ligand models (BLM) have been suggested as a possible tool assisting in the regulatory process. The aim of this study was therefore to investigate the applicability of BLM under the WFD to set environmental quality standards (EQS), in particular regarding copper in Swedish freshwaters of which many are softer than those used for model calibration. Three different BLMs, one acute and two chronic, were applied to water chemistry data from 926 lakes and 51 rivers (1530 data entries) and evaluated with respect to their calibration range for input parameters. In addition, the predicted no-effect concentration (PNEC) for copper was calculated. From the 1530 data entries, 750 ended up outside of the BLM calibration range, when looking at the chemical parameters Ca2+, alkalinity, pH and DOC, primarily due to low carbonate alkalinity. Furthermore, the calculated Cu PNECs were higher than the suggested Swedish limit for Cu (4 µg L−1) in surface waters for 98% and 99% of the cases concerning lakes and rivers, respectively. To conclude, our findings show that water chemical characteristics outside of the calibration ranges are quite common in Sweden and that the investigated models differ in how they calculate toxicity concerning Cu under these conditions. As a consequence, additional work is required to validate the BLMs by use of bioassays with representative species of soft waters. Such results will show if these models can be used outside of their calibration ranges and also which of the models that gives the most reliable results.
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| 10. |
- Hoppe, Sabina, et al.
(author)
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Predictions of Cu toxicity in three aquatic species using bioavailability tools in four Swedish soft freshwaters
- 2015
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In: Environmental Sciences Europe. - : Springer Science and Business Media LLC. - 2190-4707 .- 2190-4715. ; 27:25
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Journal article (peer-reviewed)abstract
- BackgroundThe EU member countries are currently implementing the Water Framework Directive to promote better water quality and overview of their waters. The directive recommends the usage of bioavailability tools, such as biotic ligand models (BLM), for setting environmental quality standards (EQS) for metals. These models are mainly calibrated towards a water chemistry found in the south central parts of Europe. However, freshwater chemistry in Scandinavia often has higher levels of DOC (dissolved organic carbon), Fe and Al combined with low pH compared to the central parts of Europe. In this study, copper (Cu) toxicities derived by two different BLM software were compared to bioassay-derived toxicity for Pseudokirchneriella subcapitata, Daphnia magna and D. pulex in four Swedish soft water lakes.ResultsA significant under- and over prediction between measured and BLM calculated toxicity was found; for P. subcapitata in three of the four lakes and for the daphnids in two of the four lakes. The bioassay toxicity showed the strongest relationship with Fe concentrations and DOC. Furthermore, DOC was the best predictor of BLM results, manifested as positive relationships with calculated LC50 and NOEC for P. subcapitata and D. magna, respectively.ConclusionResults from this study indicate that the two investigated BLM softwares have difficulties calculating Cu toxicity, foremost concerning the algae. The analyses made suggest that there are different chemical properties affecting the calculated toxicity as compared to the measured toxicity. We recommend that tests including Al, Fe and DOC properties as BLM input parameters should be conducted. This to observe if a better consensus between calculated and measured toxicity can be established.
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