Cardiac Rehabilitation Program effect on anxiety, depression and quality of life.

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Estrella García-Sánchez, Mirian Santamaría-Peláez, Jerónimo J. González-Bernal, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6261651/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 20 Jun, 2025 Read the published version in The Egyptian Heart Journal → Version 1 posted 22 You are reading this latest preprint version Abstract Introduction: The study aimed to evaluate the effects of a cardiac rehabilitation program based on physical exercise and the promotion of healthy habits on anxiety, depression, and health-related quality of life in patients with cardiovascular conditions. Additionally, it sought to analyze the influence of baseline anxiety and depression levels on post-treatment health-related quality of life outcomes. Methods: A longitudinal study was conducted with 189 patients who completed a structured cardiac rehabilitation program. Anxiety and depression were assessed using the Goldberg Anxiety and Depression Scale, while health-related quality of life was measured with the RAND-36 survey. Data were collected pre- and post-intervention. Statistical analyses included paired t-tests for pre-post comparisons and ANCOVA to evaluate the impact of initial anxiety and depression on health-related quality of life improvements. Results: The cardiac rehabilitation program significantly reduced anxiety (mean difference = 0.93, p < .001) and depression (mean difference = 0.62, p < .001), with improvements observed across several health-related quality of life dimensions, including emotional well-being (p = .005) and energy/fatigue (p < .001). Baseline anxiety and depression levels influenced changes in specific health-related quality of life dimensions, such as social functioning and role limitations due to physical health (p < .05). Discussion: The findings demonstrate the effectiveness of cardiac rehabilitation programs in reducing anxiety and depression and improving health-related quality of life in patients with cardiovascular conditions. Baseline psychological status plays a key role in determining the magnitude of health-related quality of life improvements, highlighting the need for tailored interventions. Cardiac Rehabilitation Physical exercise Healthy habits Anxiety Depression Quality of life Cardiovascular disease Figures Figure 1 1. Introduction Cardiac Rehabilitation Programs (CRPs) are structured outpatient initiatives designed to support individuals recovering from heart-related conditions, such as myocardial infarction, heart failure, and surgical interventions like coronary artery bypass grafting. These programs combine physical exercise, education, and psychological counseling to enhance patients' physical and mental health, thereby reducing the risk of future cardiac events and improving overall quality of life (Child et al. 2010; J et al. 2018; Patel et al. 2019; C.-Y. Wang 2017). Notably, CRPs address significant psychological comorbidities, including anxiety and depression, which are prevalent among cardiac patients and can impede recovery (Beatty et al. 2023; Child et al. 2010). The effects of CRPs on anxiety and depression have become a focal point in cardiac care research, with studies indicating that structured psychological interventions within rehabilitation settings can significantly alleviate these mental health issues (Bethge et al. 2023; L. Wang et al. 2021). Furthermore, evidence suggests that improving psychological well-being is integral to enhancing health-related quality of life (HRQoL), as patients often prioritize quality of life over mere survival post-rehabilitation (Levine et al. 2021). A systematic review has demonstrated that participation in CRPs can lead to substantial improvements in HRQoL, reinforcing the importance of a holistic approach that encompasses both physical and mental health (de la Cuerda et al. 2012; Yamaguchi et al. 2025) . Despite the recognized benefits, challenges persist in the implementation of CRPs, including low patient adherence and varying quality across programs (Wells et al. 2018). Disparities in access due to socioeconomic factors further complicate the effectiveness of CRPs, as only a fraction of eligible patients engage fully in these programs (Beatty et al. 2023; Moreira et al. 2024). Additionally, while interventions such as cognitive-behavioral therapy and mindfulness have shown short-term efficacy, concerns regarding their long-term sustainability and impact remain (Candelaria et al. 2024; Yamaguchi et al. 2025). As such, ongoing research is critical to understanding the complexities of mental health within cardiac rehabilitation and to optimize care for diverse patient populations. Central to cardiac rehabilitation is the exercise component, which focuses on enhancing aerobic capacity, functional fitness, and strength through carefully monitored physical activity. Exercise physiologists oversee these activities to ensure safety for patients, particularly those with existing cardiac conditions (C.-Y. Wang 2017) . Programs may also integrate low-impact exercise training tailored to individual fitness levels, promoting gradual recovery and long-term health maintenance (C.-Y. Wang 2017). Educational elements of cardiac rehabilitation cover various topics, including specific cardiac diagnoses, general cardiac health, heart-healthy dietary practices, and stress management techniques. Knowledge about their condition and effective coping strategies empower patients to take charge of their health, which can lead to improvements in overall well-being (Child et al. 2010; J et al. 2018; Patel et al. 2019; C.-Y. Wang 2017). Psychological support is also integral, with interventions designed to address issues such as anxiety and depression, which are common in patients with cardiac diseases (Beatty et al. 2023; Child et al. 2010). Recognizing the interplay between mental health and physical recovery, modern CRPs often include psychological services. These may involve psychoeducation, group workshops, and individual therapy sessions focused on managing anxiety and depression, which can hinder rehabilitation progress. Studies indicate that psychological interventions can lead to reduced anxiety and depression among cardiac patients, although their impact on overall mortality remains inconclusive (Beatty et al. 2023; Child et al. 2010). The integration of psychological care within CRPs aims to address both the physical and emotional needs of patients, fostering a more holistic approach to recovery (Child et al. 2010). Efforts have been made to enhance patient engagement and accessibility within cardiac rehabilitation services. For instance, providing psychological assessments within the context of cardiac outpatient clinics reduces stigma and promotes attendance. Programs have also demonstrated improved patient acceptance of psychological referrals compared to traditional mental health services, highlighting the importance of integrated care in addressing the comprehensive needs of patients (Beatty et al. 2023; Child et al. 2010). Various studies have investigated the effects of CRPs on anxiety, depression, and quality of life among patients with cardiovascular conditions. A systematic review of eight studies revealed significant differences in intervention characteristics, with seven employing Mindfulness-Based Stress Reduction (MBSR) and one utilizing a combined approach of MBSR and Mindfulness-Based Art Therapy (MBAT) (Wells et al. 2018; Yamaguchi et al. 2025). The interventions were predominantly conducted