HIIT em Reab

Invited Review
Adherence to High-Intensity Interval Training in Cardiac

Rehabilitation
A REVIEW AND RECOMMENDATIONS
Jenna L. Taylor, PhD; David J. Holland, PhD, MBBS; Shelley E. Keating, PhD; Amanda R. Bonikowske,
PhD; Jeff S. Coombes, PhD
Purpose: High-intensity interval training (HIIT) is gaining HIIT involves submaximal or near-maximal efforts (≤100%
Downloaded from http://journals.lww.com/jcrjournal by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 03/17/2021
popularity as a training approach for patients attending cardi- maximal oxygen uptake or ≤95% HRmax), it is more com-
ac rehabilitation (CR). While the literature has focused on the monly applied to cardiac populations rather than sprint in-
efficacy of HIIT for improving cardiorespiratory fitness (CRF), terval training, which involves periods of supramaximal or
particularly when compared with moderate intensity exercise, all-out sprint efforts.1 There is interest in the use of HIIT as
less emphasis has been placed on adherence to HIIT. The aim a training modality for patients attending cardiac rehabilita-
of this review was to summarize the current literature regarding tion (CR), given the efficacy for increasing cardiorespiratory
adherence to HIIT in CR patients with coronary artery disease. ·
fitness (CRF; peak oxygen uptake [Vo2peak]). Improvement
Review Methods: A review identified 36 studies investigating ·
in Vo2peak is doubled with HIIT compared with traditional
HIIT in CR patients with coronary artery disease. Methods and moderate-intensity continuous training (MICT) in patients
data were extracted for exercise or training adherence (to atten- with cardiometabolic disease, while limiting the time com-
dance, intensity, and duration), feasibility of protocols, and CRF. mitment to training.1 Furthermore, the reported difference
The review summarizes reporting of adherence; adherence to HIIT ·
between HIIT and MICT on Vo2peak improvement in patients
and comparator/s; the influence of adherence on changes in CRF; with coronary artery disease (1.4-1.8 mL/kg/min)2-4 is clin-
and feasibility of HIIT. ically meaningful, with each 1 mL/kg/min improvement in
Summary: Adherence to the attendance of HIIT sessions was ·
Vo2peak associated with a 6% reduction in hospital readmis-
high and comparable with moderate-intensity exercise. However, sions and a 13% decrease in all-cause mortality.5
adherence to the intensity and duration of HIIT was variable and International guidelines have called for further evidence
underreported, which has implications for determining the treat- on the feasibility, safety, and adherence to HIIT, before it
ment effect of the exercise interventions being compared. Fur- is recognized as a standard option for patients attending
thermore, additional research is needed to investigate the utility CR.6 There are limited collective data on the adherence to,
of home-based HIIT and long-term adherence to HIIT following and feasibility of, HIIT in patients with cardiovascular dis-
supervised programs. This review provides recommendations ease. Quindry et al7 reported that adherence to supervised
for researchers in the measurement and reporting of adherence HIIT appeared similar to MICT based on study dropout
to HIIT and other exercise interventions to facilitate a sufficient rates. However, additional research is needed to fully un-
and consistent approach for future studies. This article also high- derstand the dynamics of adherence within supervised and
lights strategies for clinicians to improve adherence, feasibility, home-based HIIT interventions, as this is fundamental to
and enjoyment of HIIT for their patients. long-term outcomes.7 Exercise intensity does not appear to
Key Words: cardiorespiratory fitness • compliance • coronary influence the degree of adherence,8 which is more affect-
artery disease • exercise adherence • feasibility ed by training mode (running/walking more than cycling),
training duration, and overall time commitment.8
H igh-intensity interval training (HIIT) involves alternat-

ing periods of high-intensity intervals (eg, 85-95% max-
imal heart rate [HRmax] or rating of perceived exertion [RPE]:
The Consensus of Exercise Reporting Template (CERT)
was developed by a team of international experts to im-
prove the reporting of exercise interventions in exercise
15-18) with periods of lower intensity or no exercise.1 As research across all study designs9 as an adjunct to other
reporting frameworks (eg, CONSORT, EQUATOR). The
CERT was developed to increase clinical uptake of exercise
Author Affiliations: Department of Cardiovascular Medicine, Mayo Clinic,
interventions, enable research replication, reduce research
Rochester, Minnesota (Drs Taylor and Bonikowske); Centre for Research
on Exercise, Physical activity, and Health, School of Human Movement and
waste, and improve patient outcomes.9 Three components
Nutrition Sciences, The University of Queensland, Brisbane, Australia (Drs in CERT that specifically relate to describing adherence to
Taylor, Holland, Keating, and Coombes); and Department of Cardiology, exercise interventions include (1) how adherence to exer-
Sunshine Coast University Hospital, Birtinya, Australia (Dr Holland) cise is measured and reported, (2) how adherence or fidelity
The authors declare no conflicts of interest. to the exercise is assessed/measured, and (3) the extent to
which the intervention was delivered as planned.9 As well
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions
as providing an explanation for the effect or lack of effect
of this article on the journal’s Web site (www.jcrpjournal.com). of an intervention, adherence data provide valuable infor-
mation to inform future studies and clinical translation.9
Correspondence: Jenna L. Taylor, PhD, Department of Cardiovascular
Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN 55902
The aim of this review is to summarize the current literature
(taylor.jenna-lee@mayo.edu). regarding adherence to HIIT in CR. Specifically, we review
how adherence is reported in the literature, adherence results,
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved
the influence of adherence on changes in CRF, and feasibility
DOI: 10.1097/HCR.0000000000000565 of HIIT, and provide recommendations for future studies.
www.jcrpjournal.com Adherence to High-Intensity Interval Training 61

Copyright © 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
REVIEW OF THE LITERATURE tensity and duration in addition to attendance. The crite-
A review of the literature was conducted, including full- rion for adherence was used to exclude participants from
text studies published in English until September 2020. the primary analysis in 6 of 13 studies16-21 and applied for
We searched electronic databases PubMed, MEDLINE, a secondary treatment (per-protocol) analysis in 5 of 13
ProQuest, Scopus, and Web of Science using key words studies.11,13-15,22 One study23 applied the criterion solely to
“high-intensity interval training,” “interval training,” “in- determine adherence, and for one study,12 the application
terval exercise,” “cardiac rehabilitation,” “coronary artery of the criterion was not defined.
disease,” “coronary heart disease,” “acute coronary syn- For the randomized, observational, and retrospective
drome,” and “myocardial infarction.” We included studies studies, attendance was mainly reported as the number/
involving exercise interventions with intervals of high-in- proportion of sessions completed,20-22,24-34 or the number/
tensity exercise separated with active or passive recovery. proportion of participants who completed 70-100% of ses-
High-intensity exercise was defined as ≥85% peak heart sions11,13-19,27,35-41 (Table 1, Figure 1). One study reported
· attendance using both methods,23 and three studies did not
rate (HRpeak) or HRmax; ≥85% Vo2peak or maximum oxygen
· · report on attendance to the exercise sessions.12,42,43 For the
uptake (Vo2max); ≥80% heart rate reserve or Vo2 reserve;
≥15 on the Borg rating of perceived exertion scale10 (RPE); follow-up studies,19,20,44,45 adherence to the protocol was
or ≥100% peak power output. Studies specifically involv- not reported but rather the effect of group allocation on
ing patients with heart failure were beyond the scope of this exercise adherence. This was reported as the frequency or
review. A total of 36 distinct studies (from 52 publications) minutes of exercise/wk, either as self-reported sessions/
met our criteria, including 28 randomized controlled trials, wk19,46 or objectively measured time spent at moderate or
one observational study, three retrospective studies, and vigorous intensities.44,45
four long-term follow-up studies. Study characteristics are Reporting of exercise intensity during training was highly
outlined in Supplemental Digital Content 1, available at: variable among studies (Table 1, Figure 1). For randomized,
http://links.lww.com/JCRP/A217. Exercise adherence meth- observational, and retrospective studies, 12 of 32 studies re-
odology and results are outlined in Table 1 and Supplemental ported training HR.11,14,18,20,22,24-27,33,39,40 One study reported
Digital Content 2, available at: http://links.lww.com/JCRP/ only training HR for HIIT (but not MICT),39 one study re-
A218. Female participants were underrepresented, averaging ported only absolute HR values (rather than %HRpeak),18 and
20 ± 16% of recruited subjects. For studies with multiple one study reported relative HR in relation to age-predicted
publications, all related articles have been cited together in HRmax (rather than HRpeak from a maximal exercise test).26
Supplemental Digital Content 1, available at: http://links. Six studies reported that training HR was measured during the
lww.com/JCRP/A217, with the original publication. Since high-intensity intervals,11,14,22,24,33,40 while six studies did not
adherence to an exercise intervention is related to whether specify.18,20,25-27,39 One study also reported %HRmax during
the proposed exercise prescription is achieved, adherence the recovery intervals.33 There were 11 of 32 studies that re-
data were reviewed and extracted for exercise prescription ported intensity as training RPE, either in relation to the effort
components “frequency (or attendance),” “intensity,” and during the high-intensity intervals11,20,23,25,28,33,34 or at the end
“time (or duration)” of the prescribed type of exercise (ie, of the session.21,22,29,32 All studies that reported RPE used the
HIIT). 6-20 Borg scale, except for one study20 that used the 0-10 Borg
scale. Two studies also reported RPE during the recovery inter-
REPORTING OF ADHERENCE vals.23,28 Three studies reported intensity as a percentage of peak
A criterion for adherence was defined in 13 of 36 (36%) power output34 or peak work capacity.22,27 Two studies with
studies11-23 (Figure 1). For the majority, this was reported to longer interventions included self-report exercise intensity.30,41
be based on the total number of sessions attended or com- Follow-up studies also used self-report exercise intensity19,46 or
pleted12-23 and ranged from 66-100% of sessions completed accelerometry-based intensity data.44,45 Ten studies did not re-
(Table 1). One study11 reported accounting for training in- port any training intensity data.12,13,15,17,31,35-38,43
Figure 1. Graphical representation of studies reporting on aspects of exercise training adherence. Abbreviation: RPE, rating of perceived exertion.
62 Journal of Cardiopulmonary Rehabilitation and Prevention 2021;41:61-77 www.jcrpjournal.com

