OPEN ALL 3 FILES !!

Due Friday February 7, 2020 

· Read the peer-reviewed original research article (not a review article) which investigated the effects of a cardiorespiratory fitness training program (intervention) and utilized a cardiorespiratory fitness test as a dependent variable

·  Open link to access the article.

· Submit a written summary of the article and pdf of the article.

· The written summary should include….

· Description of the population being studied including

· Number of subjects

· Sex of the subjects

· Age of the subjects

· Initial cardiorespiratory fitness level and/or athletic status of the subjects

· Any other relevant details about the subjects

· Identify and briefly describe in your own words the cardiorespiratory fitness test which was utilized (do not copy and paste directly from the methods section)

· Describe the cardiorespiratory fitness program(s) used including

· Frequency of training

· Intensity of training

· Duration of training

· Mode of training

· Length of intervention

· Did the cardiorespiratory fitness implement progression and overload in an appropriate way? Explain why or why not.

· Describe the effects of the intervention in quantitative terms (do not say “the authors observed statistically significate increase in VO2 max” – indicate the magnitude of change)

· Reference in APA format

Due Friday February 7, 2020

RESEARCH ARTICLE Open Acces

s

Impact of wearable physical activity
monitoring devices with exercise
prescription or advice in the maintenance
phase of cardiac rehabilitation: systematic
review and meta-analysis
Amanda L. Hannan1* , Michael P. Harders1, Wayne Hing1, Mike Climstein2,4, Jeff S. Coombes3 and James Furness1

Abstract

Background

: Physical activity (PA) is a component of cardiac rehabilitation (CR). However, life-long engagement in
PA is required to maintain benefits gained. Wearable PA monitoring devices (WPAM) are thought to increase PA.
There appear to be no reviews which investigate the effect of WPAM in cardiac populations. We firstly aimed to
systematically review randomised controlled trials within the cardiac population that investigated the effect WPAM
had through the maintenance phase of CR. We specifically examined the effect on cardiorespiratory fitness (CRF),
amount and intensity of daily PA, and sedentary time. Secondly, we aimed to collate outcome measures reported,
reasons for drop out, adverse events, and psychological impact from utilising a WPAM.

Methods

: A systematic search (up to January 2019) of relevant databases was completed, followed by a narrative
synthesis, meta-analysis and qualitative analysis.

Results

: Nine studies involving 1,352 participants were included. CRF was improved to a greater extent in participants
using WPAM with exercise prescription or advice compared with controls (MD 1.65 mL/kg/min;95% confidence interval
[CI; 0.64–2.66]; p = 0.001; I2 = 0%). There was no significant between group difference in six-minute walk test distance.
In 70% of studies, step count was greater in participants using a WPAM with exercise prescription or advice, however
the overall effect was not significant (SMD 0.45;95% [CI; − 0.17-1.07] p = 0.15; I2 = 81%). A sensitivity analysis resulted in
significantly greater step counts in participants using a WPAM with exercise prescription or advice and reduced the
heterogeneity from 81 to 0% (SMD 0.78;95% [CI;0.54–1.02]; p < 0.001; I2 = 0%). Three out of four studies reporting on intensity, found significantly increased time spent in moderate and moderate-vigorous intensity PA. No difference between groups was found for sedentary time. Three of six studies reported improved psychological benefits. No cardiac adverse events related to physical activity were reported and 62% of non-cardiac adverse events were primarily musculoskeletal injuries. Reasons for dropping out included medical conditions, lack of motivation, loss of interest, and technical difficulties.

(Continued on next page)

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

* Correspondence: mhannan@bond.edu.au
1Faculty of Health Sciences and Medicine, Bond University, 2 Promethean
Way, Robina, Qld, Gold Coast, Queensland 4226, Australia
Full list of author information is available at the end of the article

Hannan et al. BMC Sports Science, Medicine and Rehabilitation (2019) 11:14
https://doi.org/10.1186/s13102-019-0126-8

http://crossmark.crossref.org/dialog/?doi=10.1186/s13102-019-0126-8&domain=pdf

http://orcid.org/0000-0003-1562-0109

http://creativecommons.org/licenses/by/4.0/

http://creativecommons.org/publicdomain/zero/1.0/

mailto:mhannan@bond.edu.au

(Continued from previous page)

Conclusion

s: Our meta-analysis showed WPAM with exercise prescription or advice are superior to no device in
improving CRF in the maintenance phase of CR and no cardiac adverse events were reported with WPAM use. Our
qualitative analysis showed evidence in favour of WPAM with exercise prescription or advice for both CRF and step
count. WPAM with exercise prescription or advice did not change sedentary time. Psychological health and exercise
intensity may potentially be enhanced by WPAM with exercise prescription or advice, however further research would
strengthen this conclusion.

Trial registration: PROSPERO Registration Number: CRD42019106591.

Keywords: Exercise, Cardiac rehabilitation, Maintenance phase, Cardiovascular disease, Coronary artery disease,
Wearable devices

Background
Deaths from cardiovascular disease (CVD) have risen by
14.5% globally between 2006 and 2016 [1]. A systematic
analysis for the Global Burden of Disease, which ana-
lysed 264 causes of mortality in 195 locations between
1980 and 2016, reported CVD as being responsible for
17.6 million deaths, of which 85.1% were attributed to
coronary heart disease (CHD) and stroke. Deaths attrib-
uted to CHD alone rose 19% to 9.48 million during the
same period. Additionally, the analysis reported CHD as
being the leading cause of years of life lost in 113 coun-
tries for men and 97 countries for women [1].
For those who have suffered a myocardial infarction,

the risk of subsequent cardiovascular events within
5 years increases by 20% [2]. Globally, secondary preven-
tion guidelines and action plans have been developed to
combat this healthcare burden [3–5]. For people diag-
nosed with cardiac disease, attending cardiac rehabilita-
tion (CR) is recommended to aid secondary prevention
[4–8]. Cardiac rehabilitation utilises a multidisciplinary
approach to improve health through education, risk factor
reduction, lifestyle behaviour modification, psychosocial
strategies and rehabilitative exercise programs [5–9]. Car-
diac rehabilitation is usually delivered across three phases:
phase 1 (inpatient setting), phase 2 (outpatient setting)
and, phase 3 (maintenance) [5].
Physical activity (PA) is an essential component of CR

[5]. Physical activity is any physical movement that re-
quires the expenditure of energy above resting require-
ments [10]. The exercise component of CR aims to
improve the physical functioning (cardiorespiratory
fitness (CRF), muscular strength and flexibility) of par-
ticipants. Cardiorespiratory fitness is defined as the max-
imum rate of oxygen consumption of the heart, lungs
and skeletal muscle during exercise [10]. It has been
shown to be inversely proportionate to mortality and
predicts prognosis in patients with CHD [11–13]. Re-
search has shown every metabolic equivalent increase in
CRF results in a 13–17% reduction in cardiovascular and
all-cause mortality [11–13]. Additionally, Martin et al.
[14] specifically showed a 13% decrease in overall

mortality for every MET increase in CRF following 12
weeks of CR. In addition, each MET increase was associ-
ated with a 25%-point reduction in all-cause mortality,
for those who maintained CRF gains at 1 year [14].
A recent systematic review and meta-analysis focusing

on exercise-based CR in Phase 2, which included 22
studies with 4,834 participants, found the exercise model
currently being used, although reducing hospital admis-
sions, had no effect on all-cause mortality [15]. This sug-
gests the CRF gains achieved in CR must, therefore, be
maintained long-term to offer a potential reduction in
mortality. This is further supported by studies reporting
the deleterious effects of physical inactivity [16–18].
Large reductions in daily step count over a two-week
period, significantly decreases CRF, insulin sensitivity
and lower limb muscle mass whilst increasing body fat,
liver fat and LDL cholesterol [18].
Several countries have reported one fifth to one third

of eligible patients enrol in CR [19–22]. Australia has re-
ported a higher enrolment rate (51–80%) [23]. To im-
prove this low uptake, researchers have investigated
alternate models of CR delivery. A systematic review by
Clarke et al. [24] identified 83 studies describing alter-
nate ways of providing CR. These studies were based pri-
marily in Phase 2 CR. They included multifactorial
individualised telehealth, internet-based delivery, tele-
health interventions focused on exercise, telehealth inter-
ventions focused on recovery, community or home-based
CR, rural and remote programs and multiple models of
care and alternative, complimentary models. The authors
concluded that community or home-based CR produce
similar reductions in cardiovascular risk factors compared
with hospital-based programs. Furthermore, a meta-ana-
lysis by Clark et al. [24] found home based programs
are an effective and low-cost alternative to hospital-
based CR.
In contrast to the numerous studies conducted specific

to Phase 2 of CR, there are few studies investigating

PA

in Phase 3 [25–29]. Of those, Reid et al. [28] found par-
ticipants did not maintain increased exercise levels
beyond 2 months post discharge from Phase 2 CR.

Hannan et al. BMC Sports Science, Medicine and Rehabilitation (2019) 11:14 Page 2 of 21

Furthermore, Bock et al. [25] reported that only 56% of
patients were meeting exercise guidelines at 12 months
post-discharge from CR. However, Bock et al. [25] also
showed those who participated in a Phase 3 program
were significantly more likely to continue regular and
more vigorous activity.
A systematic review and meta-analysis published by

