United States Sports Academy - "America's Sports University"

ABSTRACT

The purpose of this study was to evaluate "motivation in patients with coronary heart disease, who participated in different rehabilitation programs and those who did not participate." Fifty-one (n=51) male patients suffering from coronary heart disease participated in the present study. Fifteen participated in a rehabilitation program in a gym; eighteen participated in a swimming program and eighteen consisted of the control group. The mean age of the participants was 60.83 (SD=±3.3). Participants completed the Sport Motivation Scale (SMS). According to the results, patients who participated in the gym program had statistically higher levels in IM to knowledge, to stimulation, to accomplishment and EM to interjected regulation. On the contrary, the control group had statistically higher levels in EM to external regulation and motivation.

INTRODUCTION

Atherosclerotic cardiovascular diseases are the major cause of death in middle-aged and older-adults in Europe and United States (BC Ministry of Health and Ministry Responsible for Seniors, 1996; Giannuzzi et al., 2003; Sarafino, 1990).

Cardiac Rehabilitation programs were first developed in the 1960s when the benefits of ambulation during prolonged hospitalization for coronary events had been documented. Exercise was the primary component of these programs (Giannuzzi et al., 2003). Over the past 4 decades, numerous scientific reports have examined the relationships between physical activity, physical fitness and cardiovascular health (Cerubini, Lowenthal, Williams & Aging Clinical and Experimental Research, 1997; Fletcher, Balady & Amsterdam, 2001; Oldridge, et al., 1993; Pate et al., 1995). Randomized clinical trials of exercise training showed improvement in coronary risk factors such as blood pressure, body composition, fitness, lipid and lipoprotein profiles (Dunn et al., 1997; European Hear Failure Training Group, 1998; EUROASPIRE II Study Group, 2001; Myers, 2003; Rockhill, Willet & Manson, 2001). Swimming and exercise in a gym are included in the so-called coronary sport groups; as endurance sports with training effects suitable for rehabilitation (Lins et al., 2003).

Although exercise is considered to be the easiest type of rehabilitation for patients with coronary heart disease (CHD), their maintenance into exercise programs is difficult most of the times (Harlan et al., 1995). Reported rates of uptake of cardiac rehabilitation range from 15% to 59% (Gattiker, Goins & Dennis, 1992; Pell, Pell & Morrison, 1996). Approximately 20-25% of patients dropout of exercise programs within the first three months and about 40-50% within 6 to 12 months (Song et al., 2000; Oldridge, 1998; Oldridge, 1982).

Psychosocial variables that were found to influence the entrance and completion of a CR program include motivation, mood states, and social support (Myers, 2003). Motivation consistently has been shown to be a strong indicator of initiation and maintenance of participation in a CR program. It was found that the people that seem to have lower levels of motivation perceive more barriers or problems associated with their exercise programs. (Dishman & Ickes, 1981; Evenson & Fleury, 2000). The literature on physical rehabilitation frequently refers to patient motivation in explaining differences in outcome among patient groups with similar pathologies (King, Taylor & Haskel, 1993; Maclean, & Pound, 2000). Several studies have lent empirical support to the hypothesis that patient motivation is a determinant of rehabilitation outcome (Clark & Smith, 1997; King & Barrowclough, 1989; Oldridge & Stoedefalke, 1984; Wolf, 1969).

In general, motivation expresses the needs and the wishes that regulate the direction, the intensity and the continuation of a specific behavior (Deci & Ryan, 1985). Deci and Ryan (1985) explained intrinsic and extrinsic motivators and their influence on self-determination in their theory of self-determination. Self-determination is a quality of human functioning that involves the experience of a choice. An important distinction concerning motivation in exercise and sports is the one between intrinsic and extrinsic motivated behavior for participation (Ryan et al., 1984). Intrinsic motivation (IM) refers to an individual who participates in an activity simply for the satisfaction of doing so (Fortier, et al., 1995). Intrinsic motivation has been postulated to have three separate categories: IM to know, to accomplish things and to stimulation (Vallerand & Losier, 1999; Vallerand, et al., 1989; Vallerand &Bissonnette, 1992).

Extrinsic Motivation (EM), on the other hand, is related to external factors, such as rewards and punishment (Vallerand & Perrault, 1999; Ryan & Deci, 2000). The three types of extrinsic motivation, from the least self-determined to the most self-determined, are external regulation, interjected regulation and identification (Ryan et al., 1990).

The third type of motivation, amotivation, is characterized by the thought that actions have no control over outcomes (Deci & Ryan, 1985). In other words, amotivated individuals believe that forces out of their control determine behaviors.