Table 1
Exercise Adherence Methodology and Results From Randomized Controlled Trialsa
Improvement in Exercise
Study (Author, Year, Capacity
Country) Exercise Prescriptionb Adherence Methodologyb Adherence Resultsb (%, Mean Change)
·
Aamot et al (2014)14, HIIT: Adherence to attendance: Number of sessions Criteria for attendance: Patients meeting attendance criteria (70%): Assessed as Vo2peak
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Norway 85–95%HRpeak completed—70% criteria (≥17/24 sessions) • Treadmill group (TE): 100%, group exercise (GE): 100%, home-based • 12 wk
MICT: Adherence to intensity and/or duration: monitored by HR group (HE): 87% (26/30) TE: 12% (+4.3 mL/kg/min)
Not applicable monitors and assessed as (1) achieving target HR (2) The main reason for nonattendance was lack of time. GE: 10% (+3.3 mL/kg/min)
mean HR in final 2 min of work intervals; and (3) minutes All participants achieved the target HR. HE: 8% (+2.8 mL/kg/min)
spent in target HR Mean training HR:
TE = 90% HRpeak, GE = 89% HRpeak, HE = 90% HRpeak
Minutes spent in target HR:
• TE = 10.3±2.8 min, GE = 10.2±4.2 min, and HE = 12.3±4.5 min
Abdelhalem et al HIIT: Adherence to attendance: Number of sessions completed Attendance: All participants completed the program with no missing sessions. Assessed as treadmill METs
(2018)35, Egypt 85-95% HRR Adherence to intensity and/or duration: no methods reported Training intensity and/or duration: data not reported. • 12 wk
MICT: HIIT: 53% (+4.0 METs)
60% HRR MICT: 30% (+2.5 METs)
Boidin et al (2019)15, HIIT: Adherence to attendance: Number of sessions Attendance: Not reported
Canada 100% PPO completed—66% criteria applied for per-protocol • Completion of sessions: HIIT = 99%, and MICT = 100%
MICT: analysis. • Study dropout was 25% (6/24) for HIIT and 0/19 for MICT.
60% PPO Adherence to intensity and/or duration: no methods reported Training intensity and/or duration: data not reported.
·
Cardozo et al (2015)16, HIIT: Adherence to attendance: Number of sessions Attendance: All participants completed the program. Assessed as Vo2peak
Brazil 90% HRpeak completed—75% criteria applied for analysis exclusion Training intensity and/or duration: data not reported. • 16 wk
MICT: Adherence to intensity and/or duration: no methods reported HIIT: 18% (+3.8 mL/kg/min)
75%HRpeak MICT: 0% (+0.1 mL/kg/min)
·
Conraads et al (2015)22, HIIT: Adherence to attendance: Number of sessions Attendance: Sessions completed: Assessed as Vo2peak
Belgium 90-95% HRpeak completed—32/36 criteria applied for per-protocol • HIIT = 99% (35.7 ± 1.1), MICT = 99% (35.6 ± 1.5) • 6 wk
(SAINTEX-CAD Study) MICT: analysis or ≥10 training sessions in final 4 wk. Mean training HR: HIIT: 15% (+3.2 mL/kg/min)
65-75% HRpeak Adherence to intensity and/or duration: Mean training HRs/ • HIIT = 88% HRpeak, MICT = 80% HRpeak (P = .001) MICT: 13% (+2.8 mL/kg/min)
workloads calculated by averaging 4 × HRs/workloads Mean Training RPE: • 12 wk
of each training session (HIIT: measured at end of work • HIIT = 13.5 ± 1.6, MICT = 12.5 ± 1.5 (P = .001) HIIT: 23% (+5.1 mL/kg/min)
interval; MICT: measured every 10 min). Mean HRs/ Mean training workload: MICT: 20% (+4.4 mL/kg/min)
workloads expressed as %HRpeak/workload from most • HIIT = 86% PWC, MICT = 63% PWC (P = .001) Per-protocol analyses were not
recent CPX. RPE was measured at the end of the training different
session.
·
Currie et al (2013)26, HIIT: Adherence to attendance: Number of sessions completed— Attendance: sessions completed: Assessed as Vo2peak
Canada 89-110% PPO no criteria specified • Supervised training: HIIT = 80% (19 ± 4), MICT completed 92% (22 ± 3) • 12 wk
MICT: Adherence to intensity and/or duration: no methods reported (P >.05). HIIT: 24% (+4.7 mL/kg/min)
51-65% PPO • Home-based training: HIIT = 11 ± 10, MICT = 14 ±1 4 MICT: 19% (+3.6 mL/kg/min)
Mean training duration:
• HIIT = 40 ± 17 min/session, MICT = 45 ± 3 min/session.
Mean training HR:
• During supervised training, HIIT = 73 ± 10% of age-predicted HRmax, and
MICT = 65 ± 4% of age-predicted HRmax (P < .005)
• For home-based training HIIT = 68 ± 5% of age-predicted HRmax, and
Adherence to High-Intensity Interval Training 63

MICT = 60 ± 7% of age-predicted HRmax (P < .005)
(continues)
Table 1
Exercise Adherence Methodology and Results From Randomized Controlled Trialsa (Continued)
·
Ha-Yoon et al (2018)17, HIIT: Adherence to attendance: Number of sessions Attendance: patients completing 100% sessions: Assessed as Vo2peak
Korea 85-100% HRmax completed—18/18 criteria applied for study exclusion. • HIIT = 96% (23/24) and 95% (21/22) for MICT. • 9-10 wk
MICT: Adherence to intensity and/or duration: no methods reported • Dropout rates = 1/24 for HIIT (ankle injury) and 1/22 for MICT HIIT: 24% (+7.6 mL/kg/min)
60-70% HRmax (occupational reason). MICT: 9% (+2.4 mL/kg/min)
Training intensity and/or duration: data not reported. Investigators reported
that exercise was performed with sufficient intensity to reach the
prescribed HR value.
·
Heber et al (2020)39 HIIT: Adherence to attendance: Number of sessions completed— Attendance: Completion of training protocol according to randomization: Assessed as Vo2peak
Austria 100% PPO no criteria specified. • HIIT = 68% (27/40) and 79% (33/42) for MICT (P = .26). Data not reported, only displayed
MICT: Adherence to intensity and/or duration: no methods reported Protocol deviation: graphically.
·
60% PPO • 13% (5/40) patients unable or unwilling to perform HIIT (swapped to MICT). Improvement in Vo2peak was not
Reasons given were knee pain, discomfort, and lack of motivation. statistically different between
• 1/42 patients unwilling to perform MICT (swapped to HIIT) groups.
• Dropout rates = 8% (11/40) in HIIT, 21% (9/42) in MICT.
Percentage of time spent in target HR:
• HIIT = 94% (85-100%) for wk 1-6 and 79% (61-88%) for wk 7-12
• MICT = 93% (84-100%) for wk 1-6 and 76% (67-91%) for wk 7-12.
Mean training HR:
• HIIT = 92 ± 7% HRmax, MICT not reported.
Home-based training not evaluated because of lack of compliance with self-
report documentation.
·
Jayo-Montoya et al HIIT: Adherence to attendance: Number of sessions Attendance: Not reported. Assessed as Vo2peak
64 Journal of Cardiopulmonary Rehabilitation and Prevention 2021;41:61-77