Claes et al. [26] investigated the longer-term effects of
home-based exercise in CHD patients compared with
usual care or centre based rehabilitation. Seven studies
were included in the meta-analysis on exercise capacity.
Results showed no significant differences in exercise
capacity between home based and usual care. However,
they also found a significant difference in exercise cap-
acity in favour of home-based exercise when compared
with centre-based exercise, of small effect size (SMD
0.25, 95% CI 0.02–0.48). Therefore, encouraging life-
long PA for patients with CHD at home seems a feasible
option to maintain CRF and therefore, potentially reduce
mortality.
Activity trackers are worn by over 10% of adults [30]

and wearable technology was named number three in
the top twenty worldwide fitness trends in 2018 [31].
Wearable technology is thought to improve the amount
of, and adherence to, PA [32–35]. A 2016 systematic re-
view identifying 13 randomised controlled trials (RCTs)
and 6 quasi-experimental studies utilising a pedometer,
found 79% of trials were effective in increasing PA [36].
However, a review by Coughlin et al. [37] to determine
the efficacy of wearables in improving PA concluded that
larger studies with greater sample sizes, coupled with
longer durations, are required to fully support the adop-
tion of WPAM with exercise prescription or advice to
increase PA in healthy populations.
Previous research within the CHD population found

lack of motivation and time were the most common bar-
riers cited to engaging in PA [38]. This was further sup-
ported by Bravata et al. [39] who concluded lack of
motivation negatively influenced self-efficacy for exer-
cise. Studies investigating exercise monitoring in the
home of people diagnosed with CHD have used various
monitoring devices from pedometers through to electro-
cardiographic transmission [29, 40–49]. There is con-
flicting evidence of the benefits of WPAM in the CHD
population. A systematic review by Bravata et al. [39]
found the use of a pedometer significantly increased PA.
Similarly, a study by Butler et al. [48] also found that pe-
dometers increased adherence and PA in patients with
CHD. In contrast, an earlier study by Butler et al. [47]
found no difference in the amount of walking completed
by participants wearing a pedometer displaying the step
counts, compared to the step counts being obscured
from patients. To the authors’ knowledge there appear
to be no systematic reviews of RCTs that have

investigated the effect of WPAM on the maintenance of
PA and CRF/physical capacity in phase 3 CR. Further-
more, no systematic review has collated CRF outcome
measures, reasons for dropouts or adverse events in
studies investigating WPAM in the CHD population.
We firstly aimed to systematically review randomised

controlled trials within the cardiac population that in-
vestigated the effect WPAM with exercise prescription
or advice had through the maintenance phase of CR. We
specifically examined the effect on cardiorespiratory fit-
ness (CRF), amount and intensity of daily PA, and sed-
entary time. Secondly, we aimed to collate outcome
measures reported, reasons for drop out, adverse events,
and psychological impact from utilising a WPAM. Our
hypothesis was WPAM with exercise prescription or ad-
vice would improve CRF and step count, intensity of ex-
ercise, quality of life and, decrease sedentary time.

Methods
A narrative synthesis, and meta-analysis, was performed
in line with the protocol registered with PROSPERO, an
international database of prospectively registered sys-
tematic reviews in health and social care (Registration
Number: CRD42019106591) [50]. In January 2019, a sys-
tematic search of RCTs was completed by two authors
(AH and MH) who followed the methodology proposed
in the the Preferred Reporting Items for Systematic
Reviews and Meta-Analysis (PRISMA) guidelines [51].

Study selection
Inclusion criteria
This systematic review included RCTs, which were full-
length research articles published in peer-reviewed aca-
demic journals. No limits were set on language, date of
publication or gender. The RCTs must have compared
standard care or an attention control group to the use of
a WPAM during the maintenance phase (Phase 3) of
CR. We define a WPAM to be a small, wearable device
with accelerometer and/or pedometer capabilities. This
may include pedometers, watches and smartphones (if
the accelerometer function was used). To be eligible for
inclusion, studies required at least 4 weeks follow-up after
outpatient (Phase 2) CR. Standard care groups could in-
clude advice on PA and/or phone calls to encourage PA,
however, not receive unblinded PA self-monitoring
devices. The WPAM required data to be visible to the
subjects in the intervention groups. Eligible studies in-
cluded participants with a diagnosis of myocardial infarc-
tion, acute coronary syndrome; or who have undergone
percutaneous coronary intervention, coronary artery dis-
ease; or a history of cardiac surgery (coronary artery
bypass graft, valvular repair or replacement). Participants
were required to be older than 20 years and must have
completed Phase 2 of CR. Studies were required to have

Hannan et al. BMC Sports Science, Medicine and Rehabilitation (2019) 11:14 Page 3 of 21

reported at least one outcome measure evaluating PA or
CRF (e.g. change in peak oxygen uptake [VO2 peak] or
change in steps per day). These outcome measures were
used in the meta-analysis.

Exclusion criteria
Abstracts, poster presentations, conference presenta-
tions, unpublished books and letters to the editor or
book chapters were excluded. Studies that used WPAM
solely as an outcome measure, rather than an interven-
tion, and which did not require participants to wear the
devices throughout the entire study period, were ex-
cluded. In addition, studies that did not allow the partic-
ipants to view the device data throughout the
intervention period were also excluded.

Literature search
Databases systematically searched included CINAHL,
Cochrane Library, Embase, Medline/Ovid, Scopus,
SPORTDiscus and Web of Science. A unique search
strategy was identified, for each of the databases using
the assistance of a university librarian and is available in
the supplementary material. Reference lists of eligible ar-
ticles and conference abstracts were also searched.

Study selection
Two authors (AH and MH) independently conducted a
systematic search to identify relevant titles and abstracts
from the databases. Search results were entered into a
reference management tool (Endnote v 9) and duplicates
from different databases were removed. Both authors
screened titles/abstracts for eligibility before viewing full
text. In addition, reference lists of eligible studies were
screened for further eligible studies. The primary author
attempted to source full length text for eligible confer-
ence abstracts. The two reviewers compared studies for
inclusion and exclusion. A third author (WH) was used
to resolve discrepancies in decision making. The selec-
tion process was recorded into a PRISMA [51] diagram.

Data extraction
For each RCT that met the inclusion criteria, the pri-
mary author (AH) completed the data extraction, which
included author, year of publication, country of trial ori-
gin, number of participants, participant characteristics
(gender, age and diagnosis), percentage of participants
that completed the RCT, reasons for drop-out and
adverse events. Furthermore, trial characteristics (type of
wearable, timing of recruitment, length of trial and a de-
scription of the intervention) were also extracted. Fi-
nally, fitness and PA measures, specifically CRF and step
count changes were collated.
This data entry was subsequently checked by a second

author (MH). Discrepancies were resolved by a third

author (WH). Authors of included studies were con-
tacted if the paper stated relevant outcome measures
were obtained, but not reported. Two authors [52, 53]
were contacted and both provided additional information.

Study quality
Methodological study quality was assessed and rated
using the Physiotherapy Evidence Database Scale (PEDro
Scale) which has been demonstrated to be a reliable and
valid tool [54–56]. It identifies studies that are internally
valid and was developed based on the Delphi list pub-
lished by Verhagen et al. [57].
The PEDro-Scale ascertains the quality of reporting of

studies. For this review, we allocated points if subjects
were randomly allocated and concealed; participants had
comparable baseline measures; subjects, therapists and
assessors were blinded; more than 85% of starting sub-
jects completed outcome measure assessment; partici-
pants received the allocated treatment; analysis included
intention to treat; and if there was evidence of statistical
comparison and variability of measures. Blinding of sub-
jects or therapists was not possible because participants
were required to wear a visible WPAM and therapists
were required to discuss results of WPAM data with
participants. Reporting of eligibility criteria is assessed
for external validity; however, this is not included in the
final score as per PEDro Scale marking requirements
[55]. Therefore, removal of these criteria from the final
scoring left a maximum possible score of 8. Two authors
(AH and MH) independently used the PEDro scale’s cri-
teria checklist to produce a score (between 0 and 8) to
rate each studies’ quality. The same authors compared
scores and discussed differences of opinion. Studies were
deemed to be of good quality if the trial received a score
of > 61% of available points (≥5/8). Fair-quality studies re-
ceived 45.4–61% of available points (4/8). Studies which
received < 45.4% of available points (< 4/8) were deemed of poor quality, as described by Kennelly et al. [58].

Statistical analysis and synthesis
Review Manager (Version 5.3; The Nordic Cochrane
Centre, Copenhagen) was used to perform a meta-ana-
lysis to investigate the effect wearing a WPAM with ex-
ercise prescription or advice had on CRF (change in
VO2peak) and change in daily step count. Effect sizes for
continuous variables were calculated as either mean
difference or standardised mean differences (SMD),
otherwise known as Cohens D effect size [59]. Standar-
dised mean difference was used in cases where different
methods across studies were used to assess CRF (tread-
mill test vs cycle ergometer) and because different types
of WPAM were used across trials. The effect size was
calculated as the difference in outcome measure re-
ported from baseline to the end of the trial. Standardised

Hannan et al. BMC Sports Science, Medicine and Rehabilitation (2019) 11:14 Page 4 of 21

mean difference (SMD) was used to quantify the effect
size in place of mean differences (steps per day) due to
standard deviations being too wide for visual representa-
tion. Sub-groups were used to represent the overall influ-
ence of effect; where SMD > 0.8 represented a large effect,
0.5–0.79 represented a moderate effect, and 0.2–0.49 a
weak effect. This has been used in previous research [59].
Where standard deviation of the change was not pub-

lished, we estimated it using the p-value between groups,
then within groups, as recommended by the Cochrane
Handbook for Systematic Reviews of Interventions [60].
Random effects with standardised means model was im-
plemented due to the variability of duration, delivery
and assessment across studies. Raw data was received
from ter Hoeve et al. [52] as the actual step count in
their publication was not reported. We therefore derived
the steps by entering the raw data into statistical soft-
ware package (IBM SPSS Statistics, version 25) and per-
formed a paired t-test.
A forest plot was completed on CRF changes

(VO2peak) and step count per day. These were the only
outcome measures found in three or more studies. Het-
erogeneity, using I2 was considered significant at p < 0.1. If I2 was 0–30%, it was considered minimal, 31–50%, moderate, 51–90% substantial and considerable if >
90% [61].
Finally, due to the small number of studies that were in-

cluded in the meta-analysis, we also performed a qualita-
tive best evidence synthesis. This was considered as
inferior evidence to the quantitative analyses’ method of
meta-analyses. This method was based on previous re-
search [62] which provided recommendations on how to
conduct a qualitative analysis using five levels of evidence
from strong to no evidence. A best evidence synthesis ap-
proach has widely been used within systematic reviews
where quantitative approaches are not possible [63–66].
From this, we adapted the criteria due to the small num-
ber of studies in our review as below:

1. Strong Evidence: significant findings provided by two
or more studies with high quality and by generally
consistent findings in all studies (more than 75% of
the studies reported consistent findings).

2. Moderate Evidence: significant findings provided by
one study with high quality and/or two or more
studies with low quality, and by generally consistent
findings in all studies (more than 60% of the studies
reported consistent findings).

3. Limited Evidence: significant findings provided by
only one study with low quality.

4. Conflicting Evidence: inconsistent findings in
multiple studies (less than 60% of studies reported
consistent findings).

5. No Evidence: when no studies could be found

Results
Initially, the search strategy resulted in 183 articles. This
was reduced to 126 articles after duplicates were re-
moved. The titles and abstracts were screened, and 100
studies were excluded due to not meeting eligibility cri-
teria. Of the 26 articles that were screened, nine were
identified as meeting the inclusion criteria for the sys-
tematic review (Fig. 1).

