key: cord-0729616-zubrfbk8
authors: O'Neill, Carley D; Vidal-Almela, Sol; Terada, Tasuku; Way, Kimberly L; Kamiya, Kentaro; Sperlich, Billy; Duking, Peter; Chaput, Jean-Phillipe; Prince, Stephanie A; Pipe, Andrew L; Reed, Jennifer L
title: Moving together while staying apart: Practical recommendations for 24-hour home-based movement behaviours for those with cardiovascular disease
date: 2021-08-28
journal: CJC Open
DOI: 10.1016/j.cjco.2021.08.010
sha: db2b75ce1616d8600ac36a852c35202af8fb3d65
doc_id: 729616
cord_uid: zubrfbk8

The novel coronavirus disease 2019 (COVID-19) is a global public health crisis that disproportionately affects those with pre-existing conditions. Cardiovascular disease (CVD) is the leading cause of death worldwide and many key CVD risk factors are modifiable (e.g., physical inactivity, sedentary behavior, obesity). To limit the spread of COVID-19 most governments have implemented restrictions and recommended staying at home, reducing social contact to a select and exclusive few, and limiting large gatherings. Such public health constraints may have unintended, negative health consequences on 24-hour movement behaviour. The primary purpose of this review is to provide practical at-home recommendations for sedentary time, sleep, and physical activity in those living with CVD. Those with CVD will benefit from practical recommendations to reduce sedentary time, increase purposeful exercise, and obtain optimal sleep patterns while at-home and adhering to public health restrictions. Our recommendations include the following: (i) self-monitoring sitting time; (ii) engaging in 2-3 days per week of purposeful exercise for those with low exercise capacity and >3 days per week for those with moderate-to-high exercise capacity; (iii) self-monitoring exercise intensity through the use of scales or wearable devices; (iv) maintaining a regular sleep schedule; and, (v) moving daily. Clinicians should be particularly aware that clear communication of the importance of limiting prolonged sedentary time, regular physical activity and exercise, and ensuring good quality sleep in association with the provision of clear, comprehensible and practical advice is fundamental to ensuring that those living with CVD respond optimally to the challenges posed by the pandemic.

The novel coronavirus disease (COVID-19) is a highly contagious, viral respiratory illness that has afflicted ≥ 170 million people globally and resulted in ≥ 3.5 million deaths as of May 29, 2021 . 1 Adults with cardiovascular disease (CVD) have an increased risk of morbidity and premature mortality from COVID-19 (approximately 10% of those with pre-existing CVD who contract COVID-19 will die). 2 3 To limit the spread of COVID-19, public health authorities have implemented mobility restrictions (e.g. quarantine, self-isolation), and commercial closuresincluding many fitness facilities. The closure of in-person cardiac rehabilitation programs resulted in the transition to virtual program offerings; 4 not all programs or patients, however, have access to the necessary resources (e.g., funds, technology, internet connection) to transition effectively. There is therefore a need to provide patients with the tools required to ensure healthy 24-hour movement behaviours (i.e., sedentary time, sleep, and physical activity (PA) (any movement carried out by the muscles that requires energy)). Most governments had recommended staying home, reducing social contact and limiting large gatheringsbut subsequent surges of infections caused a return to earlier restrictions. Such public health constraints may have unintended negative health consequences as 24-hour movement behaviours are altered globally with increased sedentary time, 5 reduced physical activity and purposeful exercise, 5 6 and unhealthy (e.g. too much or too little) changes in sleeping patterns, 7 all of which pose significant risk to the health of individuals and can contribute to declines in physical and mental health during the pandemic. 8 COVID-19 public health restrictions have increased sedentary behaviour. 5 9 Strong evidence supports a positive relationship between greater sedentary behaviour and type 2 diabetes, metabolic syndrome, 10 heightened levels of anxiety 11 and depression, 12 and all-cause mortality. 13 Amid the COVID-19 pandemic, sedentary time has increased substantially and low-intensity PA and step counts have significantly declined 14 findings of particular significance for those living with CVD as pre-pandemic sedentary time was already shown to be higher among these individuals. 15 Recommendations for replacing sedentary time with PA while adhering to pandemic public health recommendations are warranted to help reduce the burden of CVD. 16 Regular aerobic and resistance exercise (i.e. planned, structured, intentional movement with the aim to maintain or improve physical fitness and health) are associated with numerous physical (e.g. lower blood pressure, higher cardiorespiratory fitness, enhanced sleep quality) and mental (e.g. lower levels of anxiety and depression) health benefits among adults with CVD. 17 18 Moderate intensity aerobic exercise is associated with a reduction in respiratory infection rates, respiratory symptom burden, and mortality, [19] [20] [21] underscoring the importance of maintaining an active lifestyle during the COVID-19 pandemic. Those infected with COVID-19 and consistently inactive have been shown to be at an increased risk of hospitalization, admission to the intensive care unit, and death as a result of the virus in comparison to counterparts who participated in some physical activity and those who met the physical activity guidelines (150 minutes of moderate-vigorous physical activity per week) 22 Aerobic and resistance training exercise have additional benefits that aid in reducing the severity and burden of CVD including: improvements in cardiorespiratory and functional fitness and mental health; minimized age-related decline in muscle mass; reduced risk of experiencing a second cardiac event; and, mortality. 23 24 Access to exercise facilities has been limited during the pandemic and those with pre-existing health conditions are urged to take additional precautions by reducing time outside the home. These restrictions have led to a marked increase in web searches for community and 'at-home' exercise guidance 25 underscoring the need for accessible, informative and 'pandemic-relevant' exercise recommendations.