in either hospital settings or through hybrid models that included both hospital and home-based sessions, highlighting the flexibility of Cardiac Rehabilitation (CR) delivery methods (Yamaguchi et al. 2025). The studies analyzed included a total of 623 participants, with a male predominance (72.2%) compared to female participants (27.8%) across various demographics (Yamaguchi et al. 2025). Participants in the included studies presented with different conditions related to coronary artery disease and had undergone various treatments, including revascularization surgeries (Yamaguchi et al. 2025). The variation in participant characteristics underscores the need for tailored interventions that consider gender and specific health conditions to enhance the effectiveness of CR programs. While CR interventions generally report positive outcomes, issues surrounding patient adherence and satisfaction have been noted. Factors contributing to low adherence rates may include lack of motivation or interest, which is often observed in clinical practice (de la Cuerda et al. 2012). Addressing these barriers is vital for optimizing the impact of CR programs on patients' mental health and quality of life. Enhanced support mechanisms and tailored interventions that foster engagement may improve adherence and the overall effectiveness of CR programs (de la Cuerda et al. 2012). CR is crucial for enhancing the psychological well-being of patients recovering from cardiovascular events. However, a significant challenge lies in the psychological support provided within CR programs. While methods such as cognitive-behavioral therapy (CBT) and mindfulness-based interventions (MBIs) show short-term psychological benefits, their long-term sustainability and effectiveness remain questionable (Candelaria et al. 2024; Yamaguchi et al. 2025). Patients frequently experience chronic stress, anxiety, and depression, which can deteriorate cardiovascular health outcomes and diminish overall quality of life over time. The immediate psychological improvements noted following MBIs may not indicate lasting stability, necessitating ongoing assessment to evaluate the durability of these benefits beyond the intervention phase (Yamaguchi et al. 2025). The aim of this research is to test whether a CRP based on physical exercise and the promotion of healthy habits improves anxiety, depression, and HRQoL in patients with cardiac pathology. Specifically, we hypothesize that participation in the program will significantly reduce anxiety and depression levels and enhance health-related quality of life. Furthermore, it aims to check whether the presence of anxiety and/or depression at the start of rehabilitation treatment influences the HRQoL achieved after treatment. We hypothesize that higher baseline levels of anxiety and/or depression will significantly impact the magnitude of improvement in HRQoL after completing the program. 2. Methods 2.1. Participants The participants were 189 patients with cardiac pathology who, after being referred by the Cardiologist in charge of the Cardiac Rehabilitation Unit to assess their inclusion in the physical training that is carried out on an outpatient basis within the CRP, completed this Program. The inclusion criteria were to have a diagnosis of cardiovascular pathology, to attend the Cardiac Rehabilitation Unit consultation referred to by Cardiology, to sign the informed consent prepared for this study and to complete the CRP. Patients who were unable to perform the physical exercise program due to some pathology, who refused to participate in the program, and those who did not complete it were excluded. This study was approved by the Ethical Committee for Research with Medicines of the Health Area of Burgos and Soria (Ref. CEIm 2569) on June 22, 2021. The research was conducted in accordance with the guidelines set out in the World Medical Association's Declaration of Helsinki. 2.2. Procedure A longitudinal cohort study was carried out with a single experimental group composed of patients with cardiovascular pathology. No sample calculation was performed, and a control group was not included in this study due to ethical considerations. Given that the treatment in question is aimed at improving the well-being of participants and has the potential to provide direct benefits to their health, it was considered inappropriate to deprive any group of access to this treatment. Instead of a traditional control group, an intervention design was chosen that ensures that all participants receive treatment, thus ensuring equity and benefit for all those involved in the study. Once the inclusion criteria had been verified, data were collected from each patient in the consultation of the Rehabilitation Service of the University Hospital of Burgos at the time of the initial consultation (pretest) from patients who were likely to join a CRP. The researcher who collected the data is a doctor specializing in physical medicine and rehabilitation; Clinical data were taken from the patients' medical history, sociodemographic data and assessment scales were collected in the consultation. Figure 1 shows the Flow chart for this research. Following referral by their cardiologists, the patients were referred to the Cardiac Rehabilitation Unit of the University Hospital of Burgos. At the initial consultation, a cardiologist took a detailed clinical history, including anamnesis and evaluation of complementary tests such as lipid profile analysis, electrocardiogram and echocardiogram. In the absence of a recent stress test, ergometry or ergospirometry was performed. Subsequently, in the nursing consultation, cardiovascular risk factors, dietary habits, smoking history and social environment were assessed, providing health education and documentation explaining the program. After that, the rehabilitation physician reviewed the clinical history, verified adherence to medical treatment and performed a general physical examination to determine the patient's ability to participate in the CRP. Finally, the patients were interviewed by a physiotherapist of the Cardiac Rehabilitation Unit who explained again the CRP and developed it. The variables collected were biological gender, distance from the place of residence to the rehabilitation center, age, anxiety, depression and HRQoL. Part of the variables are reported by the patient and others objectified in the consultation. The CRP implemented in this study was designed to comprehensively address the needs of patients with cardiovascular pathologies, combining supervised physical exercise, psychological support and health education. The CRP lasted 1 to 2 months, with training sessions scheduled 2 to 3 times per week. Each session was structured in four phases: 1. Phase 1: Warm-up (10 minutes): Mobilisation of large muscle groups by means of flexion, extension, lateralisation and rotation exercises at the cervical, upper limb, trunk and lower limb levels. Each exercise was repeated approximately 5 times. 2. Phase 2: Aerobic Exercise (35 minutes): Performed on cycloergometers or treadmills, with intensity adjusted according to the Maximum Heart Rate Frecuancy (HRF) obtained in the stress test, using the Karvonen formula (Karvonen and Vuorimaa 1988; Mj 1957) During the first third of the sessions, work was performed at 50% of the MHRF, increasing to 60% in the second third and 80% in the last third (Alemán et al. 2014; Mezzani et al. 2013; Swain and Franklin 2006). In patients evaluated by ergospirometry, the intensity was established to achieve the heart rate obtained between the first and second ventilatory threshold (Alemán et al. 2014; Gaskill et al. 2001). In general, so-called continuous training was initiated, seeking an objective heart rate at a sustained exercise intensity. Subsequently, the patient was switched to an interval regime based on the results of the Conconi Test(Conconi et al. 1982). 