Study quality
The PEDro-Scale was used to gauge the quality of indi-
vidual trials. Nine studies were scored by two authors
(AH and MH) independently and discrepancies were
discussed and agreed. Of the nine studies, none were of
poor quality, two were of fair quality (2/9) and seven
were of good quality (7/9) (Table 1).

Study characteristics
All eligible studies were published in English and were
included in the narrative analysis [52 53,67–73]. Five
studies (56%) were from Europe [52, 67, 69, 71, 73] in-
cluding Belgium (n = 1) [67], Ireland (n = 1) [69], France
(n = 1) [71], Netherlands (n = 1) [52] and a multicenter
study across Germany, Spain and Britain [73] (n = 1).
Two studies (22%) were based in Australia [53, 68], one
was from the United States of America [70], and one
study from Canada [72] The studies were published be-
tween 2009 and 2018.
The total number of participants across all studies was

1,352. Of the 870 participants that were analysed,192
(22.1%) were female and 678 (77.9%) were male. The low-
est percentage (4%) of a specific gender in the control and
intervention groups across studies was females in a single
control group [69]. Mean ages of participants ranged from
42 to 73.7 years. In five studies [52, 53, 69, 72, 73] (56%),
the mean age for the control group was < 60 years (range 56.2+/− 10.1 to 59.1+/− 8) and four studies [67, 68, 70, 71] reported mean ages > 60 years (range 61.7+/7.7 to 66.5+/
− 7.2). In contrast, six studies [52, 53, 67, 70–72] (67%) re-
ported the mean age for the intervention group as < 60 years (range 54.5+/− 12.6 to 59.9+/− 8.1) and three studies [68, 69, 73] reported the mean ages as ≥60 years (range 60–63+/− 10.4). Seven studies [52, 53, 67, 68, 70–72] (78%) reported younger mean ages for the intervention group compared to the control group, however this was not significantly different. Common presentations of par- ticipants reported by studies included myocardial infarc- tion (n = 7), coronary artery bypass graft surgery (n = 6), percutaneous coronary intervention (n = 7), acute coron- ary syndrome (n = 2), and coronary artery disease (n = 2). Four studies [67, 69–71] (44%) had durations between 1.5 and 3 months in length, three studies [53, 68, 73] (33%) were 6 months duration and two studies [71, 72] (22%) were longer than 6 months duration. Individual trial

Hannan et al. BMC Sports Science, Medicine and Rehabilitation (2019) 11:14 Page 5 of 21

breakdowns for patient characteristics can be seen in
Table 2.
All studies utilised a WPAM for the intervention

group. The devices utilised included Yamax Digiwalker
Pedometer [52, 68, 69, 72], Garmin Forerunner [67],
Fitbit Charge [70], My Wellness Key Accelerometer [71],
Gex vital signs sensor [73], Nokia Smartphone with pre-
installed applications [53], and a Sensewear Mini
Armband [67]. The timing of recruitment for study par-
ticipants ranged from 6 weeks to 18 months post cardiac
event. Participants completed a supervised phase 2 CR
program prior to participation in all studies, except one
[53]. The one exception commenced the intervention
period at the onset of phase 2 CR and continued into
phase 3 with final outcomes measured at 6 months [53].
The duration of interventions varied across studies. In

seven studies [52, 53, 67, 68, 70–72] (78%), the control
group received a pamphlet and/or face-to-face sessions
on PA and lifestyle factors. One study [69] included on-
going weekly facilitator support for the attention control
group, and another had participants in the control group
report daily PA in a paper diary [73]. Seven of the

studies (78%) included goal setting in the interventions.
This was performed by phone calls, emails, text mes-
sages or a web-based interface [53, 67–71, 73]. One
study received a socio-cognitive intervention led by a
clinical nurse specialist [72]. All studies encouraged self-
management using the WPAM to track their PA. Indi-
vidual trial characteristics can be seen in Table 3. Five
(56%) of the studies exercise interventions were based at
home [69–73], three (33%) used both home-based and
centre-based locations [52, 53, 67] and one study did not
report on the location of exercise [68]. There was a large
variety of different recommended parameters for indi-
vidual exercise sessions. Thirty minutes of daily moder-
ate intensity activity was recommended to the control
group participants in two studies [68, 69] (22%) whilst
two others (22%) reported general advice to stay active
[70, 71]. Exercise parameters for home-based exercise
were all unique and exercise prescription varied in the
amount of specific instruction given to intervention par-
ticipants. One study did not specify any exercise pre-
scription [72] and another three (33%) provided general
advice only; to exercise at moderate intensity for most

Fig. 1 PRISMA diagram of literature search strategies

Hannan et al. BMC Sports Science, Medicine and Rehabilitation (2019) 11:14 Page 6 of 21

days of the week [53, 67, 71]. Two studies (22%) recom-
mended increasing steps per day [69, 70], two (22%) pre-
scribed a specific heart rate range and duration [67, 68].
Two further studies (22%) incorporated additional exer-
cise modes, other than walking (resistance training [73]
and gymnastics [52]). Only one study [73] gave partici-
pants a detailed prescription on how to progress the ex-
ercise, however this was only for the centre-based
participants. Individual trial breakdowns for study char-
acteristics can be seen in Table 3.

Reasons for drop out
Completion rates amongst trial groups ranged from 22%
[73] to 100% [71]. The collective mean drop-out rate per-
centage was slightly lower for the intervention groups
compared with the control groups (22% versus 23% re-
spectively). For studies of less than or equal to 3 months
(4/9), the mean dropout rate for the control groups was 9
and 10% for the intervention group. For studies greater
than 6 months (5/9), the mean dropout rate for the con-
trol groups was 31 and 34% for the intervention group.

Table 2 Study and Participant Characteristics

Study Country of
Origin

No. Participants Gender
(f/m)

Age
(years±SD)

Diagnosis Study Duration
(months)

% of participants
completed study

Avila et al. [67] Belgium 30 c 60 i 84a 3/27 c 4/26 i 61.7 ± 7.7 c
58.6 ± 13 i

CAD, MI,
CABG, PCI

3 86.67 c 93.33 i

Butler et al. [68] Australia 60 c, 62 i 6/52: 50 c,
48 i; 98a 6/12: 46 c,
44 I; 90a

10/45 c
17/38 i

64.5 ± 11.2 c
63 ± 10.4 i

MI, CABG,
PCI, ACS

6 6/52: 90.9 c; 87.3
i 6/12: 83.64 c; 80 i

Cupples et al. [69] Northern
Ireland

26 c 19 i 1/25 c
3/16 i

59.2 ± 8.9 c
61.6 ± 11.3 i

Not published 1.5 96 c 90 i

Duscha et al. [70] America 11 c 21 i; 25a 3/6 c
3/13 i

66.5 ± 7.2 c
59.9 ± 8.1 i

MI with PCI or
CABG, PCI,
CABG, VR

3 81.8 c 76.2 i

Guiraud et al. [71] France 10 c 19 i 3/7 c
2/17 i

62.9 ± 10.7 c
54.5 ± 12.6 i

CAD, CABG,
PCI, HF

2 100 c 100 i

Houle et al. [72] Canada 33 c 32 i 8/25 c
6/26 i

59 ± 9 c 58 ±
8 i

MI, CABG,
PCI, UA

12 Data not published

Skobel et al. [73] Germany,
Spain, Britain

63 c 55 i 54a:42
c,12 i

8/55 c
5/ 50 i

58 c* 60 i* MI, PCI 6 66.7 c, 21.8 i

ter Hoeve et al. [52] Netherlands 163 c 161 i 32/131 c
32/129 i

59.1 ± 8 c
58.8 ± 9 i

MI, CABG,
PCI, ACS

18 3/12: 78 c, 80.1 i 12/12:
75 c,75 i 18/12: 74.7 c,74.8 i

Varnfield et al. [53] Australia 41 c 53 i 6/52:28 c
48 i; 76a 6/12: 26 c,
46 i; 72a

7/34 c
5/48 i

56.2 ± 10.1 c
54.9 ± 9.6 i

MY 6 6/52:46.7 c, 80 i 6/12:43.3
c,76.7 i

Abbreviations

: f female, m male, SD standard deviation, t total, c control, i intervention, a analysed, CAD coronary artery disease, MI myocardial infarction, CABG
coronary artery bypass graft surgery, PCI percutaneous coronary intervention, ACS acute coronary syndrome, VR valve repair, HF heart failure, UA unstable angina,
wks weeks, m months,a: *SD not published

Table 1 Quality Analysis using PEDro-Scale (Cross indicates study did not meet this criteria)

Eligibility
Criteria
Specified
(Not included
in final score)

Randomly
Allocated

Allocation
Concealed

Similar Baseline
Measure-ments

Blinding of
Assessors

Less than
15% dropout
both groups

Intention
to Treat

Statistical
Comparisons

Variability
Measures

Score

Avila et al. [67] ✓ ✓ X ✓ X ✓ ✓ ✓ ✓ 6

Butler et al. [68] ✓ ✓ X ✓ X X ✓ ✓ ✓ 5

Cupples et al. [69] ✓ X X ✓ X ✓ X ✓ ✓ 4

Duscha et al. [70] ✓ ✓ X ✓ X X X ✓ ✓ 4

Guiraud et al. [71] ✓ ✓ X ✓ X ✓ ✓ ✓ ✓ 6

Houle et al. [72] ✓ ✓ X ✓ X ✓ X ✓ ✓ 5

Skobel et al. [73] ✓ ✓ X ✓ ✓ X X ✓ ✓ 5

ter Hoeve et al. [52] ✓ ✓ ✓ ✓ X X ✓ ✓ ✓ 6

Varnfield et al. [53] ✓ ✓ ✓ ✓ X X X ✓ ✓ 5

Hannan et al. BMC Sports Science, Medicine and Rehabilitation (2019) 11:14 Page 7 of 21

T
a
b
le

3

St
u
d
y

Pa
ra
m

et
er

s

St
u
d
y

Ty
p
e

o
f

w
ea
ra
b
le

Ti
m
i

n
g

o
f

re
cr
u
it
m
en

t
In
te
rv
en

ti
o
n

D
es
cr
ip
ti
o
n

co
n
tr
o
l

in
te
rv
en

ti
o
n

p
ar
am

et
er
s

fo
r

in
d
iv
id
u
al
se
ss
io
n
s

co
n
tr
o
l
in
te
rv
en
ti
o
n

A
vi
la
et

al
.[
67
]