Several authors have reinforced the importance of regular PA/exercise during the pandemic. 5 6 26 They do not, however, provide practical recommendations as to how individuals living with CVD can engage in exercise and improve their 24-hour movement behaviours. Adults living with CVD will benefit from the application of 24-hour movement behaviour and exercise recommendations given that: (i) they are more susceptible to experiencing complications of CVD; 27 (ii) are more likely to be confined at home; and, (iii) are more vulnerable to the detrimental effects of inactivity, sedentariness and sleep disturbances on cardiovascular health. 28 Healthy sleep (broadly defined as being of adequate duration, quality, and timing) plays a fundamental role in physical and mental health. 29 Insufficient sleep (less than 7 hours per night) is a global public health concern and associated with CVD. 30 A U-shaped relationship exists between sleep duration and CVD morbidity and mortality; 31 too little or too much sleep has an impact on CVD. 31 The incidence of reported sleep disturbances has markedly increased during the COVID-19 pandemic. 28 Stress, anxiety, changes in daily routines and reduced daylight exposure are key disruptors of sleep and circadian rhythms and have been more prominent during the pandemic. 28 Others, conversely, have reported improved sleep amid the pandemic due to reduced rigidity in work/school schedules. 32 There is a need to adapt daily regimens during the COVID-19 pandemic to ensure adults living with CVD can achieve optimal 24-hour movement and exercise profiles while following public health restrictions for COVID-19. The primary purpose of this paper is to provide health care professionals and patients with a comprehensive resource of practical recommendations for achieving, maintaining, and monitoring healthy 24-hour movement behaviours and exercise in adults living with stable CVD during a pandemic. Educational resources have also been provided for physicians, physiotherapists, kinesiologists, and exercise physiologists/scientists to share widely with their patients. Figure 1 illustrates the interconnectedness of the 24-hour movement behaviours amid the pandemic. Table 1 provides a summary of the 24-hour movement behaviour recommendations discussed within this review. At minimum, any movement is better than no movement; prolonged bouts of sedentary behaviour should be reduced, and regular light intensity movement should be encouraged.