3. Phase 3: Strength Training (2 times per week): Focused on large muscle groups, using 1-2 kg weights and performing 4-5 repetitions per exercise. Emphasis was placed on proper technique and controlled breathing, exhaling during exertion and inhaling during relaxation. 4. Phase 4: Stretching and Flexibilisation (5-10 minutes): Static stretching and balancing exercises to improve flexibility and facilitate the return to calm. Recognizing the importance of psychological well-being in cardiac rehabilitation, the program included group or individual psychological therapy sessions, depending on the patient's needs, led by a clinical psychologist on a biweekly basis. In addition, relaxation workshops were offered by a physiotherapist, lasting 20-30 minutes, focused on diaphragmatic breathing techniques and progressive muscle relaxation. In addition, weekly one-hour educational talks were held, addressing topics such as heart-healthy diet, understanding of cardiovascular disease, related pharmacology, physical exercise and sexual activity, cardiovascular risk factors and strategies for smoking cessation. Before each session, vital parameters such as blood pressure and heart rate were recorded. Abdominal circumference and body weight were measured weekly. Patients requiring additional support were referred to the Smoking Unit, Clinical Psychology or Mental Health, as appropriate. Three months after completion of the CRP (post-test) a new data collection was carried out. The data were then entered into a database for further statistical analysis. At the same consultation, the importance of maintaining the lifestyle changes achieved during the program was reinforced. 2.3. Instruments HRQoL is measured with the 36-item RAND 36-Item Health Survey (RAND-36). It is originally derived from the Short Form 36 Health Survey (SF-36) which was originally developed to be a generic instrument, applicable to a wide range of health conditions and populations (Hays et al. 1993). The RAND-36 scale differs from the SF-36 in the coding of some items and in the handling of missing data (McHorney et al. 1993) For the calculation of the RAND-36 scores, the scores of each item are recoded and for the calculation of the dimensions an average of the items answered in each dimension is taken. The dimensions of the RAND-36 are physical functioning (PF), role limitations due to physical health (RP), pain (BP), general health (GH), energy/fatigue (VT), social functioning (SF), role limitations due to emotional problems (RE), emotional well-being (MH); in addition, item number 2 referring to reported health transition is scored separately (Hays et al. 1993). Anxiety and depression are measured with the Goldberg Anxiety and Depression Scale (GADS). The GADS is a short and simple questionnaire that includes two distinct subscales, one for anxiety and one for depression (García et al. 2001). In the anxiety subscale, four questions are asked initially, and if the patient responds affirmatively to two or more, five additional questions are asked. The cut-off point for identifying possible significant anxiety is 4 or more points on the total scale. In the depression subscale, if the patient responds affirmatively to at least one of the initial questions, the rest of the questionnaire is continued, and a score of 2 or more indicates possible significant depression (Montón Franco et al. 1993). The scale has been shown to have a sensitivity of 83.1 % and a specificity of 81.8 %, which makes it suitable for correctly identifying those patients with psychiatric morbidity and ruling out those without relevant disorders (Montón Franco et al. 1993) making it an effective screening tool. In addition, the EADG allows estimating the severity of the pathology, as higher scores correlate with higher levels of impairment (García et al. 2001). In this research, total anxiety and depression scores are used as quantitative variables, but cut-off points that establish dichotomous categorical variables (yes/no anxiety or depression) are also used. 2.4. Statistical analysis The IBM-SPSS V.25.0 program was used for statistical analysis. First, a descriptive analysis of the variables was carried out. Quantitative variables are described with the mean and standard deviation and qualitative variables with the distribution of frequencies and percentages. To check whether the CRP based on physical exercise and promotion of healthy habits improves anxiety, depression and HRQoL in patients with cardiac pathology, Student's t-statistical analysis was performed for related samples. In order to check whether the presence of anxiety and/or depression at the beginning of the rehabilitation treatment influences the HRQoL achieved after said treatment, the ANCOVA statistic was used in which the dependent variable was the differential HRQoL score (obtained from the T2-T1 transformed scores for each dimension of the RAND-36 scale following its scoring rules), the covariate was the pretest score of the HRQoL dimensions in each case and the fixed factor was the presence or absence of anxiety or depression. 3. Results The sample consisted of 189 patients, 157 (83.1%) were male and 32 (16.9%) were female; 145 (76.7%) reside in the locality where the rehabilitation program takes place, 23 (12.2%) patients at a distance of less than 60 km from this locality and 21 (11.2%) at a distance of more than 60 km. The mean age of the participants was 60.68 years with a maximum of 84 and a minimum of 15. The descriptive statistics of the quantitative variables anxiety, depression and quality of life in the pretest and posttest are shown in table 1. Table 1. Descriptive statistics of anxiety, depression and health related quality of life. Minimum Maximum Mean SD Anxiety pretest 0 9 2.89 3.13 Anxiety posttest 0 9 1.91 2.77 Depression pretest 0 9 1.89 2.27 Depression posttest 0 8 1.02 1.81 RAND_PF pretest 4.00 37.00 19.28 6.44 RAND_PF posttest 6.00 42.00 18.38 6.78 RAND_RP pretest .00 100.00 29.54 37.03 RAND_RP posttest .00 100.00 46.11 42.21 RAND_BP pretest .00 100.00 68.85 24.23 RAND_BP posttest .00 100.00 71.92 25.79 RAND_GH pretest 5.00 90.00 53.50 17.25 RAND_GH posttest 5.00 100.00 58.17 19.08 RAND_VT pretest 10.00 90.00 57.98 16.18 RAND_VT posttest 10.00 90.00 63.83 16.10 RAND_SF pretest .00 100.00 77.48 23.60 RAND_SF posttest .00 100.00 84.09 21.60 RAND_RE pretest .00 100.00 55.88 44.92 RAND_RE posttest .00 100.00 63.45 42.92 RAND_MH pretest 16.00 88.00 64.00 16.41 RAND_MH posttest 20.00 88.00 66.63 15.69 RAND_2 pretest .00 100.00 40.49 23.48 RAND_2 posttest .00 100.00 67.57 26.88 SD: standard deviation. RAND: RAND 36-Item Health Survey; PF: Physical Functioning; RP: Role limitations due to physical health; BP: Pain; GH: General Health; VT: Energy/Fatigue; SF: Social Functioning; RE: Role limitations due to emotional problems; MH: Emotional Well-being; RAND_2: Reported health transition item. The results of the pre- and post-intervention comparisons for the variables assessed, including anxiety, depression and HRQoL dimensions, are presented below (Table 2). Table 2. T-test results for paired samples Variable Mean Difference (95% CI) t-value p-value Anxiety 0.93 (0.44, 1.42) 3.76 < .001 Depression 0.62 (0.26, 0.99) 3.42 < .001 RAND_PF .90 (.11, -1.91) 1.75 .041 RAND_RP -16.57 (-22.79, -10.34) -5.25 < .001 RAND_BP -3.07 (-6.67, .54) -1.68 .048 RAND_GH -4.67 (-6.81, -2.54) -4.32 < .001 RAND_VT -5.85 (-7.94, -3.77) -5.54 < .001 RAND_SF -6.60 (-10.00, -3.19) -3.82 < .001 RAND_RE -7.57 (-14.29, -.86) -2.22 .014 RAND_MH -2.63 (-4.60, -.65) -2.63 .005 RAND_2 -27.08 (-31.34, -22.82) -12.54 < .001 CI: Confidence Interval; RAND: RAND 36-Item Health Survey; PF: Physical Functioning; RP: Role limitations due to physical health; BP: Pain; GH: General Health ; VT: Energy/Fatigue; SF: Social Functioning ; RE: Role limitations due to emotional problems; MH: Emotional Well-being; RAND_2: Reported health transition item. Table 3 shows that the presence of anxiety at the beginning of the rehabilitation program influences the improvement in the Role limitations due to physical health, Pain and Emotional Well-being dimensions of HRQoL achieved after treatment. Table 3. ANCOVA analysis between anxiety at the beginning and non-anxiety at the beginning groups related to HRQoL improvements. Variables Treatment group Mean difference SD P Observed power RAND_PF Anxiety -1.11 7.42 .902 .000 Non-anxiety .17 7.29 RAND_RP Anxiety 12.94 42.14 .047 .028 Non-anxiety 17.14 44.77 RAND_BP Anxiety -2.36 28.76 .035 .032 Non-anxiety 2.30 21.56 RAND_GH Anxiety 4.62 15.94 .466 .004 Non-anxiety 3.71 12.59 RAND_VT Anxiety 6.73 16.66 .121 .017 Non-anxiety 5.14 13.96 RAND_SF Anxiety 11.11 24.73 .130 .016 Non-anxiety 3.24 20.29 RAND_RE Anxiety 18.88 42.84 .109 .018 Non-anxiety 2.41 45.78 RAND_MH Anxiety 3.39 15.61 .004 .059 Non-anxiety 1.74 12.49 RAND_2 Anxiety 26.39 28.17 .459 .004 Non-anxiety 24.50 31.00 SD: Standard Deviation; RAND: RAND 36-Item Health Survey; PF: Physical Functioning; RP: Role limitations due to physical health; BP: Pain; GH: General Health ; VT: Energy/Fatigue; SF: Social Functioning ; RE: Role limitations due to emotional problems; MH: Emotional Well-being; RAND_2: Reported health transition item. Table 4 shows that the presence of depression at the beginning of the rehabilitation program influences the improvement in the Social Functioning and Emotional Well-being dimensions of HRQoL achieved after treatment. Table 4. ANCOVA analysis between depression at the beginning and non-depression at the beginning groups related to HRQoL improvements. Variables Treatment group Mean difference SD P Observed power RAND_PF Depression -1.09 7.12 .91 .000 Non-depression .37 7.49 RAND_RP Anxiety 21.18 39.40 .70 .001 Non-anxiety 11.08 46.76 RAND_BP Anxiety 3.48 28.07 .92 .000 Non-anxiety -1.70 20.81 RAND_GH Anxiety 5.82 15.66 .94 .000 Non-anxiety 2.57 12.05 RAND_VT Anxiety 8.16 17.13 .27 .009 Non-anxiety 3.71 12.65 RAND_SF Anxiety 7.86 26.06 .01 .046 Non-anxiety 4.60 18.54 RAND_RE Anxiety 14.36 43.02 .06 .025 Non-anxiety 3.37 46.77 RAND_MH Anxiety 3.73 15.67 .02 .036 Non-anxiety 1.19 11.73 RAND_2 Anxiety 30.48 29.20 .60 .002 Non-anxiety 20.18 29.99 SD: Standard Deviation; RAND: RAND 36-Item Health Survey; PF: Physical Functioning; RP: Role limitations due to physical health; BP: Pain; GH: General Health ; VT: Energy/Fatigue; SF: Social Functioning ; RE: Role limitations due to emotional problems; MH: Emotional Well-being; RAND_2: Reported health transition item. 4. Discussion The results demonstrate that the objectives of this study were achieved, as the participating patients with cardiac pathology experienced significant improvements in anxiety, depression, and HRQoL after completing a CRP focused on physical exercise and the promotion of healthy habits, thereby confirming the primary hypothesis. Furthermore, consistent with the secondary objective, the findings revealed that baseline levels of anxiety and/or depression significantly influenced the magnitude of improvement in specific HRQoL dimensions, such as emotional well-being and social functioning. These results support the secondary hypothesis, highlighting the importance of addressing psychological factors at the start of rehabilitation to optimize outcomes. The relationship between anxiety and cardiovascular health has garnered increasing attention in recent research. Anxiety disorders are prevalent among patients with coronary heart disease (CHD) and have been linked to poorer clinical outcomes, including increased mortality and new cardiac events (L. Wang et al. 2021). Consistent with this evidence, our study found that participation in a CRP significantly reduced anxiety levels among patients, highlighting the effectiveness of exercise-based rehabilitation programs in alleviating psychological distress. These findings align with a meta-analysis demonstrating that exercise therapy can significantly alleviate anxiety symptoms in cardiac patients (Bethge et al. 2023). Research highlights the role of anxiety in accelerating the development of cardiovascular disease risk factors as studies have shown that ongoing stress and anxiety can lead to the adoption of poor lifestyle behaviors, such as smoking and physical inactivity, which further compromise cardiovascular health (Abdul Manan et al. 2024). By addressing anxiety through structured interventions, including physical exercise and psychological support, CRPs not only improve psychological well-being, as demonstrated in our results, but may also enhance overall physical health outcomes. This underscores the importance of routinely assessing and addressing anxiety levels in cardiac rehabilitation settings, as done in this study using the Goldberg Anxiety and Depression Scale (GADS), which effectively identified changes in anxiety pre- and post-intervention. These results emphasize the need for a collaborative approach between healthcare professionals and patients to optimize both mental and cardiovascular health. The cumulative evidence suggests that addressing anxiety through structured interventions, including exercise therapy, not only improves psychological well-being but may also enhance overall physical health outcomes (Abdul Manan et al. 2024). The prevalence of depression among patients undergoing cardiac rehabilitation is significantly higher than that in the general population, with estimates ranging from 15% to 45% following acute cardiac events (Child et al. 2010). In a recent study, depressive tendencies were observed in 47.6% of patients at the 9-month evaluation, with 40.5% of participants exhibiting type D personality traits (Ibrahim et al. 2025). These comorbidities, including depression and anxiety, are known to exacerbate health outcomes and reduce quality of life. Consistent with this context, our findings highlight the importance of addressing psychological factors like depression in cardiac rehabilitation to optimize recovery and improve patients’ overall well-being. A comparison of baseline characteristics between patients with and without depressive tendencies revealed that 72.5% of those who were depressed at the 9-month mark had also shown depressive symptoms at baseline, compared to only 40.9% of the non-depressed group (p = 0.004) (Ibrahim et al. 2025). Similarly, our study found that baseline depression significantly influenced improvements in HRQoL dimensions, such as social functioning (RAND-SF: p = 0.01) and emotional well-being (RAND-MH: p = 0.02), underscoring the lasting impact of initial depressive symptoms on rehabilitation outcomes. Additionally, patients with depressive tendencies were more likely to utilize maladaptive coping strategies, such as "abandonment or resignation," which is associated with a higher likelihood of ongoing depressive symptoms (p = 0.033) (Ibrahim et al. 2025). Conversely, those who engaged in adaptive coping strategies, like "planning" and "positive interpretation," were less likely to exhibit