Home Exercise Therapy in Patients with Stable Congestive Heart Failure (CHF): A Scoping Review

Introduction

Heart failure (HF), or congestive heart failure, is a serious condition in which the heart cannot pump sufficient blood to meet the body’s metabolic demands, often requiring higher filling pressures. Affecting around 38 million people worldwide, its prevalence continues to rise, with over 6.5 million cases and approximately 960,000 new diagnoses annually.¹ In fact, data from 2018 shows that heart failure is among the top 10 non-communicable diseases in Indonesia, with an estimated 229,696 (0.13%) people suffering from heart failure.² The incidence of heart failure, particularly chronic or congestive heart failure (CHF), continues to rise despite advances in detection and management. In 2020, the Global Health Data Exchange reported 64.34 million cases of CHF worldwide, resulting in 9.91 million deaths.³ In high-income countries like the United States, 1–2% of adults have chronic heart failure, with treatment costs estimated at $346.17 billion. In China, approximately 0.9% of the population, or around 4 million people, are affected by CHF.

Fatigue experienced by heart failure patients occurs when they carry out daily activities.⁴ Heart failure is an incurable disease, so sufferers must undergo lifelong treatment to reduce morbidity and mortality. They must undergo treatment, therapy, and regular health checkups. Another study showed that of the 60 heart failure patients studied, 27 patients (42.2%) took their medication on time, 28 patients (43.8%) took the correct dosage, and 32 patients (50%) took the correct type of medication, concluding that heart failure patients have low compliance in managing their treatment. Non-compliance with medication can lead to rehospitalization.⁵

Rehospitalizations are additionally related to a decreased in patients’ quality of life. One effort to address these incidents is through cardiac rehabilitation programs. Cardiac rehabilitation programs for heart failure benefit patient fitness, can improve quality of life, increase VO2Max and cardiac endurance capacity, and serve as a preventive measure by preventing worsening heart health.⁶ Cardiac rehabilitation is a program that includes exercise, health education, and risk factor counseling for people with heart failure. Home-based cardiac rehabilitation is more cost-effective and time-efficient than hospital-based cardiac rehabilitation. Physical activity is one method of cardiac rehabilitation.⁷ Physical activity at home has also been proven to increase exercise capacity and self-efficacy, reduce rehospitalization rates, increase physical capacity, reduce weight, improve autonomic nerve control, improve blood vessel endothelial function, and increase skeletal muscle oxidation capacity.⁸ Therefore, the purpose of this study is to identify and map the scientific evidence related to the application of home exercise therapy in stable CHF patients and the clinical outcomes it produces.

Methods

This literature study utilizes a scoping review design, which maps the concepts underlying the research area, sources of evidence, and available evidence types.⁹ As shown in Figure 1, the article search was undertaken methodically in accordance with the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) Flow criteria.

Figure 1 Illustration of the PRISMA flow diagram.

This method was chosen because it can improve the quality of publication reporting.¹⁰ The databases used in the article search were PubMed, Science Direct, Research Gate, Sage Journals, mbase, Web of Science, Google Scholar and Neliti.

This literature evaluation included studies on physical activity treatment in adult patients with congestive heart failure (CHF). The selected publications were published within the previous ten years (2012–2023) and were either experimental or interventional studies. The target articles were from all Indonesian and English-speaking countries and were full-text.

The search was conducted using keywords related to the previously determined topic of discussion by applying the PICO approach according to the database used. The first article search used the PICO formula as described in Table 1:

Table 1 PICO Approach

Literature selection utilized The Joanna Briggs Institute (JBI) Critical Appraisal to examine and analyse the methodological quality of the retrieved papers. The selected papers for evaluation were then assessed for eligibility using (JBI) Critical Appraisal Tools. An article is considered eligible if it meets > 60% of the assessment criteria. All articles (n = 16) in this review were considered eligible because they scored higher than 60%. Table 2 shows the outcomes of the evaluation.

Table 2 Literature Selection Evaluation Findings

Results

The search results based on the keywords found 214 articles, Articles excluded after applying inclusion criteria 198, Screening Results Based on Inclusion Criteria 16, and 16 Articles that met the criteria discussing “Home exercise therapy for adult patients with congestive heart failure.” Following selection using the predefined inclusion criteria, 16 articles were found relevant. These are shown in Table 3.