Greater mortality risks have been associated with >9-10 hours of device-assessed sedentary time, 16 >7-8 hours of self-reported sitting time, 13 and >3 h/day of television viewing. 33 The risks are comparable among those living with CVD. 34 35 There is evidence that moderate-to-vigorous intensity PA (MVPA) may reduce or negate the effects associated with prolonged television viewing and total sitting (30-40 to 60-75 min/day). 36 This is troubling given that globally very few adults (27.5%) currently meet such PA guidelines. 37 Importantly, evidence has shown that it is not solely the total volume of sedentary time that places individuals at greater risk for poor health outcomes, but also the pattern in which this time is accrued. 38 Individuals who frequently break up their sedentary time (i.e., accrue sedentary time in bouts < 30 minutes) have a lower risk of mortality compared to those who spend more time in longer bouts. 39 Experimental studies have also supported that breaking up sitting time with standing and movement can result in favourable metabolic changes and improve cardiovascular risk factors (e.g. reduced weight, waist circumference, and blood pressure). 40 41 The public health response to the COVID-19 pandemic (e.g., social distancing, closing of many recreational and occupational venues) has resulted in an increase in sedentariness (e.g. screen usage/watching). 5 In Canada, survey data revealed that during the pandemic's first wave, most adults reported spending more time on the Internet (68%), watching television (63%), and video games (22%). 9 Maintaining or decreasing screen time related to television and video game usage was associated with superior self-rated physical and mental health. 9 Global movement data collected using smartphone technology identified that daily step counts decreased sharply during the first 10 days of the pandemic declaration; these reductions were sustained over a 30 day period. 42 The declines varied regionally, with more dramatic reductions among countries with stricter social distancing protocols. 42 Steps are highly correlated with sedentary behaviour as they reflect ambulatory and sporadic daily movement. 43 During the COVID-19 pandemic, the World Health Organization (WHO) released a guidance document addressing PA and sedentary behaviour during self-quarantine for those without symptoms or diagnosis of acute respiratory illness. 44 The WHO tips for remaining active and pandemic among those with CVD include: (i) self-monitoring through the use of a wearable device or recording the time you spend sittingbeing aware of how much you sit and when you sit for long periods (e.g., working at a computer, watching television) is important to understand where you can make changes; (ii) set up the home environment to encourage movement (e.g., move your waste basket away from your home office, leave the remote controls across the room); (iii) drink water regularlythis promotes frequent trips to the bathroom; (iv) set up external cues/idle alerts through the use of wearables, smart phone aps or activity alarms to prompt you to stand every 20-30 minutes; (v) create habit reminders by standing or moving during routine habits (e.g., choose to stand when having a drink, lap your home every time you use the washroom, or take phone calls standing); and, (vi) no more than eight hours of sedentary time per day including no more than three hours of recreational screen time. A review of techniques for reducing sedentary behaviour found that self-monitoring, problem solving, and restructuring the social or physical environment were the most promising techniques. 45 Use of wearable devices and prompts and cues to get up and move can help promote reductions in time spent sedentary in adults and among patients with CVD. 46 Establishing sedentary behaviour breaks during routine events will help to form habits easier. 47 Evidence supports the interruption of sedentary bouts every 20-30 minutes, with two minutes or more of light-intensity PA. 48 

Pre-exercise considerations Medical condition(s), risk factors, medications, and previous exercise history should be considered prior to providing exercise advice. National risk screening tools are readily available (e.g. Canadian Society for Exercise Physiology, Get Active Questionnaire; American College of Sports Medicine, Exercise Preparticipation Health Screening) to ensure patients are cleared for exercise participation. It must be recognized, however, that the majority of patients can safely increase their normal levels of physical activitya little is much better than none! These tools can be completed virtually or in-person between the health care provider and patient. It must be acknowledged that during a pandemic the introduction of exercise testing schema should reflect a practical, straightforward approach appropriate for the challenge of helping the sedentary become more active and supporting the development of increasing levels of regular PA for all.