G
ar
m
in

Fo
re
ru
n
n
er

21
0

Se
n
se
w
ea
r

m
in
i
ar
m
b

an
d

3
m
o
n
th
s

p
o
st

am
b
u
la
to
ry

C
R

ad
vi
se
d
to

re
m
ai
n

p
h
ys
ic
al

ly
ac
ti
ve

h
o
m
e-

b
as
ed

ex
er
ci
se

w
it
h

te
le
m
o
n
it
o
rin

g
g
u
id
an
ce

w
ee
kl
y
em

ai
ls
o
r

p
h
o
n
e

ca
lls

ce
n
tr
e-
b
as
ed

d
at
a

n
o
t
p
u
b
lis
h
ed

15
0
m
in
s
o
f

ac
ti
vi
ty

/w

ee
k

6–
7

d
ay
s

/w

ee
k

m
o
d
er
at
e

in
te
n
si
ty

ex
er
ci
se

(7
0–
80
%

H
ea
rt
ra
te

re
se
rv
e)

Bu
tl
er

et
al
.[
68
]

Pe
d

o
m
et
er

Ya
m
ax

D
ig
iw
al
ke
r

70
0B

fo
llo
w
in
g

at
te
n
d
an
ce

o
f

g
ro
u
p
C
R

g
iv
en

2

g
en

er
ic
PA

b
ro
ch
u
re

s

6-

w
ee
k

se
lf-

m
o
n
it
o
re
d

ac
ti
vi
ty

w
it
h

p
ed

o
m
et
er
,d

ai
ly

st
ep

ca
le
n
d
ar
,

g
en
er
ic
PA
b
ro
ch
u
re

ap
p
ro
xi
m
at
el
y
15
-m

in
-lo

n
g
p
h
o
n
e

ca
ll
af
te
r
1,
3,
12
,1
8

w
ee
ks

2

b
eh

av
io
u
ra
l
co
u
n
se
lli
n
g

an
d

g
o
al

se
tt
in
g
se
ss
io
n
s
w
ee
k
1
an
d
3

30
m
in

s

o
f
m
o
d
er
at
e

in
te
n
si
ty
ac
ti
vi
ty

o
n
al
l

o
r

m
o
st
d
ay
s
o
f

th
e

w
ee
k
d
at
a
n
o
t
p
u
b
lis
h
ed

C
u
p
p
le
s
et

al
.[
69
]

Pe
d
o
m
et
er
Ya
m
ax

C
W
-7
01

fo
llo
w
in
g
co
m
p
le
ti
o
n

o
f
su
p
er
vi
se
d
C
R

o
n
g
o
in
g
w
ee
kl
y
fa
ci
lit
at
o
r

su
p
p
o
rt
b
u
t
n
o
fe
ed

b
ac
k

o
n
st
ep

co
u
n
ts

w
o
rk
ed

w
it
h
a
cl
in
ic
al
fa
ci
lit
at
o
r

p
ed
o
m
et
er

se
t

d
ai
ly

st
ep

co
u
n
t
g
o
al
s
w
it
h

w
ee
kl
y
re
vi
ew

s
re
co
rd

d
ai
ly
st
ep

s
in

a

d
ia
ry

h
o
m
e-
b
as
ed

30
m
in
o
f
m
o
d
er
at
e
in
te
n
si
ty
ac
ti
vi
ty
d
ai
ly

g
ra
d
u
al

in
cr
ea
se

o
f
10
%

o
f
st
ep

s
ai
m
in
g
fo
r

10
,0
00

st
ep

s/
d
ay

u
sc
h
a
et

al
.[
70
]

Fi
tb
it
C
h
ar
g
e

2
w
ee
ks

p
rio

r
to

d
is
ch
ar
g
e
fr
o
m

g
ro
u
p
C
R

p
at
ie
n
ts

w
o
re

Fi
tb
it

d
u
rin

g
la
st

2
w
ee
ks

o
f
g
ro
u
p
C
R

u
su
al

ca
re

as
ad
vi
se
d

b
y

p
h
ys
ic
ia
n

Fi
tb
it

w
o
rn

fo
r
la
st
2
w
ee
ks

o
f
st
u
d
y

p
at
ie
n
ts
w
o
re
Fi
tb
it
d
u
rin
g
la
st
2
w
ee
ks

o
f
g
ro
u
p
C
R
p
lu
s

fo
llo
w
in
g

12
w
ee
ks

ex
er
ci
se

p
re
sc
rip

ti
o
n
o
f
st
ep

co
u
n
ts

w
ee
kl
y
h
ea
lt
h
co
ac
h
in
g
(1
–
2

ti
m
es
/w

ee
k

fo
r
30
–
60

m
in
)

te
xt

m
es
sa
g
es

an
d
ed

u
ca
ti
o
n
al

m
at
er
ia
l

Vi
d
a
H
ea
lt
h
ap
p

h
o
m
e-
b
as
ed

ad
vi
ce

g
iv
en
b
y

in
d
iv
id
u
al
p
h
ys
ic
ia
n
s

sp
ec
ifi
cs

n
o
t
p
u
b
lis
h
ed
w
ee
ks

1–
4
in
cr
ea
se

PA
b
y
2,
50
0
st
ep

s
ab
o
ve

b
as
el
in
e

w
ee
ks

5–
8

in
cr
ea
se

a
fu
rt
h
er

1,
25
0

st
ep

s
w
ee
ks

9–
12

in
cr
ea
se
a
fu
rt
h
er
1,
25
0
st
ep
s

G
u
ira
u
d
et

al
.[
71
]

M
y
W
el
ln
es
s
Ke
y

A
cc
el
er
o
-m

et
er

2
m
o
n
th
s
o
r
1
ye
ar

af
te
r
d
is
ch
ar
g
e
fr
o
m

g
ro
u
p
C
R
w
o
re

ac
ce
le
ro
-m

et
er

in
la
st

w
ee
k
o
n
ly

ad
vi
ce

o
n
im

p
o
rt
an
ce

o
f

ad
h
er
in
g
to

ex
er
ci
se
p
re
sc
rip

ti
o
n
g
iv
en

ac
ce
le
ro
m
et
er

w
o
rn

th
ro
u
g
h
o
u
t

te
le
p
h
o
n
e
su
p
p
o
rt
g
iv
en

ev
er
y

15
d
ay
s
id
en

ti
fy
in
g
b
ar
rie
rs
an
d

st
ra
te
g
ie
s

h
o
m
e-
b
as
ed

n
o
co
n
ta
ct

g
iv
en

m
o
d
er
at
e
in
te
n
si
ty

PA

H
o
u
le
et

al
.[
72
]

Ya
m
ax
D
ig
iw
al
ke
r

N
L-
20
00

–
b
lin
d
ed

Ya
m
ax
D
ig
iw
al
ke
r

SW
−
20
0

w
it
h
in

4
w
ee
ks

o
f
d
is
ch
ar
g
e
fr
o
m

h
o
sp
it
al

u
su
al
ad
vi
ce

b
y
n
u
rs
e
o
r

p
h
ys
ic
ia
n

n
o
re
st
ric
ti
o
n
s
to

g
o
to

ce
n
tr
e-
b
as
ed
C
R
p
ed
o
m
et
er

PA
d
ia
ry

So
ci
o
-c
o
g
n
it
iv
e
in
te
rv
en

ti
o
n
le
d

b
y
cl
in
ic
al
n
u
rs
e
sp
ec
ia
lis
t

h
o
m
e-
b
as
ed

u
su
al
ad
vi
ce
–
sp
ec
ifi
cs

n
o
t
p
u
b
lis
h
ed
g
iv
en
p
ed

o
m
et
er
-b
as
ed

p
ro
g
ra
m

Hannan et al. BMC Sports Science, Medicine and Rehabilitation (2019) 11:14 Page 8 of 21

T
a
b
le

3
St
u
d
y
Pa
ra
m
et
er
s
(C
o
n
tin
u
ed
)

St
u
d
y

Ty
p
e
o
f
w
ea
ra
b
le

Ti
m
in
g
o
f

re
cr
u
it
m
en
t
In
te
rv
en

ti
o
n
D
es
cr
ip
ti
o
n

Sk
o
b
el
et

al
.[
73
]

G
ex

se
n
so
r
o
f
vi
ta
l

si
g
n
s
an
d
sm

ar
tp
h
o
n
e

d
u
rin

g
g
ro
u
p
C
R

Re
p
o
rt
PA

in
p
ap
er

d
ia
ry

G
u
id
ed

ex
er
ci
se

sy
st
em

(G
ex
)

in
d
iv
id
u
al
p
er
fo
rm

an
ce
s

m
o
n
it
o
re
d

an
d
ex
er
ci
se

p
re
sc
rip

ti
o
n
re
vi
ew

ed
w
eb

b
as
ed

to
o
l,
p
at
ie
n
t
st
at
io
n
an
d

p
o
rt
ab
le
st
at
io
n

h
o
m
e-
b
as
ed
sp
ec
ifi
cs

n
o
t
re
p
o
rt
ed

en
d
u
ra
n
ce

tr
ai
n
in
g

p
lu
s

re
si
st
an
ce

tr
ai
n
in
g

(b
o
th

is
o
m
et
ric

an
d

is
o
to
n
ic
ex
er
ci
se
s
u
si
n
g

a
ru
b
b
er

b
an
d
)

W
ee
k
1–
3;
2

x
w
k.
,

3
×
10

m
in
s,

Bo
rg

11
W
ee
k
4–
6;
2
x
w
k.
,

3
×
10
m
in
s,
Bo
rg

12
–
13

W
ee
k
7–
9;
2
x
w
k.
,

3x

15
m
in

s,

Bo
rg
12
–
13

W
ee
k
10
–
12
;3

x
w
k.
,
3x
15
m
in
s,
Bo
rg
12
–
13

W
ee
k
12
+
;3
+
x
w
ee
k,

3
×
20

m
in
s,
Bo
rg
12
–
13

te
r
H
o
ev
e
et

al
.[
52
]

