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Table 4 Overview of existing reviews

From: Adding exercise to usual care in patients with hypertension, type 2 diabetes mellitus and/or cardiovascular disease: a protocol for a systematic review with meta-analysis and trial sequential analysis

First author Title Year of publication Type of exercise Information source Primary outcome assessed No. of trials No. of patients Published protocol Assessment of adverse event Assessment of risk of bias Conclusion
Reviews assessing effectiveness of exercise in people with cardiovascular disease
 Powell [33] Is exercise-based cardiac rehabilitation effective? A systematic review and meta-analysis to re-examine the evidence 2018 Exercise vs usual care (Type of exercise not specified) Pubmed/Rehabilitation Medicine Total mortality, cardiovascular mortality, hospital re-admission 22 4834 No No Yes (Risk of bias tool) No reduction in total mortality and cardiovascular mortality
 Anderson L [34] Exercise based cardiac rehabilitation for coronary heart disease 2016 Exercise vs usual care (Type of exercise not specified) Cochrane/Cochrane Database Syst Rev Total mortality, cardiovascular mortality 63 14486 Yes No Yes (Risk of bias tool) Reduction in total mortality but not cardiovascular mortality
 Taylor RS [35] Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trial 2004 Exercise vs usual care (Type of exercise not specified) Pubmed/Am J Med Total mortality, cardiovascular mortality 48 8940 No No Yes (Jadad Scale) Reduction in both total mortality and cardiovascular mortality
 Gloria Y. Yeh [36] Tai Chi Exercise for Patients with Cardiovascular Conditions and Risk Factors: A Systematic Review 2010 Tai Chi Pubmed/J Cardiopulm Rehabil Prev Blood pressure, exercise capacity 14 (9 RCTs) - No No Yes
(Quality Grading)
May have some benefit but inconclusive
 Rees K [37] Exercise based rehabilitation for heart failure (Review) 2004 Exercise vs usual care (Type of exercise not specified) Cochrane/Cochrane Database Syst Rev Total mortality, morbidity, hospital re-admission, physical capacity, quality of life 29 1126 Yes Yes Yes (Jadad Scale) Exercise improved people’s fitness and quality of life, without causing harm but the trials included were small who are unrepresentative of the total population of patients with heart failure
 Long L et al. [38] Exercise-based cardiac rehabilitation for adults with stable angina 2018 Exercise vs usual care (Type of exercise not specified) Cochrane/Cochrane Database Syst Rev All-cause mortality, morbidity health-related quality of life (e.g. (SF-36), (EQ-5D), exercise capacity (e.g VO2peak, 6-min walk test), cardiovascular-related hospital admissions 8 581 Yes Yes Yes
(Risk of bias tool)
Small trials, potential risk of bias and concerns about imprecision and lack of applicability, the effects of exercise-based CR compared with control on mortality, morbidity, cardiovascular hospital admissions, adverse events, return to work and health-related quality of life in people with stable angina was uncertain
 Saunders DL et al. [39] Physical fitness training for stroke patients 2016 Cardiorespiratory training, resistance training, mixed training Cochrane/Cochrane Database Syst Rev Case fatality, death or dependence (Barthel Index score, Rankin score), disability (e.g. Functional Independence Measure, Stroke Impact scale etc.) 45 2188 Yes Yes Yes
(Risk of bias tool)
Cardiorespiratory fitness training can improve exercise ability and walking after stroke. Further well-designed randomised trials are needed to determine the optimal exercise prescription and identify long-term benefits
 Ismail et al. [40] Clinical Outcomes and Cardiovascular Responses to Different Exercise Training Intensities in Patients With Heart Failure A Systematic Review and Meta-Analysis 2013 Aerobic exercise training JACC/Heart Fail Peak VO2 (baseline and after exercise), training frequency, intensity, duration per session, length of program, participant completion rates, mortality, adverse medical events and hospitalisations 74 5877 No Yes Yes
(PEDrO Scale)
Magnitude of gain in cardiorespiratory fitness is greater with increasing exercise intensity. High and vigorous exercise intensities did not appear to increase the risk for study withdrawal, death, adverse events and hospitalisation
 Davies EJ et al. [41] Exercise training for systolic heart failure: Cochrane systematic review and meta-analysis 2010 Exercise versus usual care (Type of exercise not specified) Pubmed/European Journal of Heart Failure All-cause mortality, hospital admission/re-admission rates, HRQoL assessed by a validated outcome measure (e.g. MLWHF questionnaire or Short Form 36 (SF-36)) and cost-effectiveness 19 3647 No No Yes (Risk of bias tool) No significant difference between exercise and control in short-term (≤ 12 months) or longer term all-cause mortality or overall hospital admissions.
Reviews assessing effectiveness of exercise in people with hypertension
 Whelton SP et al. [42] Effect of Aerobic Exercise on Blood Pressure: A Meta-Analysis of Randomized, Controlled Trials 2002 Aerobic exercise Pubmed/Annals of Internal Medicine Blood pressure 54 2419 No No No Aerobic exercise reduces blood pressure in both hypertensive and normotensive persons.
 MacDonald HV et al. [43] Dynamic Resistance Training as Stand-Alone Antihypertensive Lifestyle Therapy: A Meta-Analysis 2016 Dynamic resistance training Pubmed/J Am Heart Assoc Blood pressure 64 2344 No No No For non-white adult samples with hypertension, dynamic RT may elicit BP reductions that are comparable with or greater than those reportedly achieved with AE training
 Cornelissen et al. [44] Exercise Training for Blood Pressure: A Systematic Review and Meta-analysis 2013 Endurance, Resistance, Isometric resistance, Combined exercise Pubmed/J Am Heart Assoc. Blood pressure 93 5223 No No No Endurance, dynamic resistance and isometric resistance training lower SBP and DBP, whereas combined training lowers only DBP.