The specific purpose of this study was to examine the differences in motivation between patients, who participated in different cardiac rehabilitation programs and patients who did not participated.

METHOD

Sample

A sample of 51 male patients suffering from coronary heart disease was selected and divided into 3 groups. Fifteen (n=15) participated in a rehabilitation program in a gym, eighteen (n=18) participated in a swimming program and eighteen (n=18) patients consisted of the control group. The participants couldn’t choose the type of activity and all of them followed a phase III cardiac rehabilitation program. The mean age of patients was (mean±S.D. 60.83 ± 3.3).

Procedures

The sampling procedure required that the prospective subjects met the following criteria: (1) having undergone cardiac-related procedures such as coronary artery bypass graft surgery (CABG) or percutaneous transluminal coronary angioplasty (PTCA); (2) able to participate in the cardiac rehabilitation programs for more than 15 weeks (for the exercise groups) with an attendance rate of more than 70%. Exclusion criteria were clinically unstable heart failure, unstable arrhythmias and other exercise limiting concurrent condition as skeletal or muscular disorders. All exercise patients followed the routine 3 times per week for 45-90 minutes per session at an intensity of 60-85% of the maximum heart rate (MHR).

The duration of the rehabilitation programs was 20 weeks. During the 20-week period, the type and intensity of exercise and heart rate and blood pressure before, during and after exercise were recorded for all subjects in the exercise groups. Exercise patients did not participate in any other physical training.

Each training-session in the gym rehabilitation program consisted of walking, cycling or running on an ergometer. It consisted of 10 minutes warm–up, 10 minutes stretching and flexibility exercises, of 25 minutes endurance training with heart rate (HR) maintained on 60% - 85% of the maximum heart rate (MHR) and 10 minutes cool–down.

The swimming exercise program included 10 minutes warm-up, 10 minutes stretching and flexibility exercises in the pool, 12 minutes walking in the pool with kickboards and barbell and 12 minutes running or walking in the pool with alternative intensity in a distance of about 200-250m, with heart rate (HR) maintained on 60% - 85% of the maximum heart rate (MHR) and 10 minutes cool-down.

Permission to conduct the investigation was received from the local athletic association and the individual coaches. Each participant took 10-15 minutes to complete the questionnaire and responses to the instrument were kept anonymous. The participants were advised to ask for help if confused about either the instructions or the clarity of any particular item. No problems were encountered in completing either of the inventories or understanding the nature of the questions.

Questionnaire

Patients completed the Sport Motivation Scale (SMS) developed by Pelletier, Fortier, Vallerand and Tuson (1995). The SMS consists of seven sub-scales that measure the three types of motivation: intrinsic, extrinsic, and amotivation. There are four items per sub-scale, thus there are a total of 28 items being assessed. Each item represents a possible reason why patients with coronary heart disease participated in an exercise rehabilitation program. Subjects must rate the extent to which each item corresponds to one of their participation motives on a seven-point Likert scale, ranging from “not at all” (1) to “exactly” (7). The English questionnaire is valid, consistent, and reliable. Pelletier et al. (1995) found that the English translation of the questionnaire had a satisfactory level of internal consistency. Additionally, correlations between the subscales and confirmatory factor analysis have confirmed the determination continuum and the construct validity of the scale (Pelletier, et al. 1995).

Statistical Analysis

The data was analyzed in two steps. First, internal consistency of subscales was assessed using Cronbach alphas (Cronbach, 1951). Secondly, a one –way MANOVA was used to determine if significant differences existed among patients exercise groups and control group across the seven SMS subscales. When the results of the one –way MANOVA were statistically significant, Post hoc Scheffe analysis were conducted to determine which specific patient-group means were significantly different from one another. The level of significance was 0.5.

RESULTS

The internal consistency of the Sport Motivation subscales was determined by calculating Cronbach’s Coefficient Alpha. The seven subscales of SMS demonstrated acceptable internal reliability (IM to know =. 70, IM to stimulation =. 80, IM to accomplishment =. 75, EM to external regulation =. 69, EM to interjected regulation =. 66, EM to identified regulation =. 75 and amotivation =. 70). These findings are supported by previous study (Papageorgiou, 2001).

A one - way MANOVA indicated significant differences between the three patients groups across the seven SMS subscale, Wilk’s Lambda=. 113, (F_7,14=9.892, P<0.05, eta squared=0.664).

