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0167-5273/$ see front matter 2012 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijcard.2012.04.126

Effects of home versus hospital-based exercise training in chronic

heart failure
Aynsley Cowie a,, Morag K. Thow b, Malcolm H. Granat b, Sarah L. Mitchell c
a
b
c

The Ayr Hospital, Dalmellington Road, Ayr, KA6 6DX, Scotland

Glasgow Caledonian University, Scotland
Scottish Government, Scotland

a r t i c l e

i n f o

Article history:
Received 13 April 2012
Accepted 22 April 2012
Available online 15 May 2012
Keywords:
Exercise training
Chronic heart failure

Many researchers have demonstrated that supervised hospitalbased training yields improvements in exercise capacity and quality of
life (QoL) for heart failure (HF) sufferers [1]. Though comparatively
under-researched, home-training does not involve a potentially tiring
return journey to hospital, and can be undertaken whenever the
individual feels best able to exercise, therefore may offer a more
pragmatic exercise option for this frail group [2,3]. Three previous noncontrolled trials have compared effects of home and hospital-based
exercise training in HF [46]. Two [5,6] found signicant improvements
in exercise capacity and QoL of up to 10% with both types of training,
whilst the other [4] found that only hospital-training signicantly
improved exercise capacity (by 19%). To date, this is the only trial to
compare effects of home versus hospital-based aerobic exercise training
versus control upon exercise capacity and QoL in HF.
Sixty HF sufferers were recruited via the Heart Failure Nursing
Service (HFNS), National Health Service (NHS) Ayrshire and Arran,
Scotland. All had been clinically stable for one month, were on optimised
medication dosages, and were being monitored at home by the HFNS.
Recognised exclusion criteria for exercise training in HF [7] were
adhered to throughout.
A owchart of this study's design is shown in Fig. 1. Both home and
hospital training programmes lasted 8 weeks, and followed the same
overall format [7,8] (Table 1). For training, the hospital group attended a
FUNDER: NHS Ayrshire & Arran's CHD Managed Clinical Network.
Corresponding author. Tel.: +44 1292 614550; fax: +44 1292 616459.
E-mail address: aynsley.cowie@aaaht.scot.nhs.uk (A. Cowie).

physiotherapist-led class, while a DVD and booklet (replicating the

class) was created for home use. The home group were monitored by a
physiotherapist who telephoned them every 2 weeks, and they
completed a diary detailing intensity achieved during every session.
Controls followed their usual HFNS care.
Incremental Shuttle Walk Test (SWT) [9] distance in metres (m) was
used as a measure of exercise capacity, whilst scores obtained from the
Minnesota Living with Heart Failure Questionnaire (MLHFQ) [10] and
Short Form-36 (SF-36) [11] provided measures of QoL. One-way ANOVA
or KruskalWallis were used for between-group analyses involving
three sets of data, while paired t-tests, or Wilcoxon tests were used for
within-group comparisons. Data from pairs of groups were compared
using 2-sample t-tests, or MannWhitney tests.
Characteristics of all recruited participants are shown in Table 2. The
hospital group were almost 10 years older than controls (p= 0.001).
Excluding withdrawals, mean training adherence (percentage completion of 16 exercise sessions) was 86% for hospital-training and 77% for
home, and there was no signicant difference between the groups
adherence (p = 0.32).
Both the home (+44 m, p= 0.02) and hospital (+71 m, p = 0.01)
groups demonstrated signicant within-group increases in SWT distance
after 8 weeks (Table 3). Though not shown in Table 3, these improvements were signicantly greater than observed for controls (p =0.03 for
home-training, p= 0.01 for hospital-training), however there was no
signicant difference between the training groups' effect sizes
(p = 0.59).
There were no signicant between or within-group ndings from any
MLHFQ score, or from the physical component summary (PCS) of the SF36. The hospital group's mean SF-36 mental component summary
(MCS) was signicantly higher (better) than the controls' (p = 0.02)
after 8 weeks (Table 3). Of interest, the hospital group demonstrated a
non-signicant trend for maintenance of all QoL scores.
Improvements in exercise capacity of up to 31% have been observed
with aerobic hospital-training in HF, mainly through programmes
incorporating exercise equipment (e.g., cycle ergometry) [1]. The
present study demonstrated a 31% improvement using a simple,
functional, cost-effective, equipment-free training circuit. Furthermore,