(2020)12, Spain 85-95% HRpeak completed—80% criteria applied to define adherence. • Dropout rates: HIIT = 21% (12/56), control = 21% (3/14) • 16 wk
(INTERFARCT Project) MICT: Adherence to intensity and/or duration: Exercise intensity Training intensity and/or duration: Data not reported. Control: −2% (−0.5 mL/kg/min)
Not specified controlled and monitored by HR monitors and RPE. LV HIIT: 15% (+3.5 mL/kg/min)
HV HIIT: 22% (+5.0 mL/kg/min)
·
Karlsen et al (2008)29, HIIT: Adherence to attendance: Number of sessions completed— Attendance: Participants attended 97% (29/30) of sessions. Assessed as Vo2peak
Norway 85-95% HRpeak no criteria specified. Mean training RPE: 14.4 ± 1 (after training session) • 10 wk
MICT: Adherence to intensity and/or duration: HR and RPE HIIT: 16% (+4.5 mL/kg/min)
Not applicable monitored and recorded. RPE after the training session.
·
Keteyian et al (2014)28, HIIT: Adherence to attendance: Number of sessions completed— Attendance: Number of sessions completed: Assessed as Vo2peak
United States 80-90% HRR no criteria specified. • HIIT = 29 ± 1 and MICT = 29 ± 2. • 10 wk
MICT: Adherence to intensity and/or duration: HR monitored Mean training RPE: HIIT: 16% (+3.6 mL/kg/min)
60-80% HRR continuously by HR monitor and used by staff/patients • HIIT = 15 ± 1 for work intervals and 12 ± 1 for recovery MICT: 7% (+1.7 mL/kg/min)
to adjust workload. RPE was reported during the session • MICT = 12 ± 1 during session
(during work and recovery intervals for HIIT). Mean training HR: Not reported
(continues)
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Table 1
·
Kim et al (2015)40, South HIIT: Adherence to attendance: Number of sessions completed— Attendance: Patients completing 100% of sessions: Assessed as Vo2peak
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Korea 85-95% HRR no criteria specified. • HIIT = 88% (14/16) and MICT = 100% (16/16) • 6 wk
MICT: Adherence to intensity and/or duration: All training Training HR: All HIIT subjects achieved 85% HRR within 1 min after recovery HIIT: 22% (+6.4 mL/kg/min)
70-85% HRR sessions monitored by HR. RPE was assessed during interval. The target HR was achieved during 86% of the high-intensity MICT: 8% (+2.5 mL/kg/min)
and after each training session. Workload was adjusted interval duration. Training HR data were not reported for MICT.
continuously to maintain HR target. Training RPE: No differences reported between HIIT and MICT (RPE data not
provided).
·
Kim and Choi (2020)36, HIIT: Adherence to attendance: Number of sessions completed— Adherence: Patients who attended all training sessions: Assessed as Vo2peak
South Korea 85% HRR no criteria specified. • HIIT = 80% (24/30) and maximal HIIT = 77% (23/30) • 4 wk
Maximal HIIT: Adherence to intensity and/or duration: All training sessions Training intensity and/or duration: Data not reported. HIIT: 17% (+3.7 mL/kg/min)
95-100% of HRR were monitored by HR and RPE. Workload was adjusted Maximum HIIT: 31% (+8.3 mL/
continuously to maintain HR target. kg/min)
·
Lee et al (2019)25, HIIT: Adherence to attendance: Number of sessions completed— Adherence: Proportion of exercise sessions completed: Assessed as Vo2peak
Canada 90-95% HRpeak, and/ no criteria specified. Frequency and duration recorded in • For all sessions: HIIT = 76 ± 14% and MICT 72 ± 15% (P >.05) • 26 wk
or RPE ≥17 a self-report weekly exercise diary. • For supervised sessions: HIIT = 84% (21/25) and MICT = 80% (20/25). HIIT: 6% (+1.3 mL/kg/min)
MICT: Adherence to intensity and/or duration: During supervised Mean training HR: MICT: 2% (+0.4 mL/kg/min)
60-80% Vo2peak. sessions, HR and speed data were monitored using a • HIIT = 89 ± 3% HRpeak and MICT = 68 ± 7% HRpeak
GPS watch monitor. Mean training RPE:
During home-based training, HR and RPE were recorded in a • HIIT = RPE 16.7 ± 0.6, and MICT = 11.2 ± 1.3 (P < .01).
self-report weekly exercise diary.
·
Madssen et al (2014)38, HIIT: Adherence to attendance: Number of sessions completed— Adherence: All patients attended > 90% (32/36) of sessions. Assessed as Vo2peak
Norway 85-95% HRpeak no criteria specified. Training intensity and/or duration: Data not reported. • 12 wk
MICT: Adherence to intensity and/or duration: HR monitors were HIIT: 11% (+3.3 mL/kg/min)
70% at HRpeak used to help achieve target intensity MICT: 7% (+2.0 mL/kg/min)
·
Madssen et al (2014)41, HIIT: Adherence to attendance: Number of sessions/wk—criteria Attendance: Completion of sessions was 98% (7.8/8) in maintenance and Assessed as Vo2peak
Norway 85-95% HRpeak not specified. control groups. • 12 mo
MICT: Adherence to intensity and/or duration: Assessed as physical Self-reported exercise frequency (maintenance vs control): Maintenance group: 3% (+0.9 mL/
Not applicable activity level via self-report questionnaires asking how • ≥4 times/wk: 19% (4/21) vs 4% (1/22) kg/min)
often they exercised/wk (<1, 2, 3, and >4 sessions/wk), • 2-3 times/wk = 76% (16/21) vs 77% (17/22) Control group: 3% (+0.8 mL/kg/
the mean duration of each exercise session (30, 30-45, • <1 time/wk = 0% vs 22% (5/23) min)
45-60, and >60 min/session). Self-report questionnaires Self-reported exercise duration (maintenance vs control):
also asked the mean intensity level during sessions (light, • >60 min: 29% (6/21) vs 32% (7/22)
medium, or hard intensity). Time spent in moderate or • 45-60 min: 38% (8/21) vs 23% (5/22)
vigorous physical activity was objectively measured by • 30-45 min: 29% (6/21) vs 23% (5/22)
accelerometry in a subgroup of n = 18 (37%). • 0-30 min: 5% (1/21) vs 23% (5/22)
Self-reported exercise intensity (maintenance vs control):
• at high intensity = 43% (9/21) vs 35% (6/22)
• at moderate intensity = 52% (11/21) vs 59% (10/22)
Time spent at moderate intensity:
• Maintenance = 58 min/d, control = 111 min/d
Time spent at high intensity:

Maintenance = 3 min/d, control = 7 min/d
(continues)
Table 1
·
Moholdt et al (2009)20, HIIT: Adherence to attendance: Number of sessions Attendance: Completion of supervised sessions: Assessed as Vo2peak
Norway 90% HRpeak completed—70% criteria • HIIT = 82% (16.4/20), and MICT = 84% (16.7/20) • 4 wk
MICT: Frequency of sessions was recorded by self-report exercise In addition, all subjects completed an additional 16.5 (range: 12-19) other HIIT: 12% (+3.3 mL/kg/min)
70% HRpeak diary. training sessions during 4 wk. MICT: 9% (+2.3 mL/kg/min)
Adherence to intensity and/or duration: Assessed by HR Self-reported exercise sessions at 6-mo: • 6 mo
monitors and RPE on 0-10 Borg scale. HR and RPE were • ≥3 times/wk HIIT = 74% (17/23), MICT = 68% (17/24) HIIT: 19% (+5.1 mL/kg/min)
assessed during the work intervals. • 1-2 times/wk: HIIT = 13% (3/23), MICT = 20% (5/24) MICT: 13% (+3.3 mL/kg/min)
• <1 times/wk: HIIT = 13% (3/23), MICT = 8% (2/24)
Mean training HR:
• HIIT = 92 ± 5% HRpeak and MICT = 74 ± 4% HRpeak
Mean training RPE:
• HIIT = 6.1 ± 0.9 (during work intervals), MICT = 2.9 ± 0.9.
In the other training sessions at the center, the patients exercised with high
intensity in 31% and moderate intensity in 69% of the registered sessions,
respectively.
Adherence to randomized training at 6 mo:
• ≥3 times/wk: HIIT = 52% (12/23), MICT = 64% (16/25)
Protocol deviation at 6 mo:
• HIIT = 22% (5/23) doing moderate intensity exercise
• MICT: 4% (1/25) doing higher intensity exercise
·
Moholdt et al (2012)24, HIIT: Adherence to attendance: Number of sessions completed— Attendance: Completion of sessions: Assessed as Vo2peak
Norway 90% HRpeak no criteria specified. • HIIT = 83% (20.4 ± 5.0), usual care = 79% (19.1 ± 4.0) • 12 wk