Univariate ANOVA results indicated a significant difference only for the six dependent variables. Statistically significant differences were found for IM to know (F_2,41=13.485, P<0.05, eta squared=0.397), IM to stimulation (F_2,41=43.581, P<0.05, eta squared=0.680), IM to accomplishment (F_2,41=6.581, P<0.05, eta squared=0,243), EM to external regulation (F_2,41=6.548, P<0.05, eta squared=0.242), EM to interjected regulation (F_2,41=22.913, P<0.05, eta squared=0.528) and amotivation (F_2,41=5.707, P<0.05, eta squared=0.218). Scheffe post hock analysis indicated that patients who participated in the gym rehabilitation program had statistically higher levels in IM to know, to stimulation. to accomplishment and EM to interjected regulation. Additionally, the control group had statistically higher levels in EM to external regulation and Amotivation. Table 1 provides the means and standard deviations for these dependent variables.

Table 1 Means and Standard Deviations of Motivation Variables by Group

Variables	Gym Group	Swimming Group	Control Group
M±SD	M±SD	M±SD
IM to know	4.56±0.798	3.73±0.504	3.44±0.455
IM to stimulation	4.64±0.432	4.18±0.175	3.39±0.433
IM to accomplishment	4.41±0.701	3.75±0.365	3.98±0.358
EM to external regulation	4.10±0.991	3.76±0.240	4.5±0.342
EM to introjected regulation	3.79±0.729	3.46±0.311	2.69±0.286
Amotivation	1.47±0.588	1.63±0.208	2.0±0.450

DISCUSSION AND CONCLUSION

This study explored the influence of two specific types, frequency and duration of exercise cardiac rehabilitation programs in-patient motivations.

Findings from this study indicated that patients who participated in the gym rehabilitation program had statistically higher levels in IM to know, to stimulation, to accomplishment and EM to interjected regulation, than patients who participated in the swimming rehabilitation program and patients who did not participate in any program (control group). One of the possible reasons for the differences between the two exercise patient groups may be due to the fact that swimming is not very much allowed for cardiac patients, despite the valuable advantages as an overall physical conditioning and leisure avocation (Kawahatsu et al., 1986). According Ebbeck, Gibbons and Loken-Dahle (1995) the differences in reasons for participating depend on the type of physical activity in which the individual is involved.

Specifically, patients who participated in a gym program to fulfill intimacy or acceptance needs were motivated intrinsically to participate in order to gain knowledge, to experience stimulation and accomplishment (Stults, 2001). According to previous studies, personal satisfaction, knowledge and pleasure (IM) constitute the main reasons of adult’s participation in exercise programs (Ebeck et al., 1995; Eix, 2001; Brodkin & Weiss, 1990). These findings are consistent with the findings of previous studies that suggest effects of the type of rehabilitation in-patients motivation (Papageorgiou, 2001).

However, the gym exercise group differs significantly from the swimming and control group in EM to introjected regulation. Introjection is related to the internal pressures that the patient may put on himself. The guilt that they feel when they fail to complete a health task or a training session, will motivate them so as to make it up (Vlachopoulos, Karageorghis & Terry, 2000). According to Brodkin & Weiss (1990) health reasons were rated highest by older adults for participating in exercise programs. Additionally control group had statistically higher levels in EM to external regulation and Amotivation.

Given the study findings, further research is suggested. A research design for assessing long-term adherence is recommended. Previous studies indicated that the dropout rate for an exercise program remains high until 12 months, with an average attrition rate of 50% (Comoss, 1988; Oldridge, 1979; Song et al., 2001). It is imperative to assess adherence changes over a long-term period, focusing on the motivation related variables influencing participation in rehabilitation programs.