Adults living with stable CVD are considered moderate-to-high risk for exercise participation according to the American College of Sports Medicine. 49 Walking at a comfortable self-limited pace, however, is safe for CVD patients. Prior to prescribing exercise, individuals should be made aware of symptoms that could occur during exercise and how to address them. Table 2 provides a summary of potential symptoms and how they can be managed during exercise at home for those with stable CVD. 

Low exercise capacity at baseline: patients who have a low level of fitness (<5 METS) should begin exercising two days per week and increase to three days per week as fitness improves.

Individuals who present with low exercise capacity may experience improvements and better adherence with <3 sessions per week; however, higher frequencies are likely to elicit greater improvements. 51 52 Moderate or high exercise capacity at baseline: Adults who have moderate-to-high levels of fitness (>5 METS) should exercise at least three days per week and gradually increase to five days per week as fitness improves, while the greatest exercise capacity improvements will occur with higher frequency of sessions. 52

Higher exercise frequency reduces the risk of CVD among older adults (> 60 years) 53 and improves exercise capacity regardless of age; yet, some age-related considerations pertaining to exercise frequency have been suggested. Younger patients (< 50 years) tend to have greater increases in fitness with a higher frequency of weekly aerobic exercise; older individuals (> 50 years) may still achieve improvements in exercise capacity with a low frequency of sessions. 52

A single bout of exercise elicits acute benefits including a reduction in post-exercise blood pressure 54 and blood glucose, 55 and enhanced mood. 56 These acute changes experienced regularly can substantially improve the CVD risk-factor profile. For example, MVPA performed 3-5 times per week lowers blood pressure by an average of 3.4/2.4 mmHg. 57 Less frequent (2-3 days per week) sessions of longer duration (see time recommendations below) are successful for improving fitness levels; sustained, increased exercise frequency produces additional health benefits (e.g. improved lipid profile, 58 glucose control, 59 quality of life, 60 and reduced levels of anxiety and depression). 61 Patients with time constraints or who prefer shorter exercise sessions, will benefit from a higher frequency of short-duration activity. 52 Increasing the frequency of exercise sessions or incidental PA during the week can improve fitness levels.

Intensity refers to the physical effort required for a given exercise bout. Current recommendations suggest engaging in PA within the moderate to vigorous range. 50 Yet, sedentary patients can gain considerable health benefits from being active at lower levels of intensity on a regular basis. As such, low intensity PA is the preferred recommendation for patients who are un-screened for exercise participation engaging in exercise in an unsupervised setting. For patients with CVD who have been encouraged by their physician to participate in exercise, low to moderate intensity PA can be recommended safely. Those patients interested in progressing to higher intensity exercise should only do so after proper screening by their physician. For those patients eager to progress from moderate to high intensity exercise, consultation with their physician and an exercise stress test, if recommended and available, to ensure safety should precede the progression. It is important, however, to recognize that cardiovascular health can be significantly and very safely enhanced by walking regularly at a comfortable pace.

Several methods can be used to monitor unsupervised exercise intensity. 62 Valid and reliable scales such as the Borg Rating of Perceived Exertion (RPE), 63 monitoring heart rate (HR), the Talk Test, 64 and wearable technologies can all be used with minimal equipment or expertise. Table 3 summarizes recommended methods for prescribing and monitoring low and moderate intensity exercise. RPE Scale: Prescribing and monitoring exercise intensity using the RPE scale is a simple and inexpensive option for patients. The Borg RPE scale is a 14-point Likert scale ranging from 6 (no exertion at all) to 20 (maximal exertion). 65 RPE during exercise highly correlates with objective relative indices of exercise intensity (%V O 2 max, %HRmax) in women and men regardless of training status. 66 RPE may be particularly useful for patients with CVD taking HR blunting medications (i.e. beta-blockers) 66 as they limit the ability to use other methods to monitor exercise intensity such as HR equations.