depressive tendencies at follow-up (p = 0.007 and p = 0.018, respectively) (Ibrahim et al. 2025). These findings align with our results, emphasizing the need for psychological support within CRPs to foster adaptive coping strategies and optimize recovery trajectories, particularly for patients with high baseline depression. The efficacy of various treatment modalities in addressing depression among cardiac patients remains inconsistent. For instance, cognitive-behavioral therapy has shown short-term improvements in depressive symptoms and social support, yet these benefits were not sustained at 30 months post-intervention (Child et al. 2010). Similarly, studies have indicated that antidepressant treatments did not result in significant long-term improvements in depression or cardiac prognosis following myocardial infarction (Child et al. 2010). Research highlights a strong correlation between psychological health and cardiovascular disease risk. Chronic stress and negative mental states, such as anxiety and depression, are linked to the accelerated development of cardiovascular risk factors, which can lead to adverse health outcomes (Abdul Manan et al. 2024). In line with these findings, our study demonstrated significant reductions in anxiety and depression after the CRP, emphasizing the critical role of addressing psychological health in cardiac rehabilitation. These improvements align with the American Heart Association's emphasis on the necessity for integrated approaches that target both psychological and physical well-being in cardiac care (Abdul Manan et al. 2024). Furthermore, our results highlight the importance of tailoring interventions to address baseline psychological conditions, as patients with higher initial levels of anxiety and depression showed differential improvements in HRQoL dimensions. Promoting awareness and proactive management of mental health, as evidenced by the outcomes in this study, is essential for enhancing the overall recovery and quality of life of cardiac patients. The impact of CRPs on HRQoL is significant, as these programs aim to enhance patients' overall well-being and functional capacity following cardiac events. The World Health Organization (WHO) defines quality of life as an individual's perception of their situation within their cultural context and belief systems, emphasizing the multidimensional nature of this concept (Levine et al. 2021). HRQoL assessment is increasingly utilized in clinical settings to evaluate how patients perceive their health status and the limitations imposed by chronic diseases, particularly cardiovascular conditions (Levine et al. 2021). Various instruments are employed to measure HRQoL, including generic utility measures such as Quality-Adjusted Life Years (QALYs), which offer a single score reflecting the patient's evaluation of their health (Levine et al. 2021). The EQ-5D-5L, recommended by the UK National Institute of Health and Care Excellence for economic evaluations, is one such tool used to estimate health benefits in clinical trials (McPhillips et al. 2021). The RAND 36-Item Health Survey (RAND-36) is a prominent tool for assessing HRQoL designed to be user-friendly and applicable across various health contexts, playing a crucial role in evaluating the impact of cardiovascular diseases on patients' quality of life (García-Sánchez et al. 2024; Orwelius et al. 2018). The inclusion of HRQoL as a variable in clinical trials is essential, as it serves not only to monitor treatment efficacy but also to predict patient responses to therapy and aid in future care planning (Levine et al. 2021). Evidence suggests that participation in CRPs leads to substantial improvements in HRQoL among patients with heart disease. Consistent with this evidence, our study found significant improvements in multiple HRQoL dimensions after the CRP, such as role limitations due to physical health, social functioning, and emotional well-being. Additionally, previous research indicates that physical activity post-rehabilitation can reduce cardiovascular mortality by up to 35% and enhance functional capacity and quality of life (Levine et al. 2021). Furthermore, improvements in functional capacity and quality of life are often observed, with higher rates of return to work reported among those who undergo CRPs (Levine et al. 2021). Similarly, our results emphasize the importance of CRPs in addressing both physical and psychological dimensions of health, as improvements in HRQoL were accompanied by reductions in anxiety (mean difference = 0.93, p < .001) and depression (mean difference = 0.62, p < .001). For patients with advanced heart failure or severe cardiac conditions, these findings underscore the value of prioritizing quality of life as a key treatment outcome (Levine et al. 2021). By focusing on HRQoL, healthcare providers can gain insights into the patient's subjective experience, which may include psychological aspects such as anxiety and depression that are commonly associated with cardiac conditions (Levine et al. 2021; Thomas 2024). Generally, research in this field faces several limitations that can affect the validity and generalizability of findings. Many studies report small sample sizes, resulting in reduced statistical power and fewer participants available for long-term follow-ups. Furthermore, disparities in gender representation can lead to biases in outcomes, particularly when studies primarily include male participants (Yamaguchi et al. 2025). The varying methodologies employed to measure psychological outcomes, such as different psychometric scales, introduce additional complexity in comparing results across studies. Additionally, inconsistencies in intervention durations and follow-up periods can attenuate observed effects, further complicating the analysis of CR interventions (de la Cuerda et al. 2012; Yamaguchi et al. 2025). Another significant challenge is the low adherence rates observed in cardiac rehabilitation programs. Factors contributing to treatment discontinuation may include patient motivation, interest levels, and the perceived relevance of psychological support methods, such as relaxation training and stress management techniques (Candelaria et al. 2024; de la Cuerda et al. 2012). The overall effectiveness of these interventions can be hindered by these adherence issues, which are commonly observed in clinical practice. Optimizing patient engagement through tailored approaches that address individual preferences may enhance the impact of psychological support within CR settings (de la Cuerda et al. 2012). Socioeconomic disparities also pose a barrier to participation in CR programs. Despite the proven benefits of CR, only about 25% of eligible patients enroll, with even fewer completing the program. Participation disparities are notably influenced by factors such as sex, race, ethnicity, and geographic location (Beatty et al. 2023; Moreira et al. 2024). Future efforts must focus on addressing these barriers and exploring different payment models to enhance access to psychosocial services within CR programs. Improved financial support and resources are essential for comprehensive care and to ensure that all patients can benefit from CR interventions (Bush et al. 2023). This study has several limitations that should be acknowledged. The absence of a control group limits the ability to definitively attribute the observed improvements in anxiety, depression, and HRQoL solely to the cardiac rehabilitation program. This may inflate the perceived impact, and its magnitude, while difficult to quantify, could be relevant. Additionally, the