Ya
m
ax
D
ig
iw
al
ke
r

SW
-2
00

Tr
i-a
xi
al
ac
ce
le
ro
m
et
er

o
ve
r
8-
d
ay

p
er
io
d

d
u
rin
g
g
ro
u
p
C
R

st
an
d
ar
d
C
R
fo
r
3
m
o
n
th
s

n
o
af
te
r
ca
re

g
en

er
al
in
fo
rm

at
io
n
o
f

b
en

ef
it
s
o
f
PA

St
an
d
ar
d
C
R
fo
r
3
m
o
n
th
s
+

3

fa
ce

to
fa
ce

g
ro
u
p
PA

co
u
n
se
lli
n
g
se
ss
io
n
s
an
d

p
ed

o
m
et
er
s.
Bo

o
kl
et

w
ith

g
o
al
se
tt
in
g
b
ar
rie
r
id
en

ti
fic
at
io
n

an
d
re
la
p
se

st
ra
te
g
ie
s.
Ed
u
ca
ti
o
n

ab
o
u
t
se
d
en

ta
ry

ti
m
e
g
iv
en

h
o
m
e-
b
as
ed

an
d
ce
n
tr
e-
b
as
ed

2
x
w
ee
k

75
m
in
s

g
ym

n
as
ti
cs
,

w

al
ki
n
g

sp
o
rt
s
fo
r
3

m
o
n
th
s

fo
llo
w
ed

b
y
n
o
af
te
r
ca
re

2
x
w
ee
k7
5
m
in
s

g
ym

n
as
ti
cs
,w

al
ki
n
g

sp
o
rt
s
fo
r
3
m
o
n
th
s

9
m
o
n
th
s
af
te
r

ca
re

p
ro
g
ra
m
:3

fa
ce
to
fa
ce

se
ss
io
n
s:
1-
h

ex
er
ci
se
p
ro
g
ra
m

an
d
1-
h

b
eh
av
io
u
ra
l
co
u
n
se
lli
n
g
p
ro
g
ra
m

Va
rn
fie
ld

et
al
.[
53
]

C
A
P-
C
R
vi
a
N
o
ki
a

sm
ar
tp
h
o
n
e
p
re
–

in
st
al
le
d
w
it
h
st
ep

co
u
n
te
r
an
d
h
ea
lt
h

d
ia
ry
w
it
h
ac
ce
le
ro
-m
et
er

p
at
ie
n
ts
el
ig
ib
le
fo
r
a

C
R
re
fe
rr
al

av
er
ag
e
d
ay

p
o
st

ca
rd
ia
c
ev
en

t:
co
n
tr
o
l:
68

d
ay
s

C
A
P-
C
R:
53

d
ay
s

ce
n
tr
e
b
as
ed

C
R
fo
r

6
w
ee
ks

en
co
u
ra
g
ed

to
m
ai
n
ta
in

lif
es
ty
le
ch
an
g
es

ac
h
ie
ve
d

d
u
rin

g
C
R

C
A
P-
C
R
A
p
p

h
o
m
e-
b
as
ed
an
d
ce
n
tr
e-
b
as
ed

2
x
w
ee
k
ex
er
ci
se

fo
r
6
w
ee
ks

ci
rc
u
it
b
as
ed

ex
er
ci
se

lig
h
t
to

m
o
d
er
at
e
in
te
n
si
ty
fo
llo
w
ed

b
y
se
lf-

m
an
ag
em

en
t

w
ee
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Hannan et al. BMC Sports Science, Medicine and Rehabilitation (2019) 11:14 Page 9 of 21

Common reasons participants dropped out of studies in-
cluded loss of interest/withdrew [52, 67, 68, 73], family
commitment [68], work commitment [53, 68], medical
reasons [52, 53, 68, 69, 73], lack of time [53, 73], technical
issues [53, 73], and lack of motivation [52, 53, 70, 73]. In-
dividual trial breakdowns for reasons for drop out can be
seen in Table 4.

Adverse events
Five studies (56%) reported adverse events during the
trial period [67, 69–71, 73]. No adverse events related to
exercise occurred in two of these studies [67, 71]. Ad-
verse events, which were non-cardiac related (ankle [69],
knee [69, 70] and back injuries [69], shortness of breath
[69], rare blood disease [70] and fishing hook wound
[70]), were reported in two studies [69, 70]. One study
[73] reported adverse cardiac events, of which there
were seven incidents (new onset atrial fibrillation, new
onset angina at rest and femoral artery aneurysm post
percutaneous coronary intervention), however, none
were deemed to be related to exercise. Individual trial
breakdowns for adverse events reported can be seen
in Table 4.

Outcome measures
Outcome measures used in the studies were varied.
CRF was assessed by five studies [53, 67, 68, 70, 73]
(56%). Step count was measured by five studies [52,
67, 69, 70, 72] (56%) over a one [52, 69, 72] or 2 week
[70] period, using pedometers [69, 72] or accelerome-
ters [67, 70, 71]. Avila et al. [67] did not report the time
period that step counts were measured. Exercise duration
was reported by three studies [67–69] (33%), exercise in-
tensity was reported by four studies [52, 67, 70, 71] (44%),
and two studies reported on sedentary time [52, 67]. Indi-
vidual trial outcome measures can be seen in Table 5.
Timepoints for outcome measure acquisition can be

seen in Fig. 2. The figure shows the wide range of study
lengths (12 weeks to 18 months) and timing of main out-
come measures. Two studies [69, 70] (22%) were less
than 6 months’ duration, four studies [53, 67, 68, 73]
(44%) were between five- and seven-months’ duration,
and three studies [52, 72, 72] (33%) ran for 12 months
or more. The longest duration was 18 months [52].
Duscha et al. [70] did not report the length of time of
Phase 2 CR, only the number of sessions, and Guiraud
et al. [71] used two groups of participants that had either
2 months or 12 months of no intervention between the
completion of their Phase 2 CR and the onset of the
Phase 3 CR.

Cardiorespiratory fitness/exercise capacity
Five studies [53, 67, 68, 70, 73] (56%) measured CRF/ex-
ercise capacity changes. The outcome measure varied

across studies. Three studies [67, 70, 73] (33%) measured
VO2peak. Two of these, used a cycle ergometer with
expired gas analysis [67, 73] and one used a maximal
treadmill test with expired gas analysis [70]. Another
study measured anaerobic threshold using a cycle erg-
ometer with gas analysis [68] and one study [53] utilised
a six-minute walk test (6MWT).
Figure 3 depicts the meta-analysis and forest plot re-

sults performed for VO2peak changes. The meta-anlaysis
identified three studies [67, 70, 73] that had assessed
change in VO2peak. All three studies showed WPAM
with exercise prescription or advice significantly im-
proved VO2peak as compared to not utilising a WPAM;
(MD 1.65 mL/kg/min; 95% CI [0.64–2.66]; p = 0.001;
I2 = 0%). A sensitivity analysis was performed by remov-
ing Avila et al. [67]. This resulted in a larger mean differ-
ence (1.65 [0.64–2.66] versus 2.24 [0.58–3.89]). The
heterogeneity remained at I2 = 0%. (Fig. 4). A sensitivity
analysis that removed the weighting of Avila et al. [67]
was employed due to the heterogeneity of the results of
daily step count compared to the three other studies in-
cluded in the meta-analysis. The VO2 peak results ex-
tracted from Avila et al. [67] were, however, significantly
more homogenous. Avila et al. [67] utilised a heart rate
monitor (Garmin Forerunner) to guide the participant’s
exercise sessions. Therefore, participants of this study
may not have engaged solely in walking or running dur-
ing the intervention period, but rather may have chosen
numerous other forms of exercise such as cycling or
gymnastics.
A qualitative analysis of the effect WPAM with exercise

prescription or advice had on CRF/physical capacity was
undertaken. The analysis showed a moderate level of evi-
dence for WPAM improving physical capacity to a greater
extent than no WPAM (Table 6).

Six-minute walk test
Varnfield et al. [53] completed a 6MWT test to determine
the impact of their Care Assessment Platform CR inter-
vention on exercise capacity at 6 weeks and 6 months.
They found both groups significantly increased distance
from baseline to 6 weeks and 6 months, however there
was no significant difference between groups. (6 weeks:
control 537 ± 86 m to 584 ± 99 m; p = 0.001 vs interven-
tion 510 ± 77 m to 570 ± 80; p < 0.001); (6 months: control 537 ± 86 m to 601 ± 95; p < 0.05 vs intervention 510 ± 77 m to 571 ± 88; p < 0.05). Adjusted mean difference at 6 weeks was not found to be significant p = 0.4.

Pedometer step count
Five studies [52, 67, 69, 70, 72] (56%) reported on the
number of steps completed by participants. Fig. 5 depicts
the meta-analysis and forest plot results performed for
step count change pre and post intervention. Three

Hannan et al. BMC Sports Science, Medicine and Rehabilitation (2019) 11:14 Page 10 of 21

studies [52, 69, 70] (75%) showed improved step counts
when using a WPAM versus not utilising one, however
the overall effect was not significant. (SMD 0.45; 95% CI
[− 0.17–1.07]; p = 0.15; I2 = 82%). The SMD of 0.45
equates to a medium effect size.

A sensitivity analysis was performed by removing Avila
et al. [67]. This resulted in a significant difference in step
count, favouring WPAM with exercise prescription or
advice (SMD 0.78; 95% CI [0.54–1.02]; p < 0.001). The increased SMD of 0.78 also equated to a moderate effect

Table 4 Reasons for Drop Out and Adverse Events

Study Reasons for Drop Out (n) Adverse Events

control intervention unclassified/other

Avila et al. [67] loss of interest (2)
new cardiac intervention (2)

loss of interest (2) nil events occurred

6- week follow up:
unrelated medical reasons (3)
work (1)
withdrew consent (1)
excluded (5)

6- week follow up:
unrelated medical
reasons (4)
work (1)
withdrew consent (1)
excluded (7)

data not published

Butler et al. [68] 6- month follow up:
unrelated medical reasons (3)
deceased (1)

6- month follow up:
unable to be contacted (2)
family needs (1)
work (1)

Cupples et al. [69] influenza (1) anaemia (1)
depression (1)

ankle injury
knee injury
back pain
shortness of breath
(no events prevented
completion of study)

Duscha et al. [70] reason not published (2) reason not published (3)
unusable data: failed to give a
good effort on CPX; ICD reset (2)

lost to follow up (2) randomised group not published
knee injury from falling on ice
rare blood disease diagnosis
severe fishing hook wound

Guiraud et al. [71] nil nil nil nil events occurred

Houle et al. [72] data not published data not published data not published data not published