Letters to the Editor

297

n=60 participants

Baseline measurement of exercise capacity and QoL (all participants)*

Randomised using concealed envelopes

Home-training

Hospital-training

8 weeks

Control

Repeat measurement of exercise capacity and QoL (all participants)*

Fig. 1. Study Design. *, measurements obtained by researcher blind to participants randomisation; QoL, quality of life.

though only hospital-training improved SWT distance by the minimum

clinically important difference (MCID) (Table 3), the 16% improvement
elicited by home-training exceeded that yielded by various other home
HF trials [2,3].
Both training programmes generated larger improvements in
exercise capacity than obtained from the other studies comparing
effects of home and hospital-training in HF [46]. Again, these trials
tended to use exercise equipment, whilst Daskapan et al. [4] who
found that only hospital-training signicantly improved exercise
capacityused outdoor walking for home-training, and considered
that uncontrollable outdoor variables (e.g., stopping for trafc) may
have hampered maintenance of its intensity, limiting its physiological
effect. Indeed, although the DVD, booklet and heart rate monitor used in
the present study provided continuous guidance regarding hometraining intensity, researchers could have recorded heart rate data,
rather than relying upon subjective data from training diaries. This
would have allowed more accurate objective examination of whether
sub-optimal home-training intensity limited its effect upon exercise
capacity.

Table 1
Training parameters.
Training
parameter

Details*

Frequency
Intensity

Twice weekly [7,8]

4060% heart rate reserve [7,8]

based on heart rate data obtained during baseline

measurement of exercise capacity
guided by heart rate monitor (POLARFS1 [Polar
Electro UK Ltd., England])
1213 on Borg Rating of Perceived Exertion [7,8]
Time

1-hour exercise session [8]

- 15-minute warm-up
- 30-minute aerobic overload
15-minute cool-down
Type

30-minute aerobic overload

- 15-minute circuit performed twice

- ten 90-second exercise stations per circuit
- one simple, functional aerobic exercise (e.g. knee
lifts) low-paced active recovery (toe tapping,
or slow walking) at each station
progressive interval training [7,8] achieved by
increasing aerobic exercise time and reducing
active recovery time at each station
*, parameters applied to both training groups.

Neither training programmes elicited any signicant effect upon

QoL. Certainly, psychosocial training outcomes are observed less

Table 2
Characteristics of the population studied.
Number of participants
Characteristic

Total
(n = 60)b

Home
(n = 20)

Hospital
(n = 20)

Control
(n = 20)

Mean age/range
(years)a
Males/females

65.8
(3585)
51 (85%) /
9 (15%)
27.3
37 (62%) /
23 (38%)

65.5 (3582)

71.2 (5985)

61.4 (3979)

18/2

16/4

17/3

26.6
12/8

27.3
12/8

27.1
13/7

(67%)
(10%)
(3%)
(20%)

12
1
0
7

15
2
1
2

13
3
1
3

(65%)
(35%)

11
9

15
5

13
7

(0%)
(0%)
(13%)
(29%)
(58%)

0
0
1
4
15

0
0
3
7
10

0
0
4
6
10

(18%)
(20%)
(18%)
(5%)
(10%)
(25%)
(15%)
(15%)
(12%)

4
5
4
1
3
6
1
0
2

4
2
3
2
2
2
2
2
2

3
5
4
0
1
7
0
1
3

(8%)
(6%)

2
2

2
1

1
1

(5%)
(3%)

1
0

0
2

2
0

BMI (kg/m2)
NYHA class: II/III

Employment
Retired
40
Employed
6
Unemployed
2
Sick leave
12
HF aetiology
Ischaemic
39
Non-ischaemic
21
Left ventricular impairmentc
Mild
0
Mild to moderate
0
Moderate
8
Moderate to severe
17
Severe
35
Co-morbidities
Hypertension
11
Diabetes
12
COPD
11
PVD
3
CVA
6
Arthritis/joint surgery 15
Osteoporosis
3
Anaemia
3
Renal impairment
7
Withdrawals*
Worsening HF
5
Worsening
4
co-morbidities
Moved away
3
Reason unknown
2
a

, values expressed as mean (range) and not number of participants; b, percentage of

sample expressed in brackets where relevant. c, degree of left ventricular impairment
documented as left ventricular ejection fraction data unavailable; home, home-based
training group; hospital, hospital-based training group; NYHA class, New York Heart
Association Classication of HF severity; BMI, body mass index; COPD, chronic obstructive
pulmonary disease; PVD, peripheral vascular disease; CVA, cerebrovascular accident;
*, participants withdrawing from the study after recruitment and randomisation.