predominantly male sample limits the generalizability of the findings to female patients, who are known to experience different psychological and physical responses to cardiac rehabilitation. Furthermore, the reliance on self-reported measures introduces response bias, where participants may overstate improvements due to social desirability or other subjective factors. While this bias is moderate, it highlights the need for complementary objective measures in future studies. Despite these limitations, the study has notable strengths. It provides robust evidence of significant improvements in anxiety, depression, and HRQoL following participation in a iCRP, emphasizing the importance of integrating psychological support into rehabilitation protocols. The longitudinal design allowed for the assessment of changes over time, adding depth to the analysis. Moreover, the use of validated instruments ensures reliability and facilitates comparability with previous research. Future research should incorporate comparison groups that would allow for more robust causal inferences regarding the intervention's effectiveness. Additionally, ensuring a more diverse sample, including a balanced representation of genders, would enhance the generalizability of the findings. Studies should also consider adjusting for potential confounders, such as age, comorbidities, and socioeconomic status, to better understand the factors influencing outcomes. 5. Conclusions This study demonstrates that CRPs based on physical exercise and the promotion of healthy habits significantly reduce anxiety and depression while improving HRQoL in patients with cardiovascular conditions. The findings underscore the importance of addressing psychological factors, such as baseline anxiety and depression, as they play a critical role in determining the extent of HRQoL improvements. Specifically, the presence of anxiety and depression at the start of the rehabilitation program was found to influence key HRQoL dimensions, including emotional well-being, social functioning, and role limitations. These results highlight the need for tailored and integrated interventions that simultaneously address physical and psychological aspects of recovery. Future research should explore strategies to enhance patient adherence and engagement in CRPs, as well as the long-term sustainability of psychological and HRQoL benefits. Declarations Funding Declaration: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Consent to Participate Declaration: Informed consent was obtained from all subjects involved in the study. Human Ethics Declaration: The study was conducted in accordance with the Declaration of Helsinki, and approved by the Medicines Research Ethics Committee of the Burgos and Soria Health Area (Ref. CEIm 2569) for studies involving humans. References Abdul Manan, H., Mir, I. A., Humayra, S., Tee, R. Y., & Vasu, D. T. (2024). Effect of mindfulness-based interventions on anxiety, depression, and stress in patients with coronary artery disease: a systematic review and meta-analysis of randomized controlled trials. Frontiers in Psychology , 15 , 1435243. Alemán, J. A., de Baranda Andujar, P. S., & Ortín, E. J. O. (2014). Guía para la prescripción de ejercicio físico en pacientes con riesgo cardiovascular . Seh-Lelha. Beatty, A. L., Beckie, T. M., Dodson, J., Goldstein, C. M., Hughes, J. W., Kraus, W. E., et al. (2023). A New Era in Cardiac Rehabilitation Delivery: Research Gaps, Questions, Strategies, and Priorities. Circulation , 147 (3), 254–266. https://doi.org/10.1161/CIRCULATIONAHA.122.061046 Bethge, M., Thome-Soós, F., Rašo, L. M., Weier, L., & Benninghoven, D. (2023). Cognitive-behavioral rehabilitation in patients with cardiovascular diseases: a randomized controlled trial (CBR-CARDIO, DRKS00029295). BMC cardiovascular disorders , 23 (1), 252. Bush, M., Evenson, K. R., Aylward, A., Cyr, J. M., & Kucharska-Newton, A. (2023). Psychosocial services provided by licensed cardiac rehabilitation programs. Frontiers in Rehabilitation Sciences , 4 , 1093086. Candelaria, D., Redfern, J., O’Neil, A., Brieger, D., Clark, R. A., Briffa, T., et al. (2024). Data-driven collaborative QUality improvement in Cardiac Rehabilitation (QUICR) to increase program completion: protocol for a cluster randomized controlled trial. BMC Cardiovascular Disorders , 24 (1), 302. Child, A., Sanders, J., Sigel, P., & Hunter, M. S. (2010). Meeting the psychological needs of cardiac patients: an integrated stepped-care approach within a cardiac rehabilitation setting. Br J Cardiol , 17 (4), 175–179. Conconi, F., Ferrari, M., Ziglio, P. G., Droghetti, P., & Codeca, L. (1982). Determination of the anaerobic threshold by a noninvasive field test in runners. Journal of Applied physiology , 52 (4), 869–873. de la Cuerda, R. C., Diego, I. M. A., Martín, J. J. A., Sánchez, A. M., & Page, J. C. M. (2012). Cardiac rehabilitation programs and health-related quality of life. State of the art. Revista Española de Cardiología (English Edition) , 65 (1), 72–79. García, J. L. T., Ramírez, F. B., Misol, R. C., Bentata, L. C., Alonso, C. F., Campayo, J. G., et al. (2001). Prevención de los trastornos de la salud mental desde la atención primaria de salud. Aten Primaria. , 28 (2), 100–116. García-Sánchez, E., Santamaría-Peláez, M., Benito Figuerola, E., Carballo García, M. J., Chico Hernando, M., García García, J. M., et al. (2024). Comparison of SF-36 and RAND-36 in cardiovascular diseases: a reliability study. Journal of Clinical Medicine , 13 (20), 6106. Gaskill, S. E., Ruby, B. C., Walker, A. J., Sanchez, O. A., SERFASS, R. C., & LEON, A. S. (2001). Validity and reliability of combining three methods to determine ventilatory threshold. Medicine & Science in Sports & Exercise , 33 (11), 1841–1848. Hays, R. D., Sherbourne, C. D., & Mazel, R. M. (1993). The rand 36‐item health survey 1.0. Health economics , 2 (3), 217–227. Ibrahim, D., Elkhidir, I. H., Mohammed, Z., Abdalla, D., Mohammed, O. A., Hemmeda, L., et al. (2025). The role of CBT in enhancing health outcomes in coronary artery bypass graft patients: a systematic review. BMC psychiatry , 25 (1), 22. J, T. R., Gary, B., Gaurav, B., M, B. T., Jensen, C., Sana, G., et al. (2018). 2018 ACC/AHA Clinical Performance and Quality Measures for Cardiac Rehabilitation. Journal of the American College of Cardiology , 71 (16), 1814–1837. https://doi.org/10.1016/j.jacc.2018.01.004 Karvonen, J., & Vuorimaa, T. (1988). Heart rate and exercise intensity during sports activities: practical application. Sports medicine , 5 , 303–311. Levine, G. N., Cohen, B. E., Commodore-Mensah, Y., Fleury, J., Huffman, J. C., Khalid, U., et al. (2021). Psychological Health, Well-Being, and the Mind-Heart-Body Connection A Scientific Statement From the American Heart Association. Circulation , 143 (10), E763–E783. https://doi.org/10.1161/CIR.0000000000000947 McHorney, C. A., Ware Johne, J. R., & ANASTASIAE, R. (1993). The MOS 36-Item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Medical care , 31 (3), 247–263. McPhillips, R., Capobianco, L., Cooper, B. G., Husain, Z., & Wells, A. (2021). Cardiac rehabilitation patients experiences and understanding of group metacognitive therapy: a qualitative study. Open Heart , 8 (2), e001708. Mezzani, A., Hamm, L. F., Jones, A. M., McBride, P. E., Moholdt, T., Stone, J. A., et al. (2013). Aerobic exercise intensity assessment and prescription in cardiac rehabilitation: a joint position statement of the European Association for Cardiovascular Prevention and Rehabilitation, the American Association of Cardiovascular and Pulmonary Rehabilitation and the Canadian