 Cramer H et al. [45] A Systematic Review and Meta-Analysis of Yoga for Hypertension 2014 Yoga Pubmed/Am J Hypertens Blood pressure 7 452 No No Yes
(Risk of bias tool)
Larger studies are required to confirm the emerging but low-quality evidence that yoga may be a useful adjunct intervention in the management of hypertension
 Chu P et al. [46] The effectiveness of yoga in modifying risk factors for cardiovascular disease and metabolic syndrome: A systematic review and meta-analysis of randomized controlled trials 2016 Yoga Pubmed/Eur J Prev Cardiol BMI, systolic blood pressure, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol 37 - No No Yes
(Risk of bias tool)
Promising evidence of yoga on improving cardio-metabolic health. Findings are limited by small trial sample sizes, heterogeneity and moderate quality of RCTs.
 Hagins M et al. [47] Effectiveness of Yoga for Hypertension:
Systematic Review and Meta-Analysis
2013 Yoga Pubmed/Evid Based Complement Alternat Med Systolic and diastolic blood pressure 17 - No No Yes
(Risk of bias tool)
Yoga can be preliminarily recommended as an effective intervention for reducing blood pressure. Additional rigorous controlled trials are warranted to further investigate the potential benefits of yoga.
Reviews assessing effectiveness of exercise in type 2 diabetes mellitus
 Thomas D [48] Exercise for type 2 diabetes mellitus (Review) 2009 Aerobic, fitness or progressive resistance training exercise Cochrane/Cochrane Database Syst Rev HbA1c 14 377 Yes Yes Yes (Risk of bias tool) Reduced HbA1c even without reducing weight. No trials included reported mortality. No adverse event was reported.
 Hayashino Y [49] Effects of supervised exercise on lipid profiles and blood pressure control in people with type 2 diabetes mellitus: A meta-analysis of randomized controlled trials 2012 Aerobic, resistance or combined Pubmed/Diabetes Research and Clinical Practice Blood pressure and lipid profile 42 - No No Yes (Verhagen et. al's tool) Supervised exercise is effective in improving blood pressure and lipid profile.
 Grace A et al. [50] Clinical outcomes and glycaemic responses to different aerobic exercise training intensities in type 2 diabetes: a systematic review and meta-analysis 2017 Aerobic exercise Pubmed % change in HbA1c 27 1372 No No Yes (TESTEX) Improvement in HbA1c. Higher intensity of exercise gives bigger benefit.
 Snowling NJ et al. [51] Effects of Different Modes of Exercise Training on Glucose Control and Risk Factors for Complications in Type 2 Diabetic Patients. A meta-analysis 2006 Aerobic
Resistance Combined
Pubmed/Diabetes care Glucose control HbA1c 27 - No No No All forms of exercise training produce small benefits in the main measure of glucose control: HbA1c
 Liu Y et al. [52] Resistance Exercise Intensity is Correlated with Attenuation of HbA1c and Insulin in Patients with Type 2 Diabetes: A Systematic Review and Meta-Analysis 2019 Resistance Pubmed/Int J Environ Res Public Health HbA1c Insulin 24 962 No No Yes (Risk of bias tool) High-intensity RE has greater beneficial effects than low-to-moderate-intensity in attenuation of HbA1c and insulin in T2D patients.
 Schwingshackl L et al. [25] Impact of different training modalities on glycaemic control and blood lipids in patients with type 2 diabetes: a systematic review and network meta-analysis 2014 Aerobic, Resistance, Combined Pubmed/Diabetologia HbA1c 14 915 No No Yes (Risk of bias tool) Combined interventions resulted in significantly more pronounced improvements in glycaemic control
 Innes KE et al. [53] Yoga for Adults with Type 2 Diabetes: A Systematic Review of Controlled Trials 2015 Yoga Pubmed/Journal of Diabetes Research Glycaemia and insulin resistance, lipid profile, body weight and composition, blood pressure 33 (12 RCTs) . No No Yes
(PEDrO Scale)
Methodological limitation of existing evidence to report beneficial effect of yoga
 Ciu J et al. [54] Effects of yoga in adults with type 2 diabetes mellitus: A meta-analysis 2017 Yoga Pubmed/Journal of Diabetes Investigation Fasting blood glucose 12 864 No No Yes
(Jadad Scale)
Methodological limitation and possible heterogeneity cannot confirm the beneficence of yoga, further studies needed.
 Chao et al. [55] The Effects of Tai Chi on Type 2 Diabetes Mellitus: A Meta-Analysis 2018 Tai Chi Pubmed/Journal of Diabetes Research Fasting blood glucose 14 798 No No Yes
(Jadad Scale)
Tai chi can effectively affect the management of blood glucose and HbA1c in type-2 DM patients
 Xia TW et al. [56] Different training durations and styles of tai chi for glucose control in patients with type 2 diabetes: a systematic review and meta-analysis of controlled trials 2019 Tai Chi Pubmed/BMC Complementary and Alternative Medicine HbA1c and fasting blood glucose 17 - No 2 trials reported no adverse event
Rest did not report
Yes
(Risk of bias tool)
Tai Chi seems to be effective in treating type 2 diabetes. Different training durations and styles result in variable effectiveness
 Lee MS et al. [57] Tai Chi for Management of Type 2 Diabetes Mellitus: A Systematic Review 2011 Tai Chi Pubmed/Chin J Integr Meed HbA1c and fasting blood glucose, quality of life 10 - No No No Exiting evidence does not suggest Tai chi is effective. There are few high-quality trials on which to make definitive judgements.