Usual care: Adherence to intensity and/or duration: All patients wore HR Mean training HR: HIIT: 15% (+4.6 mL/kg/min)
Not specified monitors. Training HR was calculated from HR in • HIIT = 87 ± 4% HRpeak, usual care = 78 ± 7% HRpeak (P < .001) Usual care: 8% (+2.5 mL/kg/min)
8 min with the highest intensity throughout each session.
For HIIT, this was the last 2 min of each work interval.
For the usual care exercise, this was selected by visual
inspection.
·
Moholdt et al (2012)30, HIIT: Adherence to attendance: Number of sessions completed— Attendance: Number of weekly sessions: Assessed as Vo2peak
Norway 90% HRpeak only in HIIT group. Assessed with self-report exercise • HIIT group reported in 1.6 ± 1.6 HIIT sessions/wk and 2.4 ± 1.9 • 4 wk
Residential group: diary. moderate intensity sessions/wk Usual care: 17% (+3.9 mL/kg/min)
Light, moderate, high Adherence to intensity and/or duration: No methods reported Exercise adherence not reported for residential group. • 26 wk
(RPE: 11-17) Self-reported exercise sessions at 6 mo: HIIT: 19% (+4.6 mL/kg/min)
• 42% (5/12) achieved HIIT 3 times/wk
• 17% (2/12) reported a combination of HIIT and MICT
• 33% (4/12) reported doing MICT instead of HIIT
• 1/12 did no exercise.
·
Munk et al (2009)37, HIIT: Adherence to attendance: Number of sessions completed— Attendance: Patients attending >90% sessions = 95% (19/20). Assessed as Vo2peak
Norway 80-90% HRmax no criteria specified. Training intensity and/or duration: Data not reported. • 26 wk
Usual care: Adherence to intensity and/or duration: Training sessions HIIT: 17% (+3.9 mL/kg/min)
Not applicable were monitored with HR watches allowing the patient to Control: 8% (+1.5 mL/kg/min)
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achieve the target HR.
(continues)
Table 1
·
Pedersen et al (2015)13, HIIT: Adherence to attendance: Number of sessions Attendance: Patients who completed the study per protocol with valid Assessed as Vo2peak (relative to
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Norway (The CUT-IT 85-90% HRpeak completed—≥60% criteria of attendance used for per- measurements were 74% (26/35). fat-free mass)
Trial) MICT: protocol analysis. Training intensity and/or duration: Data not reported. • 12 wk
Not applicable Adherence to intensity and/or duration: monitored using HR HIIT: 11% (+12.9 mL/kg/min need)
monitors, lactate measurements, and the RPE Borg Scale.
·
Rognmo et al (2004)21, HIIT: Adherence to attendance: Number of sessions Attendance: Completion of sessions: Assessed as Vo2peak
·
Norway 80-90% Vo2peak completed—70% criteria applied for adherence • HIIT = 94% (28.3, range: 25-30), MICT = 85% (25.4, range: 21-30) • 10 wk
85-95% HRpeak Adherence to intensity and/or duration: All subjects used (P = .074) HIIT: 18% (+6.0 mL/kg/min)
MICT: HR monitors during every training session and were Mean training RPE (at the end of the session) MICT: 8% (+2.7 mL/kg/min)
·
50-60% Vo2peak encouraged to exercise as close to the upper intensity • HIIT = 14.4 and MICT = 13.5 (P = .093).
65-75% HRpeak border as possible. Workload was continually adjusted to Mean training HR: data not reported.
maintain desired HR target. Borg RPE (6-20 scale) was
recorded at the end of the training session.
·
Taylor et al (2020)11, HIIT: Adherence to attendance: Assessed as the number Criteria for attendance: Patients meeting adherence to attendance criteria: Assessed as Vo2peak
Australia (The FITR- RPE 15-17 of randomized sessions completed with sufficient • 4 wk: HIIT = 98% (43/44), MICT = 91% (39/43), P >.05 • 4 wk (intention-to-treat)
Heart Study) MICT: duration—70% criteria (adherent if 70% of sessions • 3 mo: HIIT = 68% (25/37), MICT = 78% (31/41), P >.05 HIIT: 10% (+2.9 mL/kg/min)
RPE 11-13 completed with 70% duration). During home-based • 6 mo: HIIT = 65% (24/37), MICT = 67% (26/39), P >.05 MICT: 4% (+1.2 mL/kg/min)
training, frequency and duration were recorded in self- • 12 mo: HIIT = 56% (19/34), MICT = 70% (26/37), P >.05 • 4 wk (per protocol)
report weekly exercise diaries. Criteria for attendance and intensity: Patients meeting adherence and HIIT: 18% (+6.0 mL/kg/min)
Adherence to intensity and/or duration: Assessed as the intensity criteria combined: MICT: 8% (+2.7 mL/kg/min)
number of sessions adherent to prescribed intensity. • 4 wk: HIIT = 91% (39/44), MICT = 91% (29/43), P >.05. • 12 wk (intention-to-treat)
Deemed adherent if average training intensity was within • 3 mo: HIIT = 68% (25/37), MICT = 75% (30/41), P >.05 HIIT: 9% (+2.6 mL/kg/min)
RPE ≥15 (or ≥85% HRpeak) for HIIT during work intervals • 6 mo: HIIT = 57% (21/37), MICT = 39% (15/39), P >.05 MICT: 8% (+2.2 mL/kg/min)
and 11-13 for MICT during session. • 12 mo: HIIT = 53% (18/34), MICT = 41% (15/39), P >.05 • 26 wk (intention-to-treat)
During the supervised training, HR was measured by Criteria for intensity: Patients meeting adherence to intensity criteria: HIIT: 11% (+3.1 mL/kg/min)
ECG, pulse oximetry, or HR monitor. For MICT, HR was • 4 wk: HIIT = 91% (39/44), MICT = 98% (42/43), P >.05 MICT: 6% (+1.7 mL/kg/min)
measured >10 min into session and RPE at the end of • 3 mo: HIIT = 84% (31/37), MICT = 88% (35/41), P >.05 • 52 wk (intention-to-treat)
each exercise modality. For HIIT, the highest HR and RPE • 6 mo: HIIT = 70% (26/37), MICT = 54% (21/39), P >.05 HIIT: 10% (+2.9 mL/kg/min)
were recorded for each high-intensity interval. Exercise • 12 mo: HIIT = 68% (23/34), MICT=49% (18/41), P >.05 MICT: 7% (+1.8 mL/kg/min)
intensity was then assessed as average training RPE, Mean training HR: • 52 wk (per protocol)
peak training RPE, average training %HRpeak, and peak • Supervised training: HIIT = 87 ± 6% HRpeak, MICT = 70 ± 8% HRpeak HIIT: 18% (+5.2 mL/kg/min)
training %HRpeak. Average RPE and HR were calculated by (P < .001) MICT: 8% (+2.2 mL/kg/min)
averaging the measurements taken during each exercise • Home-based training at 3 mo: HIIT = 88 ± 7% HRpeak
modality (eg, treadmill, bike) for MICT, or each high- Mean training RPE:
intensity interval for HIIT. Training HR was not measured • Supervised training: HIIT = 16.0 ± 1.1 and MICT = 12.4 ± 0.6 (P < .001)
continuously throughout the entire exercise session. • Home-based training at 3 mo, HIIT = 16.5 ± 1.2, MICT = 12.4 ± 0.5
During home-based training, RPE was recorded by self- for MICT (P < .001)
report exercise diary. The HIIT group used HR monitors Protocol deviation: During home-based training at 6 mo, 24% of HIIT participants
for the initial 3 mo of training. They were instructed to started exercising at a lower intensity on their own accord, and 38% of MICT
record HR and RPE as per the supervised sessions. participants were exercising at higher intensities. At 12 mo, 20% of HIIT

participants started exercising at a lower intensity on their own accord, and
33% of MICT participants were exercising at higher intensities.
(continues)
Table 1
43 ·
Trachsel et al (2019) , HIIT: Adherence to intensity and/or duration: Methods not Attendance: Data not reported. Assessed as Vo2peak (relative to
Canada 100% PPO reported Training intensity and/or duration: Data not reported. fat-free mass)
(or 15 RPE) Adherence to intensity and duration: No methods reported • 12 wk
MICT: RPE 12-14. HIIT: 11% (+3.1 mL/kg/min)
Usual care: 0% (+0.1 mL/kg/min)
Tschentscher et al HIIT: Adherence to attendance: Number of sessions completed— Attendance: To exercise sessions for all groups was 99.2%. Assessed as peak exercise capacity
(2016)27, Austria 85-95% HRpeak no criteria specified. Mean training HR: (W)
MICT: Adherence to intensity and/or duration: No methods reported • HIIT = 76 ± 6% HRpeak, MICT = 74 ± 8% HRpeak, and pyramid = 72 ± • 6 wk
65-85% HRpeak 9% HRpeak (P >.05) HIIT: 23% (30W)
Other (pyramid): Mean training workload: MICT: 21% (27W)
65-95% HRpeak • HIIT = 58 ± 8% PWC, MICT = 60 ± 8% PWC, and pyramid = 56 ± Pyramid: 25% (30W)
9% PWC (P >.05)
·
Villelabeitia-Jaureguizar HIIT: Adherence to attendance: Number of sessions completed— Attendance: Completion of exercise sessions: Assessed as V o2peak
et al (2016)34, Spain 50% of PPO from no criteria specified. • HIIT = 92% and MICT = 88% (P > 0.05). • 8 wk
steep ramp test Adherence to intensity and/or duration: Patients reported Mean training RPE: HIIT: 23% (+4.5 mL/kg/min)
MICT: peak RPE (Borg 6-20) during the exercise session. The • Not different between HIIT and MICT during the first month of training (RPE MICT: 12% (+2.5 mL/kg/min)
VT1 + 10% exercise prescription for HIIT was prescribed on the basis 11-13) and second month (RPE, 14-16).
of %PPO reached in the steep ramp test, whereas the Mean training workload:
training workload is reported as %PPO reached in CPX. • HIIT = 105 ± 22% PPO (wk 1-4), 135 ± 30% PPO (wk 5-8). Training
Methods for measurement of HR not reported. workload data for MICT were not reported.
·

Mean training Vo2peak:
·
• MICT = 64 ± 9% Vo2peak (wk 1-4), corresponding to VT1, and 70 ± 9%
·
Vo2peak, corresponding to VT1 + 10%.
·
Warburton et al (2005)31, HIIT: Adherence to attendance: Number of supervised sessions Attendance: Supervised training attendance data not reported. For home- Assessed as Vo2peak
Canada 85-95% of HRR completed—no criteria specified. based training, completion rates were 99 ± 2% for both HIIT and MICT. Data not reported, only displayed
MICT: Adherence to intensity and/or duration: HR monitors used Training intensity: Data not reported. graphically.
·
65% of HRR. during supervised sessions. Individual workloads adjusted Improvement in Vo2peak was not
daily to maintain desired HR range. statistically different between
groups after 16 wk.
·
Wehmeier et al (2020)32, HIIT: Adherence to attendance: Number of supervised sessions Attendance: Both HIIT and MICT completed an average of 11.5/12 training Assessed as Vo2peak
Germany 85-95% HRmax completed—no criteria specified. sessions and 11.5 hr of cycle ergometry. • 3 wk
MICT: Adherence to intensity and/or duration: All sessions Mean training RPE (at the end of the session): HIIT: 18% (+3.4 mL/kg/min)
50-75% HRmax monitored by ECG. • HIIT = 13.1 and MICT = 12.9 MICT: 4% (+0.9 mL/kg/min)
Abbreviations: CPX, maximal cardiopulmonary exercise test; HIIT, high-intensity interval training; HR, heart rate; HRmax, percentage of maximum heart rate from maximal exercise test; METs, metabolic equivalents; MICT, moderate-intensity continuous training; %HRpeak,
percentage of peak heart rate from maximal exercise test; %HRR, percentage of heart rate reserve; %PPO, percentage of peak power output achieved during a maximal exercise test; PWC, peak work capacity; RPE, rating of perceived exertion (on the 6-20 Borg Scale
·
unless otherwise specified); Vo2peak, peak oxygen uptake measured during a maximal exercise test.
a
Exercise adherence methodology and results for Observational, Retrospective, and Follow-Up Studies is available in Supplemental Digital Content 2 (http://links.lww.com/JCRP/A218).
b
HRpeak and HRmax are often used interchangeably and have been reported within the table as consistent with how the metric was reported by the study.
www.jcrpjournal.com
Few studies reported on whether participants achieved (mean = 93%, range: 68-100%) and MICT (96%, range: 79-
the prescribed duration of exercise sessions (Table 1 and 100%) (mean difference = 3.9%, Figure 2B). Using linear re-
Figure 1). Three studies reported the mean duration of ses- gression, we found no influence of sex (as % of females recruit-
sions18,26,41 and one study included duration in the criteria ed) on (1) proportion of HIIT sessions attended; (2) proportion
for adherence.11 Overall, it was generally unclear whether a of HIIT participants meeting study adherence criteria; or (3) dif-
session deemed “completed” involved assessment of session ference between HIIT and MICT for adherence to attendance.
duration in addition to session attendance.
ADHERENCE TO INTENSITY
ADHERENCE TO ATTENDANCE Of the studies that reported training intensity as %HRpeak
The majority of studies evaluated adherence to HIIT in com- for HIIT during supervised programs (n = 10), seven
parison to a form of MICT.11,15-18,20-22,24,26-28,31,32,34,35,38-40,42,45,46 studies reported average training intensities >85%HRpeak
For supervised programs, 10 studies20-22,24-28,34,35 compared at- (range: 87-92%),11,14,20,22,24,25,39 one study reported average
tendance to sessions between HIIT and MICT, with all studies training intensity of 84%HRmax,33 and two studies reported
reporting similar attendance to sessions between HIIT (mean average intensity <80%HRpeak.26,27 Currie et al26 reported
= 92%, range: 82-100%) and MICT (mean = 90%, range: mean training intensities of 73%HRpeak and 68%HRpeak
80-100%) (mean difference = 3.6%, Figure 2A). Eight stud- for supervised and home-based training, respectively, and
ies11,15-17,35,38-40 compared the proportion of patients attending Tschentscher et al27 reported a mean training intensity of
all sessions or meeting a prespecified criteria for supervised pro- 76%HRpeak for supervised training. Neither study reported
grams, with all studies reporting no differences between HIIT methods for measuring training intensity, and, therefore,
Figure 2. (A) Session attendance. Proportion of HIIT or MICT sessions attended and the difference in proportions between the two exercise groups.
Solid squares represent differences in adherence between HIIT and MICT. The solid diamond represents the mean difference ± SD. Image created
using Comprehensive Meta-Analysis Software (V3.3.070, Biostat). (B) Participant attendance. Proportion of participants adherent to all sessions, or a
priori adherence criteria within HIIT or MICT, and the difference in proportions between the two exercise groups. Solid squares represent differences
in adherence between HIIT and MICT. The solid diamond represents the mean difference ± SD. Abbreviations: HIIT, high-intensity interval training;
MICT, moderate-intensity continuous training. Image created using Comprehensive Meta-Analysis Software V3.3.070 (Biostat).