Association of Cardiac Rehabilitation. European journal of preventive cardiology , 20 (3), 442–467. Mj, K. (1957). The effects of training on heart rate: a longitudinal study. Ann med exp biol fenn , 35 , 307–315. Montón Franco, C., Pérez Echevarría, M. J., Campos, R., García Campayo, J., & Lobo, A. (1993). Escalas de ansiedad y depresión de Goldberg: una guía de entrevista eficaz para la detección del malestar psíquico. Atención primaria , 12 (6), 345–349. Moreira, J., Bravo, J., Aguiar, P., Delgado, B., Raimundo, A., & Boto, P. (2024). Physical and Mental Components of Quality of Life after a Cardiac Rehabilitation intervention: a systematic review and Meta-analysis. Journal of Clinical Medicine , 13 (18), 5576. Orwelius, L., Nilsson, M., Nilsson, E., Wenemark, M., Walfridsson, U., Lundström, M., et al. (2018). The Swedish RAND-36 Health Survey-reliability and responsiveness assessed in patient populations using Svensson’s method for paired ordinal data. Journal of patient-reported outcomes , 2 , 1–10. Patel, D. K., Duncan, M. S., Shah, A. S., Lindman, B. R., Greevy Jr, R. A., Savage, P. D., et al. (2019). Association of Cardiac Rehabilitation With Decreased Hospitalization and Mortality Risk After Cardiac Valve Surgery. JAMA Cardiology , 4 (12), 1250–1259. https://doi.org/10.1001/jamacardio.2019.4032 Swain, D. P., & Franklin, B. A. (2006). Comparison of cardioprotective benefits of vigorous versus moderate intensity aerobic exercise. The American journal of cardiology , 97 (1), 141–147. Thomas, R. J. (2024). Cardiac Rehabilitation—challenges, advances, and the Road ahead. New England Journal of Medicine , 390 (9), 830–841. Wang, C.-Y. (2017). Circadian rhythm, exercise, and heart. Acta Cardiologica Sinica , 33 (5), 539. Wang, L., Sun, Y., Zhan, J., Wu, Z., Zhang, P., Wen, X., et al. (2021). Effects of exercise therapy on anxiety and depression in patients with coronary heart disease: a meta-analysis of a randomized controlled study. Frontiers in Cardiovascular Medicine , 8 , 730155. Wells, A., McNicol, K., Reeves, D., Salmon, P., Davies, L., Heagerty, A., et al. (2018). Improving the effectiveness of psychological interventions for depression and anxiety in the cardiac rehabilitation pathway using group-based metacognitive therapy (PATHWAY Group MCT): study protocol for a randomised controlled trial. Trials , 19 , 1–12. Yamaguchi, D., Asano, Y., Kuwahara, K., & Izawa, A. (2025). Coping strategies and changes in type D personality were associated with depressive tendency at 9 months after percutaneous coronary intervention. PloS one , 20 (1), e0316639. Additional Declarations No competing interests reported. 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These programs combine physical exercise, education, and psychological counseling to enhance patients\u0026apos; physical and mental health, thereby reducing the risk of future cardiac events and improving overall quality of life (Child et al. 2010; J et al. 2018; Patel et al. 2019; C.-Y. Wang 2017).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNotably, CRPs address significant psychological comorbidities, including anxiety and depression, which are prevalent among cardiac patients and can impede recovery (Beatty et al. 2023; Child et al. 2010). The effects of CRPs on anxiety and depression have become a focal point in cardiac care research, with studies indicating that structured psychological interventions within rehabilitation settings can significantly alleviate these mental health issues (Bethge et al. 2023; L. Wang et al. 2021).\u003c/p\u003e\n\u003cp\u003eFurthermore, evidence suggests that improving psychological well-being is integral to enhancing health-related quality of life (HRQoL), as patients often prioritize quality of life over mere survival post-rehabilitation (Levine et al. 2021).\u003cu\u003e\u0026nbsp;\u003c/u\u003eA systematic review has demonstrated that participation in CRPs can lead to substantial improvements in HRQoL, reinforcing the importance of a holistic approach that encompasses both physical and mental health (de la Cuerda et al. 2012; Yamaguchi et al. 2025)\u003cu\u003e.\u0026nbsp;\u003c/u\u003eDespite the recognized benefits, challenges persist in the implementation of CRPs, including low patient adherence and varying quality across programs (Wells et al. 2018). Disparities in access due to socioeconomic factors further complicate the effectiveness of CRPs, as only a fraction of eligible patients engage fully in these programs (Beatty et al. 2023; Moreira et al. 2024).\u003cu\u003e\u0026nbsp;\u003c/u\u003e Additionally, while interventions such as cognitive-behavioral therapy and mindfulness have shown short-term efficacy, concerns regarding their long-term sustainability and impact remain (Candelaria et al. 2024; Yamaguchi et al. 2025). As such, ongoing research is critical to understanding the complexities of mental health within cardiac rehabilitation and to optimize care for diverse patient populations.\u003c/p\u003e\n\u003cp\u003eCentral to cardiac rehabilitation is the exercise component, which focuses on enhancing aerobic capacity, functional fitness, and strength through carefully monitored physical activity. Exercise physiologists oversee these activities to ensure safety for patients, particularly those with existing cardiac conditions (C.-Y. Wang 2017)\u003cu\u003e.\u003c/u\u003e Programs may also integrate low-impact exercise training tailored to individual fitness levels, promoting gradual recovery and long-term health maintenance (C.-Y. Wang 2017).\u003c/p\u003e\n\u003cp\u003eEducational elements of cardiac rehabilitation cover various topics, including specific cardiac diagnoses, general cardiac health, heart-healthy dietary practices, and stress management techniques. Knowledge about their condition and effective coping strategies empower patients to take charge of their health, which can lead to improvements in overall well-being (Child et al. 2010; J et al. 2018; Patel et al. 2019; C.-Y. Wang 2017). Psychological support is also integral, with interventions designed to address issues such as anxiety and depression, which are common in patients with cardiac diseases (Beatty et al. 2023; Child et al. 2010).\u003c/p\u003e\n\u003cp\u003eRecognizing the interplay between mental health and physical recovery, modern CRPs often include psychological services. These may involve psychoeducation, group workshops, and individual therapy sessions focused on managing anxiety and depression, which can hinder rehabilitation progress. Studies indicate that psychological interventions can lead to reduced anxiety and depression among cardiac patients, although their impact on overall mortality remains inconclusive (Beatty et al. 2023; Child et al. 2010). The integration of psychological care within CRPs aims to address both the physical and emotional needs of patients, fostering a more holistic approach to recovery (Child et al. 2010).\u003c/p\u003e\n\u003cp\u003eEfforts have been made to enhance patient engagement and accessibility within cardiac rehabilitation services. For instance, providing psychological assessments within the context of cardiac outpatient clinics reduces stigma and promotes attendance. Programs have also demonstrated improved patient acceptance of psychological referrals compared to traditional mental health services, highlighting the importance of integrated care in addressing the comprehensive needs of patients (Beatty et al. 2023; Child et al. 2010).