Feasibility and Potential Effectiveness of a Smartphone Zero-Time Exercise Intervention for Promoting Physical Activity and Fitness in Patients With Coronary Heart Disease: A Pilot Randomized Controlled Trial

Abstract

Background: Zero-time Exercise (ZTEx), a simple strength- and stamina-enhancing physical activity (PA) requiring no extra equipment, can potentially increase PA and fitness. This pilot trial examined the feasibility and potential effectiveness of a smartphone ZTEx intervention to promote PA and fitness in patients with coronary heart disease (CHD).

Methods: A parallel-group assessor-blinded pilot randomized controlled trial was conducted on Chinese patients with stable coronary heart disease (CHD) in three cardiology clinics. The experimental group received a 15-min brief individual face-to-face session and a 12-week ZTEx instant messaging with 28 picture e-messages and a smartphone ZTEx application (ZTExApp). The control group received the same duration of individual session and number and format of e-messages, but the content was healthy eating and breathing exercise. The feasibility was assessed based on: attrition rate, usage, response rate and perception of the intervention. The outcome evaluation included primary outcome (PA), fitness, exercise self-efficacy and intention, perceived happiness and health, and quality of life. A linear mixed model was used with intention-to-treat analysis adjusting for sex, age and baseline values. A semi-structured interview was conducted to collect feedback from the experiment group.

Results: One hundred thirty-nine patients (mean age 59.8 ± 6.6; 71.2% male) were randomized to the experimental group (n = 70) or control group (n = 69), and 80% (56/70) and 82% (57/69) of patients completed the 12-week follow-up assessment, respectively. The attrition rate was 18.7%. The experimental group reported that ZTEx was feasible to integrate PA into their daily life and appreciated the picture e-messages, and 95% of them sent feedback to us, but only 19.6% (13/70) of the participants entered their PA information into the e-diary of the ZTExApp. The experimental group had a significantly greater increase in time spent walking [mean difference (95% CI): 155.3 (10.1, 300.4), P = 0.04, Cohen's d = 0.34] than the control group.

Conclusions: This pilot study showed using a brief ZTEx face-to-face session with picture e-messages empowered patients with CHD to integrate PA into daily life. Future definitive trials with a longer follow-up and a more user-friendly ZTExApp interface are necessary to determine the effectiveness of the smartphone ZTEx intervention in enhancing PA and related outcomes.

Trial registration: The research protocol was registered at the Hong Kong University Clinical Trials Registry (HKUCTR) on 22 Jul 2016 (Study identifier: HKUCTR-2165) and was also retrospectively registered at the National Institutes of Health (identifier number: NCT03464331) on 14 March 2018.

Keywords: coronary heart disease; e-message; intervention; physical activity; physical fitness; randomized controlled (clinical) trial; smartphone apps; zero-time exercise.

Figure 1

The flow of participants (The CONSORT diagram).

Figure 2

Time spent walking and moderate and vigorous physical activities in the 7 days at baseline and 12-week follow-up: Intention to treat analysis (n = 139). This was measured by the short form of International Physical Activity Questionnaire—Chinese version. *Within-group comparison was done by paired sample t-test. **Between-group comparison by linear mixed model with adjustment of age, sex and baseline values; Cohen'd effect size ~0.2, medium effect ~0.5, and large effect ~0.8 or above.

Figure 3

The proportion of participants who performed moderate and vigorous physical activities in the past 7 days at baseline and 12-week follow-up: Intention-to-treat analysis (n = 139). This was measured by the short form of International Physical Activity Questionnaire—Chinese version. *Within-group comparison was done by McNemar test. **Between-group comparison by logistic regression with adjustment of age, sex and baseline values.