Skobel et al. [73] withdrew (18)
cancelled follow up (3)

withdrew (15)
poor compliance (17)
lack of time, internet issues,
demotivation (21)
chronic infection (1)
back pain (1)

technical problems (21) control;
new onset atrial fibrillation (1)
new angina at rest (1)
pseudo aneurysm of femoral
artery after PCI (1)
intervention:
none related to exercise
patients required angiography
(not related to training) (2)
chest pain requiring CABG
before exercise (2)

ter Hoeve et al. [52] lost to follow up (62)
prematurely quit (52)
declined further participation:
poor motivation (5) unknown (4)
medical complications (1)

pedometer:
lost to follow up (57)
prematurely quit (43)
declined further participation:
poor motivation (5) unknown (8)
medical complications (1)

data not published

Varnfield et al. [53] logistical:
time16%
location 7%
transport 24%
competing life demands:
work 10%
stress 4%
change in circumstances:
deterioration of health
unrelated to CR 14%
lack of motivation 4%

change in circumstances
deterioration of health unrelated
to CR 9%
difficulty using IT tools 7%

data not published

Abbreviations: CPx cardiopulmonary exercise test, ICD implantable cardioverter-defibrillator, PCI percutaneous coronary intervention, CABG coronary artery bypass
graft surgery, CR cardiac rehabilitation, IT information technology

Hannan et al. BMC Sports Science, Medicine and Rehabilitation (2019) 11:14 Page 11 of 21

size. Removing Avila et al. [67] also reduced the hetero-
geneity to 0% (Fig. 6).
Houle et al. [72] also reported on steps of participants,

however published percentage of participants reaching >
7,500 steps per day and therefore could not be included
in the meta-analysis. They did find a significant
difference between groups. The intervention group

significantly increased the percentage of patients achiev-
ing > 7,500 steps per day more than the control group at
6,9 and 12 months (75% vs 41%;68% vs 36%;83% vs 55%,
respectively; p < 0.05). A qualitative analysis of the effect WPAM with exercise

prescription or advice had on the amount of PA per-
formed by participants was undertaken. The analysis

Table 5 Physical Activity Outcome Measures

Study Steps/Day VO2 peak (mean ± SD) Physical Activity Duration
(mean mins ± SD)

METS at AT

Avila et al. [67] Pre Post Pre Post Pre Post

6419 (2227–
13181) cb

6408 (296–
12041) cb

26.6 ± 4.9 c 26.4 ± 5.4 c 114 ± (30-311) c e 114 ± (6-382) c e

7896 (2018–
12554) ib

6469 (473–
12554) ib

26.7 ± 6.6 i 27.8 ± 6.8 i
p = 0.03

145 ± (34–299) ie 141 ± (51–259) ie

Cupples et al. [69] 7869 ± 4209 c a 42 ± 2,624 cch

6123 ± 3151 i a 2742 ± 3164 i ch

p = .004

Duscha et al. [70] 7411 ± 2811 c a 7243 ± 3209 c a 20.7 ± 5.6 c 19.1 ± 5.5 c

9003 ± 2694 i a 9414 ± 3051 i a 21 ± 5.7 c 21.7 ± 5.6 c

Houle et al. [72] 41 cd 55 cd

31 id 83 id p = .042

ter Hoeve et al. [52] 514 ± 115 cch

1504 ± 1835 i ch

Skobel et al. [73] 12.8a c 19.5 ± 4.8

13.8a i 21.9 ± 8.3
p = .005

Butler et al. [68] 367 ± 268 cf 355 ± 271 cf 3.6 ± 0.8c 3.9 ± 1.3c

343 ± 275 if 455 ± 361 if

p = .025
3.5 ± 0.7 i 3.9 ± 1.1 i

Abbreviations: c control group, i intervention group, SD standard deviation,a: mean ± SD,
b: mean (range),ch: resulting change mean ± SD,d: % of participants

achieving > 7500 steps/day, %: percentage, VO2peak: maximal oxygen uptake, METS metabolic equivalents, AT anaerobic threshold, p: p value,
e:> 3 METS; mins/

day± (range),f: mins/week; mean ± SD; Active Australia Survey

Fig. 2 Duration of Study

Hannan et al. BMC Sports Science, Medicine and Rehabilitation (2019) 11:14 Page 12 of 21

showed a moderate level of evidence for WPAM improv-
ing PA to a greater extent than no WPAM (Table 7).

Intensity/Accelerometry data
Four studies [52, 67, 70, 71] (44%) reported on intensity
of PA. One study [67] did not record how long the in-
tensity was measured for. Another study [71] recorded
intensity data throughout the intervention period in the
wearable group and for 1 week in the control group. A
third study [52] collected intensity data over 8 days, and
the final study [70] recorded intensity data for 2 weeks
at the beginning and 2 weeks at the end of the interven-
tion period.
One study found no significant differences in the in-

tensity of exercise performed by participants in either
the intervention or control group [67]. The three
remaining studies [52, 70, 71] reported different findings.
One study [70] reported the intervention group signifi-
cantly increased the time spent in moderate-high
intensity activity compared to the control group (inter-
vention; 3 ± 15 mins/day increase versus control; − 7 ± 5
mins/day decrease; p < 0.05). In addition, the authors found the control group significantly decreased the time in moderate-low and moderate-high intensity. The change between the groups was significant in both cat- egories (moderate-low; − 10 ± 1 2 mins/day p < 0.05; moderate-high − 7 ± 5 mins/day; p < 0.05). The second study [71] reported the duration of moderate intensity PA increased significantly at the 8 week compared to

baseline in the intervention group only (70.1 ± 32.4 min/
week to 137 ± 87.5 min/week);(p < 0.0004). The final study [52] showed no significant change in moderate to vigorous intensity PA between control and intervention groups (p = 0.529), however time in prolonged moderate- vigorous PA of the intervention group improved more at 3 months compared with the control group. (p = 0.054).

Sedentary time
Two studies reported on changes to time spent seden-
tary [52, 67]. Avila et al. [67] found no significant differ-
ences between the control and home-based groups
(control: 1100; range: 825–1355 min/day to 1062; range:
484–1402 versus intervention: 1039 range: 688–1260 to
1032 range:790–1455 min/day). In addition, ter Hoeve et
al. [52] also reported no change in sedentary behaviour
time.

Psychological measures/quality of life
A third of the studies (3/9) did not have outcome mea-
sures to investigate the effect of WPAM with exercise
prescription or advice on quality of life (QoL) or psycho-
logical factors [52, 70, 71]. Each study that did assess
psychological effects (6/9) used different tools, however
the EQ. 5D and Kessler scales were used in several stud-
ies. Three [67, 69, 73] of the six studies [53, 67–69, 72, 73]
that used psychological outcome measures found no signifi-
cant differences in health related quality of life [67, 69],
general health status (EQ. 5D) [69, 73], hospital anxiety and

Fig. 4 Sensitivity analysis Vo2peak

Fig. 3 Forest Plot aerobic capacity

Hannan et al. BMC Sports Science, Medicine and Rehabilitation (2019) 11:14 Page 13 of 21

depression scale [73] or stage of behavioural change [69].
However, the remaining three studies [53, 68, 72] did report
significantly improved overall quality of life [72], health re-
lated quality of life [53], general health status (EQ. 5D) [53]
and decreased depression, anxiety and stress scale
(DASS21) [53] and psychological distress scale (Kessler 6
[68] and Kessler 10 [53]) scores.
Specifically, Butler et al. [68] reported the interven-

tion group had significantly greater improvement in
behavioural (p = 0.039); and cognitive strategies (p =
0.024) compared to the control group at 6 weeks,
however, at 6 months only the cognitive strategies
remained significantly greater when adjustments were
made for baseline differences (p = 0.001).
At 6 weeks, Varnfield et al. [53] reported significant im-

provements in several components of the Kessler 10 for
both groups, however, these were not significantly differ-
ent between groups (psychological distress scale, DASS-
anxiety). The EQ. 5D scores significantly improved in the
intervention group compared with the control group (p < 0.001). At 6 months, the between group differences were not significant for Kessler 10 nor EQ. 5D. Houle et al. [72] used the Quality of Life Index-cardiac

version 111 and reported the health and functioning
score (p = 0.048) and family score (p = 0.048) were statis-
tically improved compared to control group at 6 weeks.
They also found overall QoL (p = 0.048) and the health
and functional score (p = 0.036) were significantly im-
proved compared to the control group at 12 months.

Discussion

The aim of this systematic review and meta-analysis was
firstly to determine whether using a WPAM with exer-
cise prescription or advice during the maintenance phase
of CR was effective in maintaining or improving CRF
and/or the amount of daily PA and sedentary time.
Secondly, we aimed to collate the outcome measures
used in the studies, reasons for drop out, adverse events,
and QoL/psychological impact resulting from WPAM
during the maintenance phase of CR. Our review of the
literature identified that there are no other systematic
reviews investigating the effect of WPAM on the above
parameters within the cardiac population.

Main findings
The main findings of the reviewers were that using a
WPAM with exercise prescription or advice significantly
improved CRF to a greater extent than having no device
for people with cardiac disease who are exercising
through to the maintenance phase of CR. The review
also showed that WPAM did not result in any cardiac
adverse events and may assist in improving step count
and some components of psychological measures (cogni-
tive and behavioural strategies, psychological distress,
anxiety, overall QoL).

Study quality
Overall, our results showed the quality of individual
studies in our review was good. When scoring the

Table 6 Qualitative Analysis of Physical Capacity Outcome Measures

Study Quality Outcome Measure Effect Best Evidence Synthesis

Avila et al. [67] Good VO 2 peak + Moderate
a

Butler et al. [68] Good METs at AT =

Duscha et al. [70] Fair VO 2 peak +

Skobel et al. [73] Good VO 2 peak +

Varnfield et al. [53] Good 6MWT =

+, significant difference favouring WPAM, −, significant difference favouring control, =, no significant difference between groups. aModerate Evidence: significant
findings provided by one study with high quality and/or two or more studies with low quality, and by generally consistent findings in all studies (more than 60%
of the studies reported consistent findings)
Abbreviations: VO2peak peak aerobic capacity, METs metabolic equivalents, AT anaerobic threshold, 6MWT six-minute walk test

Fig. 5 Step count

Hannan et al. BMC Sports Science, Medicine and Rehabilitation (2019) 11:14 Page 14 of 21

methodology of the studies using the PEDro scale, only
two studies [69, 70] were found to be of fair quality. In
future studies, the addition of blinding assessors and in-
corporating intention to treat in data analysis, would as-
sist in improving study quality.

Study characteristics
Our results showed that research into the effectiveness
of WPAM in the cardiac population, although limited,
has been conducted primarily in the northern hemi-
sphere (78%), with only two studies occurring south of
the equator. Most participants across the included stud-
ies were male (78%), which represents male dominated
enrolment seen in CR [74]. Future studies investigating
whether the effects of WPAM and exercise prescription
or advice differ depending on sex would be beneficial.
The participant diagnoses and cardiac interventions

across the studies represented the main patient presenta-
tions seen at CR programs and therefore, were a good
representation [5]. However, no studies investigated
whether patients’ specific diagnosis influenced the out-
comes from WPAM. This would be valuable for future
studies as this could ascertain, for instance, whether pa-
tients who are re-perfused benefit more from utilising a
WPAM than those on medical management.