training HR may not be reflective of the time spent at high 42% of participants maintaining three HIIT sessions/wk at
intensity. Furthermore Currie at al26 reported training HR 6 mo and 17% doing a combination of HIIT and MICT.
relative to age-predicted maximum, rather than HRmax The home-based HIIT group reported an average of 1.6
achieved during a maximal exercise test. ± 1.6 HIIT sessions/wk and 2.4 ± 1.9 moderate-intensity
In comparison to the training HR reported for HIIT, five sessions/wk. Aamot et al14 provided participants with two
studies reported mean training HR for MICT <75%HRpeak supervised instructional HIIT sessions prior to home-based
·
(range: 65-74%HRpeak).11,20,25-27 Two studies22,24 reported training. There were no significant differences in Vo2peak im-
training intensities for MICT of 80% and 79% HRpeak, re- provement between the 12-wk home-based HIIT program
spectively; however, neither study restrained participants to (8%) and 12-wk hospital-based HIIT programs (10-12%).
exercise at a moderate intensity. Regarding adherence, the mean number of HIIT sessions
Of the studies that reported training as RPE (n = 10) for the home-based program was 24 (10-24), similar to
during supervised programs, four studies reported average the hospital-based program of 24 (17-24). However, 13%
training RPE ≥15/20 (range: 15.0-16.7)11,25,28 or equivalent of participants in home-based HIIT did not meet the 70%
to a hard RPE on the 0-10 Borg scale (average training RPE adherence criteria, which was significantly higher than the
of 6.1),20 and six studies21-23,29,32,33 reported average RPE hospital-based programs (0%). Few studies have reported
<15 (range: 13.1-14.4). However, four of the six studies training intensity data during home-based HIIT. Two stud-
reporting an average RPE <15 or hard,21,22,29,32 measured ies11,14 have reported an average home-based HIIT training
RPE at the end of the session, which may be reflective of intensity of 89% HRpeak, compared with center-based HIIT
the effort for the session overall rather than the peak ef- training intensities of 87% and 90% HRpeak, respectively.
fort during the high-intensity intervals. Of the remaining One study11 reported an average home-based HIIT RPE of
studies,33 prescribed HIIT at a lower RPE range of 14-16 16.3, which was the same as center-based HIIT.
(compared with RPE 15-17) prescribed in other trials.11,14
The other study reported that 58% of HIIT participants INFLUENCE OF ADHERENCE ON
trained below the target RPE of 15 during the high-intensity CARDIORESPIRATORY FITNESS
intervals.23 In comparison to HIIT, seven studies reported Fourteen studies comparing HIIT with MICT included as-
mean training RPE for MICT <RPE 14/20 (range: 11.2- ·
sessment of Vo2peak directly following the supervised exercise
13.5)11,21,22,25,28,32 or equivalent to a somewhat hard RPE intervention.11,16,17,20-22,24-26,28,32,34,38,40 The average improve-
on the 0-10 Borg scale (average training RPE of 2.9).20 Be- ·
ment in Vo2peak for HIIT was 17% (range: 6-24%) compared
cause of heterogeneity of study reporting for adherence to with 8% (range: 0-20%) for MICT. Ten studies reported that
intensity, and lack of reporting for adherence to duration, ·
the improvement in Vo2peak with HIIT was significantly great-
we were unable to investigate the influence of sex on these er compared with MICT.11,16,17,21,24,28,32,34,38,40 One study25
aspects of adherence. ·
reported that the improvement in Vo2peak was greater for
HIIT only when accounting for adherence using per-protocol
LONG-TERM ADHERENCE analysis. Three studies20,22,26 reported no significant differenc-
Only two studies have assessed long-term adherence to ·
es for improvement in Vo2peak between HIIT and MICT, even
HIIT compared with MICT following supervised CR.11,20 when accounting for per-protocol analysis based on adher-
Moholdt et al20 found that after 5 mo of home-based train- ence to attendance. However, in these studies, the training
ing, 52% of HIIT participants continued HIIT ≥3 times/wk intensities of participants likely contributed to the similarities
and 64% of MICT participants continued MICT ≥3 times/ ·
in Vo2peak improvement for HIIT and MICT. In the study by
wk. The proportion of HIIT participants that stopped HIIT Currie et al,26 where HIIT was prescribed as 89-100% peak
in favor of moderate-intensity training was 35%, compared power output, the average training intensity reported for
to 4% MICT participants who started higher-intensity HIIT was 73 ± 10%HRmax, which is lower than the criteria
exercise. In contrast, The FITR-Heart Study,11 found that usually prescribed for HIIT.1 In the SAINTEX-CAD study,22
a higher proportion of MICT participants (38%) started despite the HIIT group achieving an appropriate mean
high-intensity exercise after 5-mo of home-based training, training intensity of 88%HRpeak, the authors acknowledged
and a lower proportion of HIIT participants who swapped that MICT participants trained at higher intensities (mean
to a moderate-intensity exercise (24%). However, the per- training intensity = 80%HRpeak) than prescribed for MICT
centage of HIIT participants who continued HIIT ≥3 times/ (65-75%HRpeak). Finally, in the study by Moholdt et al,20
wk in The FITR-Heart Study at 6 mo (57%) and 12 mo mean training HR during the randomized training sessions
(53%)11 was similar to Moholdt et al.20 Furthermore, to- for both HIIT (92%HRpeak) and MICT (74%HRpeak) was
tal exercise adherence (reported as the average number of within prescribed targets; however, both HIIT and MICT
weekly sessions for any exercise) was similar to MICT at participated in 3-5 additional training sessions/wk for which
6 mo (3.5 ± 1.5 vs 3.7 ± 1.6) and 12 mo (3.1 ± 1.8 vs 3.5 31% were of a high intensity.
± 2.1).11 Three studies have investigated the long-term effects of
HIIT compared with MICT on CRF and exercise adherence
ADHERENCE TO HOME-BASED HIIT at 9-mo,45 11-mo,11 and 27-mo46 following supervised CR.
Only two studies have investigated home-based HIIT com- ·
Moholdt et al46 found less deterioration in Vo2peak for HIIT
pared with center-based CR. Moholdt et al30 compared a participants compared with MICT after a 27-mo follow-up
6-mo home-based HIIT program with a 4-wk residential period. This is likely a result of the HIIT group maintain-
CR program. While Aamot and colleagues14 compared a ing a greater frequency of total exercise than MICT, with
12-wk home-based HIIT with 12-wk center-based HIIT 82% of the group HIIT engaging in any exercise ≥2 times/
programs and then completed a follow-up at 12 mo,44 wk compared with 52% in the MICT group. The SAIN-
Moholdt et al30 provided verbal instructions but no su- TEX-CAD study45 found that both HIIT and MICT main-
pervised HIIT sessions prior to home-based HIIT. The ·
· tained Vo2peak equally after a 9-mo follow-up period. The
authors found a similar improvement in Vo2peak with the authors did not report on adherence to the randomized
6-mo home-based HIIT program compared with an in- training, instead reporting exercise adherence as meeting
tensive 4-wk CR program (17 vs 19%, respectively), with physical activity guidelines and time spent in moderate and

