Effect of a Home-Based Exercise Intervention of Wearable Technology and Telephone Coaching on Walking Performance in Peripheral Artery Disease: The HONOR Randomized Clinical Trial

Abstract

A total of 200 patients with peripheral arterial disease (PAD) were randomized to home-based exercise consisting of on-site sessions for the first month, active exercise, and coaching (99 patients) vs usual care (101 patients) for 9 months. The mean change in walking distance was better in the usual care group than in the exercise group. Conclusion:A home-based exercise program consisting of a wearable activity monitor and telephone coaching did not improve walking performance at 9-month follow-up. These results do not support home-based exercise program of wearable devices and telephone counseling without periodic on-site medical center visits to improve walking performance in patients with PAD.Commentary: Clinical practice guidelines recommend either supervised treadmill exercise (class IA recommendation) or home-based walking exercise (class IIA recommendation) as first-line therapy to improve walking in patients with lower extremity PAD. But importantly, both programs required frequent visits to the medical center. But, how often should these visits be required? In this randomized study, the exercise group received four weekly medical center visits during the first month, followed by 8 months of a wearable activity monitor and telephone coaching. The authors suggest increased frequency of periodic on-site visits might have yielded improvedresults. I assume that they mean that if the subjects had visited the medical center three or four times a week instead of once a week, or if they continued to visit the medical center for the full 9-month trial, the exercise program would have resulted in improved walking distances. The study emphasizes that simply telling patients to walk more or involving them in a less than strenuous walking program to improve claudication will not do much good. The problem is that not many vascular surgeons have access to rigorous exercise programs to treat claudication. Until that happens, and until reimbursements for such exercise programs become widespread, the only realistic noninterventional options to treat disabling claudication due to PAD are cilostazol and smoking cessation programs.

Meta-analysis of clinical trials examining the benefit of structured home exercise in patients with peripheral artery disease

“…These sessions included discussion of objectively assessed or patient‐reported adherence to the walking programmes in all trials ( Table ). Recognized counselling methods, such as motivational interviewing or patient‐centred assessment and counselling for exercise, were employed in three trials. The motivational sessions included attending a limited number of group exercise sessions at a central location in some programmes ( Table ).…”

“…All trials reported random allocation of patients to the intervention and control groups, although the method of random sequence generation was not reported in two trials. Only four trials reported blinding of the outcome assessors and only four reported sample size calculations. All but three trials reported that the analysis was by intention to treat.…”

“…As a result, there has been interest in developing structured exercise programmes that are undertaken away from central facilities at a convenient location for the patient near to their home. Home exercise programmes are not supervised in the same way as standard exercise programmes. A systematic review published in 2013 suggested that there was only low‐level evidence supporting the benefit of home exercise programmes and more robust trials were needed.…”

“…A recent Cochrane review also suggested that home exercise had no benefit over walking advice alone and was less effective than supervised exercise in improving walking performance in patients with PAD. Since publication of these systematic reviews, more randomized trials of home exercise programmes have been reported. Furthermore, the recent Cochrane review focused on summating outcomes reported at the same time point rather than summating results at the planned primary assessment point of each trial.…”

Mobile health and cardiac rehabilitation in older adults

“…42 The recent HONOR trial, which evaluated an mHealth-augmented home-based exercise program for patients with PAD (in patients with a mean age of 70 years), also found no significant difference in significant adverse events between the intervention and control group. 58 While further research is needed into the safety of home-based CR programs, these results provide indirect support that they can be prescribed safely.…”