298

Letters to the Editor

Table 3
Effects of training upon exercise capacity and QoL.
Outcome

SWT a(m)
MLHFQb:
Total
Physical
Emotional
SF-36c:
PCS
MCS

Home

Hospital

Control

0 weeks

8 weeks

withingroup

0 weeks

8 weeks

withingroup

0 weeks

8 weeks

withingroup

betweengroups1

betweengroups2

270 ( 142)

318 ( 153)

0.02

227 ( 207)

312 ( 155)

0.01

233 ( 132)

241 ( 143)

0.42

0.52

0.27

43
19
10

37
21
7

0.65
0.35
0.58

41
24
7

32
19
7

0.5
0.82
-

59
26
16

50
26
12

0.37
0.79

0.2
0.11
0.14

0.18
0.31
0.13

35.29 ( 10.31)
45.18 ( 12.24)

34.01 ( 11.04)
44.44 ( 12.23)

0.34
0.71

31.33 ( 7.97)
46.17 ( 12.05)

33.83 ( 10)
48.25 ( 11.21)

0.38
0.81

32.69 ( 7.54)
39.6 ( 13.55)

32.08
( 7.05)
37.44 ( 10.89)

0.51
0.73

0.34
0.18

0.82
0.04d

Data are presented as mean values SD for the SWT and SF-36, whilst median values are presented for the MLHFQ; m, metres; a, minimum clinically important difference (MCID) =
47.5 m [9]; b, MCID = 5 (total score) 3 (physical and emotional sub-scores) [10] (higher score = poorer QoL); c, MCID = 23 (PCS) 3 (MCS) [11] (higher score = better QoL);
0 weeks, baseline data; 8 weeks, data obtained after 8 weeks; wg, within-group p-value; between-group 1, between-group p-value at baseline; between-group 2, between-group
p-value after 8 weeks; bold type, statistically signicant result; d, further analysis of these data revealed a signicantly higher SF-36 MCS for the hospital group compared to
control (p = 0.02).

consistently within the evidence base than improvements in exercise

capacity [1,2]. In the present study, several changes in QoL score across
all three groups did achieve the MCID (Table 3). Whilst a larger sample
may have enabled these results to attain statistical signicance, perhaps
maintaining QoLas was observed for the hospital groupmay be a
realistic goal for this population, whose psychosocial health will decline
with disease progression [12].
Notably, the hospital group's MCS was signicantly higher (better)
than the control group's after 8 weeks (p = 0.02) (Table 2). However,
controls had the lowest mean MCS at baseline, whilst the hospital group
had the highest; perhaps this gap simply widened to a signicant level
over 8 weeks.
Of the three previous trials comparing effects of home and hospitaltraining in HF [46] only two [5,6] examined QoL, and both generated
comparable improvements in QoL for both types of training. The
authors directly attributed these ndings to the comparable improvements observed for exercise capacity for both training groups [5].
Subsequently, perhaps QoL was only maintained for the hospital group
because only their improvement in SWT distance achieved the MCID.
Although the hospital group was signicantly older than the control
group (p = 0.001) (Table 2), the hospital group's pre-intervention
characteristics did not differ from the other two groups otherwise. Thus,
rather than skewing outcomes, their older age enhances transferability
of the hospital group's results to a typical elderly HF population.
In conclusion, both training programmes signicantly improved
exercise capacity, though neither signicantly improved QoL. Only the
hospital group maintained their QoL, which may be a realistic
rehabilitation aim in this group, whose psychosocial health will decline
with disease progression.

0167-5273/$ see front matter 2012 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijcard.2012.04.117

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