REFERENCES

1. BC Ministry of Health and Ministry Responsible for Seniors (1996). Selected Vital Statistics and Health Status Indicators: Annual report 1995 (Victoria: Division of Vital Statistics).
2. Brodkin, P. & Weiss, M.R. (1990). Developmental differences in motivation for participation in competitive swimming. Journal of Sport and Exercise Psychology, 12, 248-263.
3. Cerubini, A., Lowenthal, D.T., Williams, L.S. & Aging Clinical and Experimental Research (1997). Physical activity and cardiovascular health in the elderly, 10, 13-25.
4. Clark, MS. & Smith, DS. (1997). Abnormal illness behavior in rehabilitation from stroke. Clinical Rehabilitation, 11, 162-70.
5. Commos, P.M. (1988). Nursing strategies to improve compliance with lifestyle changes in a cardiac rehabilitation population. Journal of Cardiovascular Nursing, 2, 3, 23-36.
6. Cronbach, L.J. (1951). Coefficient alpha and the internal structure of tests. Psychometrika, 16, 297-334.
7. Deci, E.L. & Ryan, R.M. (1985). Intrinsic motivation and self-determination in human behavior. New York: Plenum Press.
8. Dickey, C. & Gavin, J. (2002). Behavioral counseling benefits older adults in cardiac rehabilitation programs. Medicine and Science in Sport and Exercise, 34, 11, 1705-1713.
9. Dishman, RK. & Ickes, W. (1981). Self-motivation and adherence to therapeutic exercise. Journal of Behavioral Medicine, 4(4) 421–438
10. Dunn, AL., Marcus, BH., Kampert, JB., Melisa, E., Garcia, M.P.H., Kohl, H.W. & Blair, S.N. (1997). Reduction in cardiovascular disease risk factors: 6 – months results from project active. Preventive Medicine, 26, 883-892.
11. Ebbeck, V., Gibbons, S.L. & Loken-Dahle, L.J. (1995). Reasons for adult’s participation in physical activity: an interactional approach. IInternational Journal of Sport and Exercise Psychology, 26, 262-275.
12. Eix, T. (2001). Intrinsic and extrinsic motivation in sport: An analysis of gender differences. Unpublished Doctoral Dissertation, Department of Psychology, Carleton University.
13. European Heart Failure Training Group. (1998). Experience from controlled trials of physical training in chronic heart failure. Protocol and patients factors in effectiveness in the improvement in exercise tolerance. European Heart Journal, 19, 466-475.
14. EUROASPIRE II Study Group (2001). EUROASPIRE II. Lifestyle and risk factor management and use of drug therapies in coronary patients from 15 countries. European Heart Journal, 22, 554-572.
15. Evenson, KR. & Fleury, J. (2000). Barriers to outpatient cardiac rehabilitation participation and adherence. Journal of Cardiopulmonary Rehabilitation, 20, 4, 241–246.
16. Fletcher, G.F., Balady, G.J. & Amsterdam, E.A. (2001). Exercise standards for testing and training: a statement for healthcare professionals from the American Heart Association. Circulation, 104, 1694-1740.
17. Fortier, M.S., Vallerand, R.J., Briere, N.M. & Provencher, P.J. (1995). Competitive and recreational sport structures and gender: A test of their relationship with sport motivation. International Journal of Sport Psychology, 26, 24-39.
18. Gattiker, H., Goins, P.& Dennis, C. (1992). Cardiac rehabilitation. Current status and future directions. West Journal of Medicine, 156, 183-188.
19. Giannuzzi, P., Saner, H., Bjornstad, P., Fioretti, P., Mendes, M., Cohen-Solal, A., Dugmore, L., Hambrecht, R., Hellemans, I., McGee, H., Perk, J., Vanhees, L. & Veress, G. (2003). Position paper of the working group on cardiac rehabilitation and exercise physiology of the European Society of Cardiology. European Heart Journal, 24, 1273-1278.
20. Harlan, W.R., Sandler, S.A., Lee, K.L., Lam, L.C. & Mark, D.B. (1995). Importance of baseline functional and socioeconomic factors for participation in cardiac rehabilitation. American Journal of Cardiology, 76, 36-39.
21. Kawahatsu, K., Itoh, Saida, Hamazaki, Aoto, Ayai, Nohara, Hashimoto, Go, Kambara, H. & Kawai, C. (1986). Application of swimming to a long-term sporttherapy in coronary artery disease. Japanese Journal of Physical Education, 30, 4, 103-315.
22. King, P. & Barrowclough, C. (1989). Rating the motivation of elderly patients on a rehabilitation ward. Clinical Rehabilitation, 3, 289-91.
23. King, A.C., Taylor, C.B. & Haskel, W.L. (1993). Effects of differing intensities and formats of 12 months of exercise training on psychological outcomes in older adults. Health Psychology, 12, 292-300.
24. Lins, M., Speidel, T., Bastian, A., Zurbon, K.H., Bruhn, H.D. & Simon, R. (2003). Swimming and hemostasis during rehabilitation in patients with coronary heart disease. Thrombosis Research, 108, 191-194.