There were many different WPAM used across studies.
Therefore, the results need to be viewed with caution as
none of the studies included in this review compared the
effectiveness of different devices at increasing PA. A
study by Cadmus-Bertram et al. [75] showed Fitbits to
be more effective than pedometers at increasing exercise
intensity of participants, therefore comparisons between
devices would be useful.
Our review noted that the duration of less than half

the studies was 3 months or less and the longest study
duration was 18 months. Most studies, therefore, were
too short to predict the effect of WPAM with exercise
prescription or advice on mortality, hospital admission
and long-term adherence to PA. Our results found
greater dropout rates were seen in the studies lasting
more than 6 months compared with those lasting three
or fewer months. Longer duration studies are warranted
to determine whether adherence to the usage of a WPAM
decreases over time.
There were large variations across studies regarding

exercise advice given to participants, recording practices
of daily exercise, and additional input given to improve
adherence. It is difficult to determine whether WPAM
alone are responsible for the improvements shown and
what contribution these confounding variables may have
made to the results.

Fig. 6 Sensitivity Analysis step count

Table 7 Qualitative Analysis of Physical Activity Outcome Measures

Study Quality Outcome Measure Effect Best Evidence Synthesis

Avila et al. [67] Good Steps/day and PA Duration = Moderate a

Butler et al. [68] Good PA Duration +

Cupples et al. [69] Fair Steps/day +

Shower and a. [70] Fair Steps/day =

Guiraud et al. [71] Good Total Active Energy Expenditure +

Houle et al. [72] Good % of participants over 7,500 steps/day +

ter Hoeve et al. [52] Good Steps/day +

+, significant difference favouring WPAM, −, significant difference favouring control, =, no significant difference between groups. aModerate Evidence: significant
findings provided by one study with high quality and/or two or more studies with low quality, and by generally consistent findings in all studies (more than 60%
of the studies reported consistent findings)
Abbreviations: PA physical activity, % percentage

Hannan et al. BMC Sports Science, Medicine and Rehabilitation (2019) 11:14 Page 15 of 21

Reasons for drop out
According to a review by Dishman et al. [76], 50% or
more of participants drop out of exercise in clinical set-
tings within 6 months. Apart from one study [73], the
dropout rate for the studies in our review was found to
be less (< 33%) than this. Our results also suggested that using a WPAM did not affect the dropout rates com- pared to using no device. The review by Dishman et al. [76] reported that atti-

tudes to exercise, self-perceptions, health beliefs, goals,
and motivation were the main influencing factors to ad-
herence. Our findings were similar as most participants
reported lack of interest and motivation, other commit-
ments and medical reasons as the main reasons for drop
out across all trials.

Adverse events
Although only half the studies reported on adverse
events, most were non-cardiac related. No cardiac events
reported were related to exercise training, which sug-
gests that exercise and the addition of WPAM does not
increase incidences of cardiac events. This is in line with
numerous studies that have shown low adverse event
rates with CR exercise [23, 77, 78]. The specific effect of
WPAM on safety cannot be determined from these stud-
ies, as only one reported which group (control or inter-
vention) the participants who suffered an adverse event
were in.

Outcome measures
Cardiorespiratory fitness/exercise capacity
Our results showed WPAM with exercise prescription
or advice improved CRF to a greater extent than no de-
vice with the mean overall difference being 1.65 mL/kg/
min. A study by Laukkanen et al. [79], observed a 9% re-
duction in all-cause mortality in those that increased
CRF by 1 mL/kg/min over an 11-year period. Our results
were higher than Laukkanen et al. [79] suggesting our
results are clinically significant. The qualitative best evi-
dence synthesis we conducted also mirrored the results
of the meta-analysis in favour of WPAM and suggests
there is moderate evidence to support the use of WPAM
with exercise prescription or advice on improving CRF/
physical capacity in Phase 3 CR populations.
To the authors’ knowledge, there appears to be no other

systematic reviews that have investigated the effect of
WPAM with exercise prescription or advice on change in
CRF in any population group. It is therefore difficult to
directly compare our results to previous studies. However,
two studies compared CRF changes as a result of using
mobile phone interventions, rather than WPAM. Direito
et al. [80] investigated fitness changes in 51 active, young
people. Cardiorespiratory fitness was assessed using the 1-
mile run/walk test. Our study results contrasted with the

results found by Direito et al. [80] as they reported no sig-
nificant difference in physical fitness compared to the con-
trol group. Similarly, another study by Maddison et al.
[81] found peak oxygen uptake did not change as a result
of a mobile phone intervention including text messages,
websites and video messages. The results of this review
contrast with studies based within the healthy population
as it showed improvements in CRF and may support the
use of WPAM with exercise prescription or advice to im-
prove CRF in the cardiac population.
Few studies have investigated the effect of WPAM with

exercise prescription or advice on six-minute walk test
distance. We found only one study in our review [53] that
used the 6MWT as an outcome measure. Varnfield et al.
[53] found both control and intervention groups improved
six-minute walk test distance, however there was no
significant difference between groups. To the authors’
knowledge, there has only been one other study [82] in-
vestigating WPAM that used the 6MWT as an outcome
measure and was performed with people diagnosed with
heart failure. Evangelista et al. [82] reported that patients
who showed improvements in their pedometer scores
over 6 months also improved their 6MWT distance when
compared with patients whose pedometers reflected min-
imal change in distance walked. Our findings cannot be
directly compared; however, the study suggests that partic-
ipants who adhere more to WPAM with exercise prescrip-
tion or advice may increase their functional capacity to a
greater extent than those adhering less.

Pedometer step count
Although our results did not show a significant total ef-
fect increase in step count, 70% of the studies reported
significant increases in step counts. The sensitivity ana-
lysis which removed one study [67] however, did result
in a significant difference in step count. It also changed
the heterogeneity from substantial to minimal. The sen-
sitivity analysis also increased the effect size (SMD) from
0.45 to 0.78 indicating a moderate effect size [58]. As
previously stated, the sensitivity analysis was carried out
due to an identified methodological factor which pre-
disposed the results to a poorer outcome. This may ex-
plain why VO2 peak data supported the hypothesis,
whilst daily step count data contradicted the hypothesis,
and the results of the other three studies. Our qualitative
analysis, which compared the results from seven studies,
suggests there is moderate evidence to support the use
of WPAM with exercise prescription or advice on im-
proving PA in the maintenance phase of CR.
As there have been no systematic reviews investigating

the effect of WPAM on step count in the cardiac popu-
lation, our results cannot be directly compared to the lit-
erature. There have been two recent systematic reviews
surrounding the effect of smartphone technology and

Hannan et al. BMC Sports Science, Medicine and Rehabilitation (2019) 11:14 Page 16 of 21

WPAM on the amount of PA performed in healthy sub-
jects. Bort-Roig et al. [83] found five studies with partici-
pant numbers ranging from 12 to 42 that investigated
PA duration. All studies used step count as the outcome
measure. Of the five studies, four (80%) reported in-
creased step count ranging from 800 to 1,104 more
steps/day. The duration of the studies ranged between 2
weeks and 6 months. The second systematic review by
Muntaner et al. [84] included 12 publications. They in-
vestigated the impact of mobile devices on PA. All par-
ticipants were healthy subjects. The trials used mobile
applications, self-reported questionnaires, accelerome-
ters and pedometers. Half of these (6/12) reported sig-
nificant increases in PA. However, only two of the
studies utilised WPAM. Both studies did not investigate
the effect of using a WPAM in improving PA. Both
groups used pedometers or accelerometers for outcome
measures, rather than an intervention. The results of
this review resemble findings from the healthy popula-
tion and suggest the use of WPAM with exercise pre-
scription or advice with exercise prescription or advice
may improve step count in the cardiac population.

Intensity/Accelerometry data
There are minimal studies investigating the effect of
WPAM with exercise prescription or advice on intensity of
exercise. Our results showed 75% of studies which mea-
sured intensity found a significant increase in the amount
of moderate and moderate-high intensity PA of participants
compared to the control group for at least one time point.
Our results are similar to that found in the Fitbit group by
Cadmus-Bertram et al. [75] who investigated the effect of
wearing a Fitbit versus wearing a pedometer. Those who
wore a Fitbit increased moderate-vigorous activity by 62 ±
108 mins/week. However, those who wore a pedometer
did not significantly increase intensity. A further study by
Ayabe et al. [85] who investigated WPAM within a
chronic disease population, found after 3 weeks, partici-
pants who could monitor their intensity using an acceler-
ometer increased time spent in moderate-vigorous activity
significantly more than participants who only wore a ped-
ometer. Another study by Finkelstein et al. [34] found the
WPAM group performed significantly more moderate-
vigorous activity than the control group at 12 months.
However, this was not significant at 6 months and further
supports the need for longer duration studies. Our results
are similar to that reported previously in the literature and
suggests WPAM with exercise prescription or advice with
exercise prescription or advice may assist in increasing ex-
ercise intensity for people diagnosed with cardiac disease.

Sedentary time
Our review identified two studies that investigated the
effect of WPAM with exercise prescription or advice on

sedentary time in the cardiac population. Both studies
found no significant differences in sedentary time be-
tween the intervention and control groups. These results
are similar to that found by Sloan et al. [86], who inves-
tigated the effect WPAM had on sedentary behavior in
the healthy population. Sloan et al. [86] reported in-
creases in step counts resulted in a decrease in sedentary
time, however there was no significant decrease between
groups. It appears sedentary time is not influenced by
utilising WPAM with exercise prescription or advice.

Psychological measures
Our analysis revealed mixed results relating to the im-
provement of psychological measures when using WPAM
with exercise prescription or advice in the maintenance
phase of CR. Half the studies showed some statistical dif-
ference between group differences in some categories of
the respective outcome measure (EDQ5, DASS 21, Kessler
6,overall quality of life) suggesting there may be an effect,
although, the studies used a broad range of different mea-
sures to investigate psychological effects. There appears to
have been no previous reviews or studies that have expli-
citly aimed to examine the psychological effects of WPAM
in people with CVD. However, Maddison et al. [81] did
explore the effect of a mobile phone on changes in self
efficacy and quality of life. They reported significant im-
provements in self efficacy and general health domain of
the SF 36. In addition, Thorup et al. [49] found partici-
pants who used a pedometer reported increased compe-
tence to achieve step goals and feelings of support.
Participants also reported improved motivation to exer-
cise. Due to our mixed findings, it is therefore difficult to
conclude whether WPAM with exercise prescription or
advice improve psychological measures or not which is
similar to that found by previous literature.