vigorous activities, which was not different between HIIT DISCUSSION
and MICT.45 The FITR Heart Study11 also found that both A review of the current literature found that adherence to
·
HIIT and MICT had similar improvements in Vo2peak at
the attendance of HIIT sessions in CR patients with coro-
12 mo for intention-to-treat analyses. However, when ad-
nary artery disease is high and comparable with MICT. In
herence to the recommended frequency (>3 times/wk) and
contrast, adherence to the intensity and duration of HIIT is
intensity of HIIT and MICT were accounted for in the pre-
· underreported. Only 36% of studies defined an adherence
specified per-protocol analysis, the improvement in Vo2peak
criterion for the exercise interventions, and for the majority
was superior for HIIT compared with MICT with a clinical-
of studies, this was reported to be based on sessions attended
ly relevant mean difference of 3.0 mL/kg/min.11
or completed. Whether adherence to intensity and duration
was assumed or incorporated into determining whether a
FEASIBILITY OF HIIT session was attended or completed was not reported. Based
Eleven studies commented on the feasibility of HIIT com- on the available literature, adherence to HIIT (encompassing
pared with MICT. Feasibility referred to various aspects
all necessary components of attendance, intensity, and du-
including adherence to attendance,11,23,26,33 adherence to
ration) could not be determined. This review illustrates that
intensity,22,23,25 tolerability or enjoyment of the proto-
adherence to intensity influences the improvement in CRF
col,11,23,25,28,32,33,39 safety,23,33 and implementation of the pro-
which can have important implications for determining the
tocol into the CR program.11,28 In some studies, the definition
treatment effect of exercise interventions being compared.
of feasibility was not specified.15,27 Eight studies determined
Previous studies have observed that participants will tend to
HIIT to be feasible11,15,23,26-28,32,33 and three studies reported
lower the intensity from high to moderate as time goes on.49
that HIIT was less feasible than MICT.22,25,39 Two of these
Therefore, including the reporting of adherence to intensity
studies reported that HIIT was not feasible in relation to
and duration is important for determining whether the cor-
maintaining ≥ 90%HRpeak for the entire 4-min duration.22,25
rect dose of exercise was delivered.
Two studies also reported that HIIT was less feasible based
on patient perspectives.25,39 Heber et al39 reported that HIIT With important questions still to be answered relating
was not feasible in five patients (13%), with patients report- to HIIT in CR, including the optimal protocol, reporting
ing knee pain, discomfort, and lack of motivation, and that of adherence to HIIT protocols and its comparators is vital
it was too demanding. All patients instead completed MICT for determining effectiveness. For example, for studies de-
for the remainder of the intervention. Lee et al25 studied HIIT signed to determine whether HIIT is superior to MICT for
·
compared with MICT in a female-only cohort. Although improving Vo2peak and other outcomes, reporting and jus-
some women expressed a sense of enjoyment and accom- tifying whether the comparison is truly moderate-intensity
plishment associated with performing HIIT, the majority of exercise or a continuous training of a moderate to high in-
women described HIIT to be a daunting undertaking and ex- tensity. Furthermore, adherence to the interventions should
pressed preference for performing MICT over HIIT.25 Specif- be reported and can be considered in sensitivity or explan-
ically, women reported physical discomfort related to biome- atory analyses (such as treatment or per-protocol analysis,
chanical limitations to jogging or running, back or hip pain, or used as a covariate) to illustrate the treatment effect in
shortness of breath, and hyperventilation.47 In contrast, Way addition to the intention-to-treat effect.
et al23 found that all male and female participants expressed Conducting exercise training trials is challenging, espe-
satisfaction with HIIT participation, and Taylor et al11 found cially when sample sizes are calculated according to a pre-
similar rates of enjoyment between HIIT and MICT. Further- sumed level of adherence to the intervention. Treatment or
more, Taylor et al11 found that the frequency and reasons per-protocol analysis, which excludes nonadherent partici-
stated for being unable to complete the exercise protocol pants from the analysis, is a form of explanatory analysis
were similar between HIIT and MICT, as well as unpleasant that describes the treatment effect or efficacy of an interven-
symptoms and injuries.11 Both studies11,23 employed a vari- tion for those who adhered to it. While intention-to-treat
ety of modes for HIIT, including cycling, treadmill, elliptical, analysis should be the primary analysis for randomized con-
and dance/movement-based routines. trolled trials, given it limits bias in estimating the efficacy of
Supplemental Digital Content 3, available at: http://links. an intervention,50 it can underestimate the magnitude of the
lww.com/JCRP/A219, presents qualitative data from The treatment effect if there is substantial nonadherence to one
FITR-Heart Study,48 relating to why participants were or or all of the interventions being compared.51 Calculation
were not continuing with HIIT following supervised train- of required sample sizes should be performed accordingly.
ing and home-based training (male: 28; female: 4). For With appropriate measuring, reporting, and application of
comparison, Supplemental Digital Content 4, available at: adherence data, treatment analysis is a valuable secondary
http://links.lww.com/JCRP/A220, presents the same qual- analysis to explore the treatment effect of an intervention.
itative data for MICT participants (male: 25; female: 6). Long-term follow-up studies consistently report the in-
Twelve participants for HIIT (male: 11, female: 1) and 13 fluence of HIIT on overall exercise adherence, rather than
participants for MICT (male: 13; female: 0) did not provide whether participants want to, are able to, and/or actually
any qualitative comments. One of 43 HIIT participants at do continue HIIT long-term. Therefore, it remains unclear
4 wk and 6 of 34 (18%) HIIT participants at 12 mo (all whether adhering to HIIT offers superior benefit for CRF,
male) reported not continuing with HIIT. Four of the six and whether HIIT can be performed effectively and safely by
participants discontinued HIIT to exercise at a lighter in- patients with coronary artery disease in home-based settings.
tensity. For MICT, one of 44 participants at 4 wk and 10 This is even more important, given the recent closures of cen-
of 37 (27%) participants at 12 mo (male: 9; female: 1) re- ter-based CR facilities during a global pandemic. Therefore,
ported not continuing with MICT. Six of the 10 (all male) we recommend that follow-up studies also report ongoing
instead chose to exercise at a higher intensity. However, adherence to HIIT, in addition to the effect of the interven-
many of the comments from patients participating in HIIT tions on overall exercise adherence.
and MICT reported feelings of motivation, confidence, en- This review was limited to patients with coronary ar-
joyment, and beneficial effects for their physical and mental tery disease. Therefore, our findings cannot be generalized
well-being. Way et al23 found similar common themes with- to other patients attending CR, including those with heart
in their qualitative analysis of HIIT. failure, implanted devices, valve surgery, congenital heart

disease, and spontaneous coronary artery dissection. Fur- HIIT interventions. In this framework, adherence to the
thermore, to facilitate a timely review of the literature, we intervention encompasses components from the American
used a rapid review process, which is less rigorous than a College of Sports Medicine (ACSM) exercise prescription
systematic review. Study selection and data extraction were principles (type, frequency, intensity, and duration).53
conducted by a single author, and quality of the included First, we outline 10 recommendations to provide a con-
studies was not assessed. This process may increase the risk sistent approach for measuring and reporting adherence
of bias, data extraction errors, and study omission, com- to HIIT interventions. Second, for each recommendation,
pared with a comprehensive systematic review process. detailed descriptions are provided with examples to report
methods and calculate the variables. A third component
APPLICATION TO PRACTICE is an example table for how the data may be presented.
Finally, additional outcomes are suggested to inform fea-
Recommendations for Clinicians sibility or tolerability of the intervention. These recom-
As with any exercise prescription, HIIT should be prescribed mendations were formulated on the basis of the ACSM
with consideration of patient goals and preferences. A recent exercise prescription principles, the literature examined as
statement from the American Association of Cardiovascular part of this review, the challenges identified when compar-
and Pulmonary Rehabilitation has advocated the importance ing studies, practical experience of the authors, and meth-
of progressing the intensity of exercise for patients in CR pro- ods that will allow for comparison of studies in relation to
grams including considering HIIT.52 It provides an additional adherence data in the future.
exercise option for patients to be used in conjunction with For measurement and reporting of intensity, we recom-
other forms of exercise (such as MICT) to achieve the recommend both subjective (eg, RPE) and objective measures (eg,
mended exercise volumes for health and/or weight loss.53,54 %HRpeak and/or % peak work capacity). Objective mea-
To improve adherence to and enjoyment of HIIT, realistic ex- sures of intensity should be reported relative to peak values
pectations regarding target intensities should be set. For ex- to allow for comparison between interventions and other
ample, the 4 × 4 min HIIT protocol commonly prescribed on studies. For shorter high-intensity intervals (eg, <2 min),
the basis of the Norwegian model54 (ie, four bouts of 4-min using % peak work capacity is recommended as %HRpeak
high-intensity intervals, interspersed with 3-min active recov- may underestimate the training stimulus when there is in-
ery intervals) was not designed to elicit a training intensity of sufficient time for HR to rise. For %HRpeak, an accurate
85-95%HRpeak for the entire 4-min work interval. Instead, HRpeak obtained during a maximal exercise test should be
the goal is to reach the target intensity (85-95%HRpeak) with- used (while taking any prescribed HR-modulating ther-
in 2-min and maintain target intensity for the final 2-min of apy), rather than age-predicted equations that can show
each interval.55,56 The RPE scale can also be used when pre- significant variation in populations with58 and without
scribing HIIT due to the potential limitations for using HR rate-limiting medical therapy (ie, β-blockade).59 To avoid
in isolation.56 Alternatively, RPE can be used in isolation for overestimating training intensity, we recommend using the
prescribing HIIT if accurate HRpeak data are not available HRpeak from the CPX with highest HR, unless there has
or patients are taking HR-modulating therapy.56 To increase been an adjustment in HR-modulating therapy during the
enjoyment and reduce the impact/discomfort on musculo- intervention.55 Using HRpeak from the baseline CPX instead
skeletal joints, a variety of modalities should be encouraged. of the CPX with the highest HR can overestimate training
In addition to walking or jogging, HIIT can be applied to intensity by 4-5%HRpeak.11 We recommend using subjective
cycling, rowing ergometer, elliptical, aerobics/dance classes, measures in addition to objective measures as there may
or swimming/water aerobics. Furthermore, progressive HIIT be limitations in solely using %HRpeak.56 These include
protocols may be better tolerated,42 allowing patients time an inaccurate HRpeak if a maximal effort is not achieved
to adapt and manage longer intervals of high-intensity ex- during the maximal test (eg, due to peripheral fatigue); if
ercise over a period of time. Music can also provide further HR-modulating therapy is up-titrated throughout the in-
enjoyment. The Norwegian Ullevaal model19 provides an ex- tervention period; and when exercise testing and training
ample of how the traditional Norwegian 4 × 4 min HIIT occur at a different time of day, the HR-modulating effect
protocol can be applied to aerobic exercise classes. Intensity of therapy may be different.60 As an alternative to reporting
is adjusted using individual %HRpeak, RPE, and the speed %HRpeak, relative intensity can be reported as the training
(beats/min) of the music, with faster-paced songs used for the workload relative to peak work capacity during the initial
aerobic-style exercises during the high-intensity intervals and maximal exercise test. Although this may be difficult when
slower-pace songs used for resistance and flexibility exercises a variety of exercise modalities are utilized, converting
during the recovery intervals. While studies in patients with workload to metabolic equivalents using the FRIEND (Fit-
coronary artery disease have consistently demonstrated a fa- ness Registry and the Importance of Exercise: a National
vorable safety profile,11,22,24,28,57 it should be acknowledged Database)61,62 or ACSM53 prediction equations can provide
that the majority of studies to date have employed maximal a standardized workload metric. To determine whether a
cardiopulmonary exercise testing (CPX) to medically evalu- significant difference in training intensity exists between
ate patients prior to HIIT participation. To maximize safe- training interventions, we recommend that HIIT intensity
ty in patients with cardiometabolic disease, guidelines have is recorded toward the end of the high-intensity interval.
been developed to assist clinicians with appropriate screening Additional measurement of intensity parameters at the end
and monitoring for HIIT.56 Initially, there may be addition- of the recovery intervals may help explain adherence to in-
al time commitment regarding education and monitoring of tensity during the high-intensity intervals. If physiological
HIIT. It may also be challenging for patients with cognitive recovery is inadequate, this can lead to premature fatigue
impairment or multiple comorbidities to manage HIIT inde- whereby patients may be unable to tolerate or provide suffi-
pendently. cient exertion for subsequent intervals.62 Finally, measuring
and reporting the duration of the intervention (in terms of
Recommendations for Researchers total session duration, number of intervals, and time spent
Table 2 and Supplemental Digital Content 5, available at high intensity) in addition to intensity allows for the de-
at: http://links.lww.com/JCRP/A221, outline a set of rec- termination of exercise volume, which may help identify the
ommendations for measuring and reporting adherence to existence of dose-response effects.