25. Maclean, N. & Pound, P. (2000). A critical review of the concept of patient motivation in the literature on physical rehabilitation. Social Science and Medicine, 50, 495-506.
26. Myers, J. (2003). Exercise and cardiovascular helath. Circulation, 107(1), 20-26.
27. Oldridge, N.B. (1979). Compliance of post myocardial infarction patients to exercise program. Medicine and Sciene in Sports, 11, 373-375.
28. Oldridge, N.B. (1982). Compliance and exercise in primary and secondary prevention of coronary heart disease: A review. Preventing Medicine, 11, 56-70.
29. Oldridge, N.B. & Stoedefalke, K.G. (1984). Compliance and motivation in cardiac exercise programs. Clinical Sports Medicine, 3(2), 443-454.
30. Oldridge, N., Furlong, W., Feeny, D., Torrance, G., Guyatt, G., Crowe, J. & Jones N. (1993). Economic evaluation of cardiac rehabilitation soon after acute myocardial infarction. American Journal of Cardiology, 72, 154-61.
31. Oldridge, N.B., Guyatt, G.H., Fischer, M.E. & Rimm, A.A. (1998). Cardiac rehabilitation after myocardial infarction. Combined experience of randomized clinical trials. Journal of the American Medical Association, 260, 5-50.
32. Papageorgiou, P. (2001). Forecast of participation in exercise program: Health adults and patients with coronary heart disease. Unpublished Master Dissertation, University of Thrace, Department of Physical Education and Sports Science
33. Pate, R.R., Pratt, M., Blair, S.N., Haskell, W.L., Macera, C.A., Buchenr, D., Ettinger, W., Heath, G.W., King, A.C., Kriska, A., Leon, A.S., Marcus, B.H., Morris, J., Paffenbarger, R.S., Patrick, K., Pollock, M.L., Rippe, J.M., Sallis, J. & Wilmore, J.H. (1995). Physical activity and public health. Journal of the American Medical Association, 273, 402-407.
34. Pelletier, L.G., Fortier, M.S., Vallerand, R.J., Tuson, K., Brier, N.M. & Blais, N.M. (1995). Toward a new measure of intrinsic motivation, extrinsic motivation and amotivation in sports: The sport motivation scale (SMS). Journal of Sport and Exercise Psychology, 17, 35-53.
35. Pell, J., Pell. A. & Morrison, C. (1996). Retrospective study of influence of reprivation on uptake of cardiac rehabilitation. British Medicine Journal, 313, 276-268.
36. Rockhill, B. Willet, W.C. & Manson, J.E. (2001). Physical activity and mortality: a prospective study among women. American Journal of Public Health, 91(4), 578-583.
37. Ryan, R.M., Vallerand, R.J. & Deci, E.L. (1984). Intrinsic motivation in sports: A cognitive evaluation theory interpretation. In W.F. Staub & J.M. Williams (Eds.), Cognitive Sport Psychology (pp. 231-242). Lansing, NY: Sport Science Associates.
38. Ryan, R.M., Connell, J.P. & Crolnick, W.S. (1990). When achievement is not intrinsically motivated: A theory of self regulation in school. In A.K. Boggiano & T.S.
39. Pittman (Eds.), Achievement and Motivation: A social-development perspective (pp. 143-158). New York: Cambridge University Press.Ryan, R.M. & Deci, E.L. (2000). Intrinsic and extrinsic motivation: Classic definition and new directions. Contemporary Educational Psychology, 25, 54-67.
40. Sarafino, E.P. (1990). Health psychology: biopsychological interactions. New York: John Wiley & Sons.
41. Song, R. & Lee, H. (2001). Effects oa 12-week cardiac rehabilitation exercise program on motivation and health promoting lifestyle. Heart and Lung, 30, 3, 200-209.
42. Stults, M.P. (2001). Motivation and Perceived Relatedness. Presented at the Meeting of the Midwesten Psychological Association. Psi Chi Poster Session, Chicago, May.
43. Vallerand, R.J., Blais, M.R., Briere, N.M. & Pelletier, L.G. (1989). Construction et validation de l’echelle de motivation en education (EME). Revue Canadienne des Sciences du Comportement, 21, 323-349.
44. Vallerand, R.J. & Bissonnette, R. (1992). Intrinsic, extrinsic and amotivational styles as predictors of behavior: A prospective study. Journal of Personality, 60, 599-620.
45. Vallerand, R.J. & Losier, G. F. (1999). An integrative analysis of intrinsic and extrinsic motivation in sport. Journal of Applied Sport Psychology, 11, 142-169.
46. Vallerand, R.J. & Perrault, S. (1999). Intrinsic and extrinsic motivation in sport: Toward a hierarchical model. In R. Lidor & M. Bar-Eli (Eds.), Sport Psychology: Linking Theory and Practice (pp. 191-212). Morgantown, WV: Fitness Information Technology, Inc.
47. Vlachopoulos, S.P., Karageorghis, C.I. & Terry, P.C. (2000). Motivation profiles in sport: A self-determination theory perspective. Research Quarterly for Exercise and Sport, 71(4), 387-397.
48. Wolff, B.B. (1969). How do rheumatic diseases relate to economic potential as influenced by personal attitudes and motivation. Palliative Medicine, 72, 68-70.