Talk Test: The talk test is an easy to use, inexpensive, and valid tool to monitor exercise intensity among patients with CVD. 64 67-69 The Talk Test can be used when exercising at-home with a partner by self-determining whether comfortable speech is possible, comfortable speech is difficult, or comfortable speech is not possible corresponding to light, moderate, and high intensity, respectively. During at-home exercise without a partner, the Talk Test can be implemented by self-reflecting or actively determining whether comfortable speech is possible.

When prescribing intensity using the Talk Test, those with CVD should be encouraged to exercise at a moderate intensity (i.e. maintaining conversation is possible). The talk test has particular applicability during a pandemic. Advice regarding the use of this 'instrument' can be provided simply; it requires little instruction and does not rely on calculations of HR or estimations of exertion (which can be perplexing and troublesome for many patients).

Heart Rate Equations: Exercise intensity is frequently prescribed and monitored using HR or oxygen uptake (V O 2 ) values. This is based on the observed direct and proportional increase in HR and V O 2 during dynamic, aerobic exercise in women 1 and men. 2 This approach may lead to an under-or over-prescription of exercise intensity in patients taking medications (e.g. βblockers) which blunt HR responses or when the exercise session leads to a disproportionate increase in HR (e.g. aerobic dance exercise, high intensity). 3 Table 4 highlights our recommended HR equation for patients with CVD and provides additional equations which may be used to predict HR during exercise.

Wearable Technologies: Wearables are available in a variety of modes (e.g., smartwatches, smart patches, smart phones, etc.). These technologies provide an easy-to-use method of monitoring and receiving feedback on numerous PA parameters including HR, heart rhythm, walking/running distance, walking/running speed, and steps taken. 70 71 The reliability, validity, cost-effectiveness, and features of these technologies vary, thus, interpretation of the results produced by such devices, especially HR, should be performed cautiously. 72 73 During a when many challenges exist, not the least of which may be financial, the cost of such technologies may serve as a barrier. TIME Time refers to minutes spent engaging in exercise per session and/or throughout one week.

Exercise guidelines recommend at least 150 minutes of MVPA, which aligns with 5400-7900 steps per day. 74 Emerging evidence has demonstrated that any level of activity is superior to being sedentary and that frequent, short duration sessions of high intensity may effectively and efficiently enhance health. 16 75 76 A higher total volume of MVPA is associated with many health benefits including improvements in anxiety, depression, quality of life, cardiorespiratory fitness, blood pressure, and blood lipid levels. 77 Shorter bouts of exercise (e.g. <10 minutes) may initially be more feasible for those who are less fit, can elicit the aforementioned improvements in mental and physical health, and contribute to increasing the total volume of exercise. 75 Short bouts of exercise throughout the day can also promote the interruption of prolonged sitting. Interval training is a time-efficient mode of structured exercise comprised of short bouts of increased intensity activity followed by intermittent recovery periods. Intervals can vary in length (e.g., 1 minute at an increased intensity, 2 minutes of active recovery; 1 minute at an increased intensity, 4 minutes of active recovery). Importantly, exercise sessions of varying lengths (e.g., long moderate intensity continuous exercise, long/short high intensity interval training) have been shown to elicit similar physiological responses 78 thus, patient preferences merit careful consideration.