Table 2
Recommendations for Measuring and Reporting Adherence to HIIT and Other Exercise Interventionsa
Recommendations
1. Define criteria for global adherence in the methods to assess whether adherence to the intervention was achieved, and whether this was accounted for in analysis.
2. Describe in the methods how adherence was measured and recorded for allocated training sessions.
3. Describe in the methods how nonprotocol exercise/physical activity was measured and reported.
4. Report the adherence to attendance of prescribed sessions for all exercise groups (as % of sessions attended compared with sessions prescribed, and the number and % of participants who meet the attendance criteria for adherence).
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5. Report the mean training intensity data for all exercise groups (subjective and objective).
6. Report the adherence to intensity of the attended sessions for all exercise groups (as % of sessions meeting the intensity criteria compared with sessions attended).
7. Report the mean training duration data of sessions attended for all exercise groups.
8. Report the adherence to duration of the attended sessions for all exercise groups (as % of sessions meeting the duration criteria compared with sessions attended).
9. Report nonprotocol exercise/physical activity.
10. Report the global adherence of prescribed sessions for all exercise groups (as the % of sessions adherent compared with sessions prescribed, and the number and % of participants who meet the global criteria for adherence). If
per-protocol analysis was performed, report whether study results were different for those who adhered to the intervention (treatment effect).
Detailed description of recommendations and examples
1. Define criteria for global adherence in the methods to assess whether adherence to the intervention was achieved, and whether this was accounted for in the analysis.
• Describe criteria for global adherence in the methods to assess whether adherence to the intervention was achieved.
 Global criteria for adherence should encompass components of attendance, intensity, and duration.
 Consider alternatives to %HR

peak as intensity criteria for short intervals (eg, % peak work capacity) or with patients on rate-limiting therapy (eg, RPE).
Example: Global adherence to the intervention was assessed as ≥70% attendance at sessions where training was at the prescribed intensity and ≥75% of the prescribed duration. For the HIIT group, adherence to intensity was assessed
as an average training intensity ≥85% HRpeak and/or RPE ≥ 15, and the MICT group was assessed as an average training intensity between 65% and 75% HRpeak and/or RPE between 11 and 13. Adherence to duration was assessed
as completing ≥75% of session time (23 min out of 30 min) and for the HIIT group ≥3 of the 4 × 4 min high-intensity intervals.
• Describe whether intervention adherence was accounted for in the analysis.
Example: An explanatory per-protocol analysis was performed, including only participants meeting the global criteria for adherence to the intervention.
2. Describe in the methods how adherence was measured and recorded for allocated training sessions.
• Describe how intensity was measured for the allocated training.
 Parameters of training intensity should include subjective measures of intensity (RPE) and objective measures of intensity (training HR or workload).
 Training workload may be measured using treadmill speed and incline, or watts, and/or metabolic equivalents (METs). To convert treadmill or cycle workloads to METs, the use of prediction equations from the FRIEND registry58,59 or
American College of Sports Medicine (ACSM)54 is recommended.

 For high-intensity intervals ≥ 2 min, we recommend measuring HR in the final minute or at the end of the high-intensity interval.
 For high-intensity intervals of short duration (<2 min), we recommend using training workload as the objective measure, as HR may underestimate the training stimulus if there is not sufficient time to increase.
 Details that should be included: How often and when was intensity measured? Was intensity measured continuously (eg, HR) and/or at certain time points during the session (eg, RPE, workload). Was intensity measured and
recorded during each high-intensity interval? By whom was the intensity measured and recorded? (eg, did study staff measure and record or did patient self-report and self-record?).
Example 1: Training HR was measured by pulse oximetry and RPE was measured using the 6-20 Borg scale. For HIIT, HR and RPE were measured during the last minute of each high-intensity interval. For MICT, HR and RPE were measured halfway through and at
the end of training prior to cooldown. For each session, both HR and RPE were recorded as peak intensity using the highest HR and RPE recorded. Average intensity was determined from all HR and RPE data recorded during the high-intensity intervals.
Example 2: Training HR was measured continuously by an HR monitor, and RPE was measured using the 6-20 Borg scale. For HIIT, HR was averaged over the final 2 min of each high-intensity interval and RPE was measured at the end of
each high-intensity interval. For MICT, HR was averaged for the entire exercise time (excluding warm-up and cooldown) and RPE was measured at the end of the session prior to cooldown.
Example 3: Training workload was measured by treadmill speed and incline or cycling watts, and RPE was measured using the 6-20 Borg scale. For HIIT, training workload and RPE were measured during the final minute of each high-
intensity interval and for MICT, workload and RPE were measured at the end of each exercise bout prior to cooldown.
• Describe how intensity was recorded for the allocated training.
Example 1: For each session, both HR and RPE were recorded as peak intensity using the highest HR and RPE recorded, and average intensity using an average of all HR and RPE data recorded.
Example 2: For each session, both workload and RPE were recorded as peak intensity using the highest workload and RPE recorded, and average intensity using an average of all workload and RPE data recorded. Workload from each
exercise machine was converted to metabolic equivalents using standardized equations to allow for a standardized metric to be recorded and averaged.
• Describe how duration was measured and recorded for allocated training.
 Parameters of training duration may include total session duration, minutes spent in high-intensity intervals, or number of intervals.
Example 1: For both exercise groups, session duration was measured and recorded as the total session duration. For HIIT, the number of high-intensity intervals was also measured and recorded.

Example 2: For both HIIT groups, session duration was measured and recorded as the time spent in the high-intensity intervals by measuring the number of high-intensity intervals completed and the duration of each high-intensity interval (eg, if
patient managed 3 × 4 min high-intensity intervals but only 2 min for the last high-intensity interval, time spent in high-intensity intervals = 14 min.
(continues)
Table 2
Recommendations for Measuring and Reporting Adherence to HIIT and Other Exercise Interventionsa (Continued)
3. Describe in the methods how nonprotocol exercise/physical activity was measured and recorded.
• Describe how nonprotocol exercise or physical activity was measured and recorded.
 Nonprotocol exercise can be measured as the additional exercise sessions and exercise minutes, and whether exercise intensity is different to allocated training.
 Can use self-report exercise diaries and/or fitness tracking devices with automatic upload to capture frequency, intensity, and duration of additional exercise.
 Overall physical activity can be measured by accelerometry or self-report physical activity questionnaires (eg, International Physical Activity Questionnaire).
Example: Participants were provided with an exercise diary to record the type, frequency, and duration of their exercise each week, as well as a rating of intensity using the 6-20 Borg scale. These exercise diaries were checked by study
staff for nonprotocol exercise, which was recorded as the number of additional exercise sessions and exercise minutes, and whether the intensity was different to the allocated training. Accelerometers were also used to measure
physical activity for a 7-d period at each time point.
4. Report the adherence to attendance of prescribed sessions for all exercise groups as the % of sessions attended compared with sessions prescribed, and the number and % of participants who meet the attendance criteria for adherence.
• For each participant, determine the adherence to attendance as the % of sessions attended compared with the number prescribed.
Example: If a participant attends 10 sessions compared with 12 prescribed, adherence to attendance for that participant will be 10/12 = 83%.
• For each exercise group, average the adherence to attendance from each participant to calculate and report the group adherence to attendance (as % of sessions).
• For each exercise group, determine and report the number and % of participants who meet the attendance criteria for adherence.
Example: Based on the example criteria (≥70% attendance at sessions), any participant with an adherence to attendance ≥70% would meet the criteria and any participant with adherence to attendance <70% would not meet the
criteria. The example participant above with an adherence to attendance of 83% would meet the adherence criteria.
5. Report the mean training intensity data for all exercise groups (subjective and objective).
• For each participant, calculate the mean training intensity across all training sessions.
 For HR or workload intensities, calculate the relative %HR
peak or % peak work capacity, based on the peak values from the maximal exercise test.
 For %HR
peak, use the maximal exercise test with the highest HRpeak. For % peak work capacity, use the peak workload from the initial maximal exercise test.
Example 1: If a participant attends three sessions with a training RPE of 17.0, 16.0, and 16.0, the average training RPE will be the average of the three sessions = RPE 16.3.
Example 2: If a participant attends three sessions with a training HR of 145 bpm, 148 bpm, and 150 bpm, the average training HR will be the average of the three sessions = 148 bpm. If the participant’s HRpeak was 155 bpm during the
baseline test and 160 bpm during the follow-up test, the average training %HRpeak should be calculated as 148/160 = 93% HRpeak based on the follow-up test (highest HRpeak).