Strengths of the review
The strengths of this review include its methodology and
statistical analysis. As previously stated, this review is the
only analysis of the effectiveness of WPAM with exercise
prescription or advice during the maintenance phase of
CR. The review also used strict methodology under
PROSPERO registration and PRISMA guidelines. Statis-
tical analysis used a conservative approach to calculating
standard deviations and reporting was transparent.

Limitations
There were several limitations to this review. Using the
PEDro scale, we determined that although approximately
one third of studies were of good quality, two thirds
were of fair quality. There are several improvements that
could be made to all studies to increase the confidence
in the results. For example, only one study blinded as-
sessors [73] and only two concealed allocation [52, 53].

Hannan et al. BMC Sports Science, Medicine and Rehabilitation (2019) 11:14 Page 17 of 21

Study quality assessed through the PEDro scale numer-
ical rating method does not allow for the individual
reporting of significant other bias. There were several
significant other biases identified during the appraisal of
the studies. This included poor completion rates (22% in
the intervention group [73] and 43% in the control
group [53]) that may have introduced attrition bias by
only analysing participants who finished the trial. Poor
female representation [52, 67–73] can influence results
by measuring a disproportionate gender sample of the
population, therefore the results may not have been rep-
resentative of the general CR population and may be
more relevant to males. Finally, one study [69] used
block randomisation that delivered treatments over dif-
ferent times of the year. This study was conducted in
Ireland where outside temperatures and daylight hours
during seasons vary greatly and may have introduced a
significant bias by reducing adherence to exercise.
Another significant limitation of this review is the use

of concurrent educational/motivational therapies based
on the information that a WPAM gives a participant
about their activity levels by all studies. Additionally,
some studies prescribed specific exercise interventions
along with WPAM. These confounding variables make it
difficult to distinguish how much influence the WPAM
itself or additional exercise prescription, and/or educa-
tional/motivational strategies had on the results. How-
ever, this review still provides valuable insight into the
potential effects of WPAM in the cardiac population
despite uncontrolled, concurrent treatments such as ex-
ercise prescription potentially contributing to improve-
ments made to key outcomes.
The studies had low homogeneity in several attri-

butes such as timing, length of study, type and par-
ameter of intervention, as well as and type and
parameters of control conditions. This is a because
our review used data from studies that had different
aims to the review, but still, still collected appropriate
data on the use of a WPAM in the maintenance
phase of CR. For example, one study’s main aim was
to evaluate the effectiveness of WPAM in a specific
sub- group of non-compliant participants that were
up to 1 year post cardiac incident [71]. In particular,
the varying commencement of intervention (end of
phase 2 or phase 3) may have potentially influenced
the results.
Outcome measures used were also a significant source

of heterogeneity. Therefore, despite including nine stud-
ies in the review, the meta-analysis could only include
three studies [67, 70, 73] for VO2 peak and four studies
[52, 67, 69, 70] for daily step count. These factors imply
that although the meta-analyses and review support the
hypothesis that WPAM with exercise prescription or
advice help to maintain PA in the maintenance phase of

CR, these results are based on a small number of
studies.

Future directions
Additional primary research is needed to investigate
the effectiveness of WPAM with exercise prescription
or advice on maintaining PA, peak aerobic capacity,
intensity of exercise and psychological effects in pa-
tients diagnosed with cardiac disease in the mainten-
ance phase of CR. Future studies should attempt to
use an attention control group to further strengthen
their results by reducing the variables of extra forms
of therapy such as specific exercise prescription and
motivational therapies. Future studies should blind as-
sessors and incorporate intention to treat analysis to
improve quality of trials. With respect to psychological
measures, future studies may benefit from investigating
general health status (EQ. 5D), psychological distress,
(Kessler 6) and Quality of Life index (cardiac version 111),
as only these tools showed significant differences between
groups in our review. Future studies should focus on good
quality methodology, include a large sample number, and
utilise consistent outcome measures over a longer follow
up period. This would allow analysis of the effects WPAM
may have on hospital readmission and mortality rates to
be conducted. Comparing effect of WPAM on different
genders, specific diagnoses and ensuring reporting which
group (control or intervention) participants are in if ad-
verse events occur would be of interest. This would also
improve the evidence base for future systematic reviews
and strengthening confidence in the results.

Conclusion
This systematic review and meta-analysis showed that
WPAM with exercise prescription or advice significantly
improves CRF in the cardiac population to a greater ex-
tent than no WPAM. Additionally, our qualitative ana-
lysis showed moderate evidence in favour of WPAM for
both CRF and step count. The wearing of a WPAM did
not change sedentary time. Psychological effects and ex-
ercise intensity may potentially be enhanced by using a
WPAM. There were no reported cardiac events related
to exercise and unrelated medical conditions, lack of
motivation and loss of interest were reported as the
main reasons for dropping out of trials. Additional lon-
ger-term good quality research is required to strengthen
these conclusions.

Abbreviations
6MWT: Six-minute walk test; AH: Amanda Hannan; CAP-CR: Care assessment
platform; CHD: Coronary heart disease; CI: Confidence interval;
CPx: Cardiopulmonary exercise test; CR: Cardiac rehabilitation;
CRF: Cardiorespiratory fitness; CVD: Cardiovascular disease; ICD: Implantable
cardioverter-defibrillator; IT: Information technology; MD: Mean difference;
MH: Michael Harders; PA: Physical activity; PEDro-Scale: Physiotherapy
Evidence Database Scale; RCT: Randomised controlled trial;

Hannan et al. BMC Sports Science, Medicine and Rehabilitation (2019) 11:14 Page 18 of 21

RCTs: Randomised controlled trials; SMD: Standardised mean difference; VO2
peak: Peak oxygen uptake; WH: Wayne Hing; WPAM: Wearable PA
monitoring devices

Acknowledgements

David Honeyman, Bond University Librarian, reviewed the search terms for
the systematic search.

Authors’ contributions

AH; substantial contribution to the conception, systematic searching, study
quality scoring (Pedro Scale), data extraction, analysis and drafting
manuscript (interpreting data) and creating tables and figures, proof reading.
MH; systematic searching, study quality scoring (Pedro Scale) checking data
extraction, checking tables, creating figure, assisting in reviewing draft
manuscript, proof reading. WH; substantial contribution to both the
conception and revision and editing of manuscript, resolved discrepancies
between author 1 and 2 regarding inclusion of studies. MC; reviewed and
edited draft manuscript. JC; reviewed and edited draft manuscript. JF;
reviewed and edited draft manuscript. All authors read and approved the
final manuscript.

Funding

The authors report that the research was not funded by any specific grant or
funding agency.

Availability of data and materials

All data analysed for this review are included in this published article and
supplementary material.

Ethics approval and consent to participate

Not applicable

Consent for publication

Not applicable

Competing interests

The authors declare that they have no competing interests.

Author details

1Faculty of Health Sciences and Medicine, Bond University, 2 Promethean
Way, Robina, Qld, Gold Coast, Queensland 4226, Australia. 2Physical Activity,
Lifestyle, Ageing and Wellbeing Faculty Research Group Faculty of Health
Sciences, University of Sydney, Lidcombe, NSW, Australia. 3School of Human
Movement and Nutrition Sciences, The University of Queensland, Brisbane,
Australia. 4School of Health and Human Sciences, Southern Cross University,
Gold Coast, QLD, Australia.

Received: 13 May 2019 Accepted: 18 July 2019

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Abstract
Background
Methods
Results
Conclusions
Trial registration
Background
Methods
Study selection
Inclusion criteria
Exclusion criteria
Literature search
Study selection
Data extraction
Study quality
Statistical analysis and synthesis
Results
Study quality
Study characteristics
Reasons for drop out
Adverse events
Outcome measures
Cardiorespiratory fitness/exercise capacity
Six-minute walk test
Pedometer step count
Intensity/Accelerometry data
Sedentary time
Psychological measures/quality of life
Discussion
Main findings
Study quality
Study characteristics
Reasons for drop out
Adverse events
Outcome measures
Cardiorespiratory fitness/exercise capacity
Pedometer step count
Intensity/Accelerometry data
Sedentary time
Psychological measures
Strengths of the review
Limitations
Future directions

Conclusion
Abbreviations
Acknowledgements
Authors’ contributions
Funding
Availability of data and materials
Ethics approval and consent to participate
Consent for publication
Competing interests
Author details
References
Publisher’s Note

Aerobic Training Article Rubric

Partial Credit
Identified but did not explain the test used to measure cardiorespiratory fitness

0.0 pts

No Marks
Did not include any details regarding the cardiorespiratory fitness test performed

5.0 pts

5.0 pts

Full Marks
Addressed both progression and overload

2.0 pts

Partial credit
Addressed only how either progression or overload was included

0.0 pts

No Marks
Did not address progression or overload

3.0 pts

2.0 pts

5.0 pts

Aerobic Training Article Rubric
Criteria	Ratings	Pts
This criterion is linked to a Learning OutcomeDescriptions of Subjects Includes number, sex, age, fitness status, and any other relevant details	5.0 to >4.0 pts Full Marks Included all relevant details 4.0 to >0.0 pts Partial Credit Included some but not all relevant details of subjects 0.0 pts No Marks Did not include relevant details about subjects				5.0 pts
This criterion is linked to a Learning OutcomeCardiorespiratory Fitness Test Description Identifies and describes the cardiorespiratory fitness test	5.0 pts Full Marks Identified and explained cardiorespiratory fitness test	2.0 pts
This criterion is linked to a Learning OutcomeCardiorespiratory Fitness Program Description Describes the cardiorespiratory fitness program including the frequency, intensity, duration, mode and length	5.0 to >4.0 pts Full Marks Included full description of the cardiorespiratory fitness program 4.0 to >0.0 pts Partial Credit Included some but not all details of the cardiorespiratory fitness program 0.0 pts No Marks Did not include any information about cardiorespiratory fitness program
This criterion is linked to a Learning OutcomeProgression and Overload Addresses whether or not the program included progression and overload appropriately		3.0 pts
This criterion is linked to a Learning OutcomeResults of Program Summarizes the results of the program in terms of cardiorespiratory fitness	2.0 pts Full Marks Included results of main outcome 0.0 pts No Marks Did not include results of main outcome
This criterion is linked to a Learning OutcomeIncluded PDF of Article Submits the PDF of the article with assignment	5.0 pts Full Marks 0.0 pts No Marks
Total Points: 25.0