Despite clinical practice guideline recommendations that cardiovascular disease patients participate, cardiac rehabilitation (CR) programs are highly unavailable and underutilized. This is particularly true in low-resource settings, where the epidemic is at its’ worst. The reasons are complex, and include health system, program and patient-level barriers. This is the first study to assess barriers at all these levels concurrently, and to do so in a low-resource setting. In this cross-sectional study, data from three cohorts (healthcare administrators, CR coordinators and patients) were triangulated. Healthcare administrators from all institutions offering cardiac services, and providers from all CR programs in public and private institutions of Minas Gerais state, Brazil were invited to complete a questionnaire. Patients from a random subsample of 12 outpatient cardiac clinics and 11 CR programs in these institutions completed the CR Barriers Scale. Thirty-two (35.2%) healthcare administrators, 16 (28.6%) CR providers and 805 cardiac patients (305 [37.9%] attending CR) consented to participate. Administrators recognized the importance of CR, but also the lack of resources to deliver it; CR providers noted referral is lacking. Patients who were not enrolled in CR reported significantly greater barriers related to comorbidities/functional status, perceived need, personal/family issues and access than enrollees, and enrollees reported travel/work conflicts as greater barriers than non-enrollees (all p < 0.01). The inter-relationship among barriers at each level is evident; without resources to offer more programs, there are no programs to which physicians can refer (and hence inform and encourage patients to attend), and patients will continue to have barriers related to distance, cost and transport. Advocacy for services is needed.

Fear of falling is a common and potentially disabling problem among older adults. However, little is known about this condition in older adults with diabetes mellitus. The aims of this study were to investigate the impact of the fear of falling on clinical, functional and gait variables in older women with type 2 diabetes and to identify which variables could predict the fear of falling in this population. Ninety-nine community-dwelling older women with type 2 diabetes (aged 65 to 89 years) were stratified in two groups based on their Falls Efficacy Scale-International score. Participants with a score < 23 were assigned to the group without the fear of falling (n = 50) and those with a score ≥ 23 were assigned to the group with the fear of falling (n = 49). Clinical data included demographics, anthropometrics, number of diseases and medications, physical activity level, fall history, frailty level, cognition, depressive symptoms, fasting glucose level and disease duration. Functional measures included the Timed Up and Go test (TUG), the five times sit-to-stand test (5-STS) and handgrip strength. Gait parameters were obtained using the GAITRite® system. Participants with a fear of falling were frailer and presented more depressive symptoms and worse performance on the TUG and 5-STS tests compared with those without a fear of falling. The group with the fear of falling also walked with a lower velocity, cadence and step length and increased step time and swing time variability. The multivariate regression analysis showed that the likelihood of having a fear of falling increased 1.34 times (OR 1.34, 95 % CI 1.11–1.61) for a one-point increase in the Geriatric Depression Scale (GDS-15) score and 1.36 times (OR 1.36, 95 % CI 1.07–1.73) for each second of increase in the TUG performance. The fear of falling in community-dwelling older women with type 2 diabetes mellitus is associated with frailty, depressive symptoms and dynamic balance, functional mobility and gait deficits. Furthermore, both the GDS-15 and the TUG test predict a fear of falling in this population. Therefore, these instruments should be considered during the assessment of diabetic older women with fear of falling.

To contrast the reliability of the 6-min walking test (6MW) with that of the shuttle walking test (SWT) in patients with intermittent claudication attributable to peripheral obstructive arterial disease (POAD), and to examine the relationships of the walking tests, medical outcomes, and hemodynamic variables. Twenty-three patients were randomly assigned to perform both walking tests on two different occasions. Total distance walked (DW), time of pain onset (PO), and time of limiting claudicating symptom (TLS) were analyzed. The reliability coefficients (ICC) generated with the 6MW for DW, PO, and TLS were 0.84, 0.81, and 0.63, respectively, and the coefficients of variation (CV) across trials were 18, 31.8, and 20.3%, respectively. With the SWT, the ICCs were 0.95, 0.72, and 0.90 for each variable, respectively, whereas the CV was 10.9% for DW, 26.8% for PO, and 9.1% for TLS. There was a significant correlation between DW and double product with the SWT (r=0.51, P=0.01), but there was no correlation with the 6MW. Both the 6MW and the SWT are reliable walking tests for claudicant patients. However, the reliability coefficients obtained with the SWT are higher, the measurements are less variable, and there were better associations between this walking test and hemodynamic variables.