Table 3 Article Review Results

Discussion

Several studies have shown that home exercise treatment is a safe and effective non-pharmacological intervention for stable congestive heart failure (CHF) patients. A training program that includes light-to-moderate intensity aerobic exercise, strength training, and breathing exercises has been proven to enhance patients’ functional ability, as seen by increases in 6-Minute Walk Test distance, higher activity tolerance, and peak VO₂.

Furthermore, the majority of trials indicated benefits in quality of life, notably in physical aspects and symptom management such as fatigue and shortness of breath, however the extent of the impact varied depending on the length of the intervention and adherence. Home-based exercise therapy is also linked to fewer hospital admissions and better symptom management, with no increase in serious cardiovascular events, making it a viable option for cardiac rehabilitation, particularly for stable CHF patients with limited access to healthcare services.

In the study¹¹ Indonesia, The intervention consisted of 30 minutes walking three times a week for four weeks at an intensity of 40–60% heart rate reserve in stable heart failure patients who were recommended for termination or outpatient therapy. After receiving Home-Based Exercise Training (HBET) for 4 weeks, the functional capacity of both the control and intervention groups improved. HBET can be used as a nursing modality for heart failure patients. This study demonstrates that home-based cardiac rehabilitation improves aerobic capacity, quality of life, and lowers readmission rates in CHF patients.²⁷ Research suggests that home-based exercise improves peak VO₂ and 6MWT distance in CHF patients compared to regular activities.²⁸

According to research^29, Using a randomized, prospective controlled trial, 50 patients with persistent heart failure and sleep apnea were randomized and put into two groups: one with aerobic exercise, 2 with aerobic and strength training, and 3 with no training. During the training sessions, no traumatic, orthopedic, or cardiovascular concerns occurred. The results of the data analysis showed significant rise in functional ability, strength, and muscular endurance compared to the non-training group. According to research,³⁰ it is concluded that cardiac rehabilitation at home is safe and effective in improving the functional capacity of HF patients, although the effects on quality of life, mortality, and readmission vary.

Supporting research results, such as those conducted by³¹ In all, 92 (86%) individuals in the REACH-HF group and 93 (85%) in the control group contributed to the primary result. Participants were mostly male (78%) and New York Heart Association class II (59%), with a mean age of 70 years and a mean left ventricular ejection fraction of 34%. Participants with HFrEF (heart failure with preserved ejection fraction), who underwent the innovative 12-week REACH-HF home cardiac rehabilitation intervention in addition to usual treatment, exhibited benefits in disease-specific HRQoL and self-management at 12 months compared with usual care alone. Other research findings reported that home-based exercise had a positive impact on functional capacity, quality of life, and reduced readmission rates within 2–12 months.³²

Similar studies, such as the results of the study¹⁴ According to the data analysis results, all treatments had a significant impact on the functional capacity of the hearts of patients with heart failure, and the combined effects of tai chi physical exercise, treadmill exercise, and stationary bicycle exercise were significantly more optimal in patients with heart failure than treatment without physical combination.

In the study²⁴ Used a prospective feasibility study. There were 40 patients at Gothenburg University Hospital in Sweden met the inclusion criteria, namely patients diagnosed with CHF, NYHA functional class II–IV with symptoms of shortness of breath and/or weariness. All were randomly assigned to two groups: a control group of 18 participants and an intervention training group (MBI) of 22. This intervention was performed immediately by qualified educators. The first session featured an overview of the MBI curriculum, which was subsequently examined and reflected on regularly. After that, individuals may do this intervention at home for 20–30 minutes each day, six days a week, for eight weeks.