Example 3: If a participant attends three sessions with a training workload of 7.1 METs, 7.3 METs, and 7.8 METS, the average training workload will be the average of the three sessions = 7.4 METs. If the participant’s peak workload
was 7.1 METs in the baseline test and 8.0 METs during the follow-up test, the average training intensity should be calculated as 7.4/7.1 = 104% peak work capacity based on the baseline test.
• For each exercise group, calculate and report the mean training intensity from the average training intensities from each participant.
6. Report the adherence to intensity of the attended sessions for all exercise groups (as the % of sessions meeting the intensity criteria compared with sessions attended).
• For each participant, determine the adherence to intensity as the % of sessions meeting the intensity criteria compared with the number of sessions attended. This may be determined separately for supervised sessions, home-based
sessions, or as a combination.
Example: If a participant meets the intensity criteria of ≥85% HRpeak for eight sessions compared with 10 sessions attended, the adherence to intensity for that participant will be 8/10 = 80%.
• For each exercise group, average the adherence to intensity for each participant to calculate and report the group adherence to intensity (as % of sessions).
7. Report the mean training duration data for all exercise groups.
• For each participant, calculate the mean training duration.
Example 1: If a participant attends three sessions with training durations of 30 min, 30 min, and 28 min, the average training duration will be the average of the three sessions = 29 min.
Example 2: If a participant attends three sessions with time spent in high-intensity intervals of 16 min, 12 min, and 16 min, the average time spent in high-intensity intervals will be the average for the three sessions = 15 min.
Example 3: If a participant attends three sessions and completes four intervals, three intervals, and four intervals, respectively, the average number of intervals will be the average for the three sessions = 3.7 intervals.
• For each exercise group, calculate and report the mean training duration from the average training intensities for each participant.
(continues)
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Table 2
Recommendations for Measuring and Reporting Adherence to HIIT and Other Exercise Interventionsa (Continued)
8. Report the adherence to duration of the attended sessions for all exercise groups (as the % of sessions meeting the duration criteria compared with sessions attended).
• For each participant, determine the adherence to duration as the % sessions meeting the duration criteria compared with the number of sessions attended.
www.jcrpjournal.com
Example 1: If a participant completes at least three out of four high-intensity intervals for nine sessions compared with the 10 sessions he or she attended, the adherence to duration for that participant will be 9/10 = 90%.
Example 2: If a participant completes a session time of ≥ 27 min out of 30 min for nine sessions compared with the 10 sessions he or she attended, the adherence to duration for that participant will be 9/10 = 90%.
• For each exercise group, average the adherence to duration for each participant to calculate and report the group adherence to duration (as % of sessions).
9. Report non-protocol exercise/physical activity.
• For each participant, calculate the number of additional exercise sessions and exercise minutes and the number of additional sessions reported to be at a different intensity to the allocated training.
• For each exercise group, calculate and report the mean additional exercise sessions and exercise minutes from each participant.
• For each exercise group, determine the number of participants who trained at a different exercise intensity to the allocated training.
10. Report the global adherence of prescribed sessions for all exercise groups (as the % of sessions adherent compared with sessions prescribed, and the number and % of participants who meet the global criteria for adherence). If per-
protocol analysis was performed, report whether study results were different for those who adhered to the intervention (treatment effect).
• For each participant, determine global adherence as the % of sessions meeting both intensity and duration criteria compared with sessions prescribed.
Example: Using the example outlined in Recommendation no. 1 as the global criteria for adherence (≥70% attendance at sessions where training is at the prescribed intensity and ≥75% of the prescribed duration). If a participant
attends 10 sessions out of the prescribed 12 sessions, however, he or she meets only the prescribed intensity for eight sessions (Recommendation no. 6 example), and meets the duration criteria for nine sessions (Recommendation
no. 8 example), the number of sessions meeting both criteria is eight sessions, and therefore global adherence for that participant will be 8/12 = 66%.
• For each exercise group, average the global adherence from each participant to calculate and report the group global adherence (as % of sessions).
• For each exercise group, determine and report the number and % of participants who meet the global criteria for adherence.
Example: Based on the example criteria, any participant with a global adherence ≥70% would meet the criteria and any participant with a global adherence <70% would not meet the criteria. The aforementioned example participant
with a global adherence of 66% would not meet the global criteria for adherence.
• For secondary per-protocol analysis, exclude participants who do not meet the global criteria for adherence and rerun the analyses. Report whether the study results were different for per-protocol analyses compared with intention-to-treat analyses.
Additional data collection to inform feasibility (or tolerability) of the intervention
• Number of participants who dropped out of the study (and reasons why)
• Number of participants who discontinued the intervention but remained in the study
• Number of participants with an interruption to the intervention (eg, missed ≥3 consecutive sessions or ≥1 wk of training), and whether sessions were rescheduled and completed accordingly.
• Reason for nonattendance to training session and/or interruption or discontinuation of training intervention
 Advised by study staff or clinicians due to medical or safety reason
 Patient decision (eg, due to lack of time, lack of motivation, symptoms, injury, fatigue, or recent medical history)
• Reason for nonadherence to the prescribed intensity:

 Clinician reduced intensity (eg, due to signs, symptoms, injury, fatigue, or recent medical history)
 Patient unable to exercise at prescribed intensity (eg, due to symptoms, fatigue, injury, physiological limitation)
 Patient unwilling to exercise at prescribed intensity (eg, due to lack of motivation, fear, chose to work at a lower or higher intensity)
• Reason for nonadherence to the prescribed duration

 Clinician stopped session early (eg, due to patient signs, symptoms, injury, or fatigue)
 Patient stopped exercising early (eg,. due to lack of time, lack of motivation, symptoms, injury, or fatigue)
• Training intensity parameters (RPE, HR, or workload) at the end of the recovery intervals
Abbreviations: HIIT, high-intensity interval training; HR, heart rate; HRpeak, peak heart rate (obtained from maximal exercise test); METs, metabolic equivalents; MICT, moderate-intensity continuous training; RPE, rating of perceived exertion (based on 6-20 or 1-10 Borg scale).
a
See Supplemental Digital Content 5, available at: http://links.lww.com/JCRP/A221, for Example Results Reporting template.

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studies, including HIIT interventions, we recommend using Parameters. Heart Lung Circ. 2016;25(2):166–174.
the CERT9 as a framework to ensure a comprehensive de- 4. Pattyn N, Coeckelberghs E, Buys R, Cornelissen V, Vanhees L.
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parallel precise reporting of the adherence to the interven- 5. Mikkelsen N, Cadarso-Suarez C, Lado-Baleato O, et al. Improve-
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used to determine whether nonadherence underestimated the 8. Reljic D, Lampe D, Wolf F, Zopf Y, Herrmann HJ, Fischer J.
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9. Slade SC, Dionne CE, Underwood M, Buchbinder R. Consensus
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12. Jayo-Montoya JA, Maldonado-Martin S, Aispuru GR, et al.
are not available, we recommend including self-report mea-
Low-volume high-intensity aerobic interval training is an efficient
sures of exercise intensity (eg, RPE) in addition to duration method to improve cardiorespiratory fitness after myocardial in-
and exercise type (eg, randomized vs nonprotocol exercise). farction: PILOT STUDY FROM THE INTERFARCT PROJECT.
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Invited Review

Adherence to High-Intensity Interval Training in Cardiac

H igh-intensity interval training (HIIT) involves alternat-

www.jcrpjournal.com Adherence to High-Intensity Interval Training 61

62 Journal of Cardiopulmonary Rehabilitation and Prevention 2021;41:61-77 www.jcrpjournal.com

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64 Journal of Cardiopulmonary Rehabilitation and Prevention 2021;41:61-77

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66 Journal of Cardiopulmonary Rehabilitation and Prevention 2021;41:61-77

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68 Journal of Cardiopulmonary Rehabilitation and Prevention 2021;41:61-77

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70 Journal of Cardiopulmonary Rehabilitation and Prevention 2021;41:61-77 www.jcrpjournal.com

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72 Journal of Cardiopulmonary Rehabilitation and Prevention 2021;41:61-77 www.jcrpjournal.com

 Consider alternatives to %HR

American College of Sports Medicine (ACSM)54 is recommended.

Adherence to High-Intensity Interval Training 73

74 Journal of Cardiopulmonary Rehabilitation and Prevention 2021;41:61-77

• Reason for nonadherence to the prescribed intensity:

• Reason for nonadherence to the prescribed duration

Adherence to High-Intensity Interval Training 75

76 Journal of Cardiopulmonary Rehabilitation and Prevention 2021;41:61-77 www.jcrpjournal.com

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