Prescribing the type of exercise for those living with CVD should be, whenever possible, a collaborative process between the clinician and patient. Exercise enjoyment is a strong predictor of exercise participation and greater exercise enjoyment is associated with more frequent MVPA. 79 'Fun' and 'feasibility' are important determinants of sustained patterns of PAclinicians must be particularly aware of the dangers of 'medicalizing' PA and provide PA guidance that is realistic, comprehensible and in keeping with the circumstances and preferences of their patients. During the pandemic, creativity may be required to ensure appropriate and enjoyable PA (e.g., virtual activity sessions with a friend, time-limited challenges such as holding a wall-sit for the duration of two television commercials, etc.). Listening to music and watching television can be done during exercise at home and have been associated with superior mood and greater exercise enjoyment. 80 81 Amidst the COVID-19 pandemic, various exercise classes and cardiac rehabilitation programs have transitioned to online platforms. Virtual exercise classes (e.g., offered through cardiac rehabilitation programs such as the University of Ottawa Heart Institute Heart Wise Exercise, 82 community programs, or local fitness centres) may allow for those living with stable CVD to participate in structured programs with a trained instructor and permit social interaction (e.g., viewing others on the screen, chatting after the class online). An example of an exercise prescription for patients with CVD is provided in the supplementary material. Supplementary Tables S1 provide examples of exercise prescription for those with low and moderate levels of fitness and can be modified based on individual needs.

Supplementary Material S3 provides an example of a physical activity log for tracking daily and weekly activity.

Muscular strength and endurance, flexibility, and balance are integral elements for improving and maintaining functional fitness, reducing CVD risk factors, and managing chronic disease. 83 For many patients with CVD an emphasis on 'repetition' rather than 'resistance' may be appropriate to ensure safety during muscular strength and endurance exercise. Patients with CVD should aim to complete 10-15 repetitions and 2-3 sets of a weight or resistance that can be comfortably repeated with proper form, with ≤ 90 second rest intervals between sets, on 2 to 3 occasions per week. 84 Body weight strength training exercises can be modified to suit individuals of varying fitness levels (e.g. wall push-ups, sit-to-stand, or squats). Additional exercises and flexibility and balance training activities and instructions can be found for free via the Osteoporosis Canada website. The use of common household items such as soup cans or frozen water bottles can be incorporated into strength training exercises for added resistance (e.g., bicep curls with soup cans). For those patients with access to resistance bands or free-weights strength training exercises can be prescribed based on appropriate tension (resistance bands) and weight (free weights) that allows for the completion of 10-15 reps and 2-3 sets of the exercise with proper technique (e.g., appropriate range of motion, avoiding the Valsalver maneuver. For many, unfamiliar with the practice or precepts of resistance training, the provision of simple guidelines and examples regarding home-based activities may be a practical approach during a pandemic to ensure the benefits of such activities are more generally available.

A regularly active lifestyle is key for sleep health. Recent systematic reviews and meta-analyses have shown that exercise improves many sleep outcomes. 85 Sleep health can be easily monitored at home using simple tools such as sleep diaries (i.e., paper or electronic notebooks for recording hours of sleep per day, Appendix S2) or wearable technology. Examples of simple and validated questions to assess sleep health have recently been published. 88 These questions can be answered in less than two minutes and provide information on key sleep health characteristics such as sleep duration, sleep quality, sleep timing, daytime alertness, and the absence of a sleep disorder (with desired answers).

This review highlights the impact the COVID-19 pandemic continues to have on the 24-hour movement behaviours and exercise, how these changes negatively impact those living with CVD, and provides practical recommendations that can be provided to patients during these unprecedented times. An understanding of the tools available to each patient (e.g., access to technologies, diaries/logs) will aid in recommending and monitoring exercise, sedentary behaviour, and sleep. The supplementary material provided in this article can be used to guide low to moderate intensity exercise prescription for those with CVD who should reduce sedentary time, aim to get 7-9 hours of sleep per night, and accumulate 150 minutes of MVPA per week.

Of note, evidence is emerging regarding the long-term symptoms associated with a previous COVID-19 infection that could negatively impact achieving and maintaining healthy 24-hour movement behaviours (e.g., fatigue, breathlessness,); 89 greater efforts to individualize, sedentary behaviour, sleep, and physical activity recommendations may, therefore, be warranted. Sedentary behaviour has increased amid the pandemic 14 and is recognized as an independent risk factor for several CVDs and risk factors (e.g. atrial fibrillation, hypertension, dyslipidemia) and premature mortality. 39 

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