Mindfulness meditation activities focus attention on thoughts, emotions, and physiological sensations to make persons more aware of sickness and limits in life. The results showed that the intervention group had a significantly lower felt weariness than the control group. Furthermore, the intervention group reported lower symptoms of dizziness or lightheadedness and increased physical function.⁴

Freudman Marilyn’s functional structural model theory explains the family structure in terms of how families are organized. This concept focuses on role structure, value systems, communication patterns, and power structures. According to Friedman³³ The functions of the family a) Affective function; b) Socialization and socialization venue function; c) Reproductive function; d) Economic function; e) Health care/maintenance function. This health care function is relevant to home care. In this function, the family provides all the needs of the family, both physical food, clothing, shelter, and health care. The ability of families to care for their sick members needs to be improved to achieve a prosperous condition.³⁴

Therefore, Friedman’s theoretical model was chosen as a guide for the family nursing process because it facilitated the analysis of interactions between family members and between families and the community.^35,36 Based on this theory, our evidence-based practice uses the concepts of Friedman’s theoretical model to maximize the family’s ability to care for family members with heart failure by implementing interventions carried out by the family from home through telenursing or telehealth.

Friedman’s Structural-Functional Model Theory (Marilyn M. Friedman) is used because home exercise therapy for stable Congestive Heart Failure (CHF) patients is highly dependent on the family’s role as the primary support system. This model views the family as a system whose structure and function mutually influence the health maintenance of family members. A clear family structure allows for the division of roles in monitoring, motivating, and ensuring patient safety during exercise, while family functions particularly healthcare, affective, and coping functions play a crucial role in improving adherence, exercise sustainability, and adaptation to chronic illness. Thus, Friedman’s model provides a strong conceptual framework for explaining how family support contributes to the success of home exercise therapy, improved functional capacity, and the quality of life of stable CHF patients.

Chronic heart failure patients can combine standard care with non-pharmacological therapy that can be performed at home. Physical activity can reduce symptoms, enhance exercise tolerance and quality of life, and help patients.¹¹ Physical activity at home can increase exercise capacity and self-efficacy while decreasing readmissions.¹¹

Heart failure patients experience a decline in heart function and neurobiochemical changes as a compensatory response to the disorder. A heart that fails to pump can cause an increase in ventricular volume at the end of diastole, which leads to increased venous pressure and a decrease in cardiac output. This problem results in poor blood circulation and decreased peripheral perfusion, causing heart failure patients to experience fatigue.³⁷

We found several physical exercise interventions from articles we reviewed for adult patients with heart failure: walking therapy, aerobic exercise, ancient baduanjin gymnastics, inspiratory muscle training, Tele Yoga, physical education and exercise programs, and chair exercises. These interventions produced different results, but they all helped heart failure patients improve their condition, especially regarding their physical activity capacity.

Based on these interventions, determining the exercises that families can do at home for patients with heart failure requires consideration not only of effectiveness, but also of the ability of families and clients to apply the exercise therapy. Physical exercise instructions are important for defining treatments in telehealth, which comprise components such as frequency, intensity, duration, and form of physical activity. The current trend is to regularly tailor exercises to the patient’s capabilities, and to ensure that patients meet their expected targets, individual adjustments and continuous monitoring are required.¹¹

Based on our review, walking therapy is the most effective intervention to be included in telehealth interventions. This is because, besides being able to be performed by family members without direct supervision by an expert, this intervention also does not require any equipment or costs.^38,39 In addition, the results obtained from this exercise therapy are increased functional capacity, increased respiratory muscle strength, and increased peak VO2.^40,41 Adult patients with chronic heart failure who have been stable for 3 months, with or without sleep apnea, have limited physical functional capacity, a ventricular ejection fraction (EF) ≤ 40%, and are receiving outpatient treatment are eligible for this intervention.⁴²

Meanwhile, the intensity and duration of walking exercises are adjusted to each patient’s condition. However, exercising three times a week is the minimum requirement to positively affect heart function, with an ideal duration of 3–6 months to achieve optimal results.^43,44

Limitations

This scoping review has limitations, including that most studies originate from countries with more advanced healthcare facilities, making them potentially less relevant to the local context; variations in exercise methods and intensity, leading to heterogeneity; relatively small sample sizes and short intervention durations; and language limitations, as it only includes articles in English and Indonesian.

Conclusion

Heart failure is a chronic condition that need ongoing treatment and monitoring, with tiredness being a common and severe symptom that hampers everyday activities. Exercise therapy is an essential nonpharmacological treatment for this illness. Walking, aerobic and strength training, tai chi, cardiac rehabilitation, and home-based physical activity have all been shown to improve functional ability, activity tolerance, and health status in adult patients with heart failure.