Strengths and Limitations
weight loss, weight reduction
MINOR, OBESE, BLIND
The strength of this study is that the conventional cardiac rehabilitation, rehabilitation staff, and background were the same in both the groups. Another strength is that this study evaluated the added value of technology in the everyday lives of rehabilitees in their home environments during self-rehabilitation periods. Most previous studies have evaluated the effectiveness of technology in clinical settings; however, in this study, we also investigated the effectiveness of rehabilitation during the self-rehabilitation period. A strength of this study is the comprehensive view it provides, in which the measurements were based on the biopsychosocial aspect of a rehabilitee. To the best of our knowledge, only one study [A strength of this study is that cardiac rehabilitation was implemented by a multidisciplinary team. Previous studies have revealed that multidisciplinary rehabilitation is effective in body weight reduction [The strength of this study was controlling for significant background factors of rehabilitation (similarity of rehabilitation context and seasonal effects) before intervention and the factors of the rehabilitees (comorbidities and cointervention) at baseline. There were only minor differences in the number of comorbidities and no statistically significant differences in the background factors of the rehabilitees at baseline. In addition, the rehabilitees did not show statistically significant lifestyle changes before the rehabilitation intervention. We used pairwise randomization in a consecutive order to control seasonal variety (winter, spring, and autumn), which may have caused systematic effect bias. Because we were able to control several confounding factors, the statistically significant changes in waist circumference and environmental domain may be associated with the added remote technology–assisted rehabilitation intervention.A major limitation of this study is its small sample size, which affects its generalizability. However, the dropout rates were low in both groups. Because of the small sample size, we emphasized the guidance provided by the technology use. In this study, there was significant variance in the CIs. This could affect the internal validity of the study, which is typical of small studies. Another limitation of this study was blinding. It was not possible to blind the participants, caregivers, or outcome assessors because of the nature of the intervention. The protocol for cardiac rehabilitation was strictly standardized by the Social Insurance Institute of Finland, which is also responsible for rehabilitation costs. In addition, the risk of selection bias is present because the rehabilitees who participated in cardiac rehabilitation applied to the rehabilitation of their own will. In Finland, everyone who has undergone cardiac surgery has the opportunity to undergo rehabilitation. However, it is known that everyone who has undergone cardiac surgery does not apply for rehabilitation. One limitation is that we did not control for the use of health care services. The rehabilitees had normal health care services if needed.According to the nature of the study protocol, the inclusion criteria were determined such that only severe functional ability problems were determined as exclusion criteria. The main purpose of the inclusion criteria was to ensure that the rehabilitees were capable of using technology regardless of the rehabilitation background. We kept the inclusion criteria broad and created an opportunity for a larger number of rehabilitees to participate in the study. All rehabilitees met the inclusion criteria. Real-life interdisciplinary rehabilitation study designs are valuable for producing new information on rehabilitation that can be implemented directly in real-life situations and environments, compared with laboratory research. Unfortunately, in a real environment, we must make concessions in some aspects of study design, such as determining the sample size of the study population and using cluster randomization instead of randomization at individual level. In the future, with a larger study group, it would be important to study more specifically the effects of individual factors, such as medication or comorbidities, in added value of technology-based rehabilitation.Because there was some level of systematic (blinding and selection bias) error during the intervention and samples were relatively small, care must be taken in generalizing the study results beyond the target population. In order to confirm the perceptions of the added value of remote technology in rehabilitation interventions, more studies involving rehabilitees with cardiac rehabilitation are required.Several measurements were used in this cluster randomized trial, which are widely used, but have some limitations. In the 6MWT, small changes in the test methodology can affect the results. Therefore, the measurer should carefully follow the test protocol [Although weight loss has been widely studied, we still do not understand all the aspects of weight loss. Therefore, in the future, it would be important to study the factors considered essential for cardiac or obese rehabilitation to help maintain motivation for weight loss. Social support and the amount of technology used are relevant to the effectiveness of an intervention [