\u003c/p\u003e\n\u003cp\u003eVarious studies have investigated the effects of CRPs on anxiety, depression, and quality of life among patients with cardiovascular conditions. A systematic review of eight studies revealed significant differences in intervention characteristics, with seven employing Mindfulness-Based Stress Reduction (MBSR) and one utilizing a combined approach of MBSR and Mindfulness-Based Art Therapy (MBAT) (Wells et al. 2018; Yamaguchi et al. 2025). The interventions were predominantly conducted in either hospital settings or through hybrid models that included both hospital and home-based sessions, highlighting the flexibility of Cardiac Rehabilitation (CR) delivery methods (Yamaguchi et al. 2025). The studies analyzed included a total of 623 participants, with a male predominance (72.2%) compared to female participants (27.8%) across various demographics (Yamaguchi et al. 2025). Participants in the included studies presented with different conditions related to coronary artery disease and had undergone various treatments, including revascularization surgeries (Yamaguchi et al. 2025). The variation in participant characteristics underscores the need for tailored interventions that consider gender and specific health conditions to enhance the effectiveness of CR programs.\u003c/p\u003e\n\u003cp\u003eWhile CR interventions generally report positive outcomes, issues surrounding patient adherence and satisfaction have been noted. Factors contributing to low adherence rates may include lack of motivation or interest, which is often observed in clinical practice (de la Cuerda et al. 2012). Addressing these barriers is vital for optimizing the impact of CR programs on patients\u0026apos; mental health and quality of life. Enhanced support mechanisms and tailored interventions that foster engagement may improve adherence and the overall effectiveness of CR programs (de la Cuerda et al. 2012).\u003c/p\u003e\n\u003cp\u003eCR is crucial for enhancing the psychological well-being of patients recovering from cardiovascular events. However, a significant challenge lies in the psychological support provided within CR programs. While methods such as cognitive-behavioral therapy (CBT) and mindfulness-based interventions (MBIs) show short-term psychological benefits, their long-term sustainability and effectiveness remain questionable (Candelaria et al. 2024; Yamaguchi et al. 2025). Patients frequently experience chronic stress, anxiety, and depression, which can deteriorate cardiovascular health outcomes and diminish overall quality of life over time. The immediate psychological improvements noted following MBIs may not indicate lasting stability, necessitating ongoing assessment to evaluate the durability of these benefits beyond the intervention phase (Yamaguchi et al. 2025).\u003c/p\u003e\n\u003cp\u003eThe aim of this research is to test whether a CRP based on physical exercise and the promotion of healthy habits improves anxiety, depression, and HRQoL in patients with cardiac pathology. Specifically, we hypothesize that participation in the program will significantly reduce anxiety and depression levels and enhance health-related quality of life. Furthermore, it aims to check whether the presence of anxiety and/or depression at the start of rehabilitation treatment influences the HRQoL achieved after treatment. We hypothesize that higher baseline levels of anxiety and/or depression will significantly impact the magnitude of improvement in HRQoL after completing the program.\u003c/p\u003e"},{"header":"2.\tMethods","content":"\u003cp\u003e\u003cstrong\u003e2.1. Participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe participants were 189 patients with cardiac pathology who, after being referred by the Cardiologist in charge of the Cardiac Rehabilitation Unit to assess their inclusion in the physical training that is carried out on an outpatient basis within the CRP, completed this Program. \u003c/p\u003e\n\u003cp\u003eThe inclusion criteria were to have a diagnosis of cardiovascular pathology, to attend the Cardiac Rehabilitation Unit consultation referred to by Cardiology, to sign the informed consent prepared for this study and to complete the CRP. Patients who were unable to perform the physical exercise program due to some pathology, who refused to participate in the program, and those who did not complete it were excluded.\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethical Committee for Research with Medicines of the Health Area of Burgos and Soria (Ref. CEIm 2569) on June 22, 2021. The research was conducted in accordance with the guidelines set out in the World Medical Association's Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2. Procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA longitudinal cohort study was carried out with a single experimental group composed of patients with cardiovascular pathology. No sample calculation was performed, and a control group was not included in this study due to ethical considerations. Given that the treatment in question is aimed at improving the well-being of participants and has the potential to provide direct benefits to their health, it was considered inappropriate to deprive any group of access to this treatment. Instead of a traditional control group, an intervention design was chosen that ensures that all participants receive treatment, thus ensuring equity and benefit for all those involved in the study.\u003c/p\u003e\n\u003cp\u003eOnce the inclusion criteria had been verified, data were collected from each patient in the consultation of the Rehabilitation Service of the University Hospital of Burgos at the time of the initial consultation (pretest) from patients who were likely to join a CRP. The researcher who collected the data is a doctor specializing in physical medicine and rehabilitation; Clinical data were taken from the patients' medical history, sociodemographic data and assessment scales were collected in the consultation. Figure 1 shows the Flow chart for this research.\u003c/p\u003e\n\u003cp\u003eFollowing referral by their cardiologists, the patients were referred to the Cardiac Rehabilitation Unit of the University Hospital of Burgos. At the initial consultation, a cardiologist took a detailed clinical history, including anamnesis and evaluation of complementary tests such as lipid profile analysis, electrocardiogram and echocardiogram. In the absence of a recent stress test, ergometry or ergospirometry was performed. Subsequently, in the nursing consultation, cardiovascular risk factors, dietary habits, smoking history and social environment were assessed, providing health education and documentation explaining the program. After that, the rehabilitation physician reviewed the clinical history, verified adherence to medical treatment and performed a general physical examination to determine the patient's ability to participate in the CRP. Finally, the patients were interviewed by a physiotherapist of the Cardiac Rehabilitation Unit who explained again the CRP and developed it.\u003c/p\u003e\n\u003cp\u003eThe variables collected were biological gender, distance from the place of residence to the rehabilitation center, age, anxiety, depression and HRQoL. Part of the variables are reported by the patient and others objectified in the consultation.\u003c/p\u003e\n\u003cp\u003eThe CRP implemented in this study was designed to comprehensively address the needs of patients with cardiovascular pathologies, combining supervised physical exercise, psychological support and health education.\u003c/p\u003e\n\u003cp\u003eThe CRP lasted 1 to 2 months, with training sessions scheduled 2 to 3 times per week. Each session was structured in four phases:\u003c/p\u003e\n\u003cp\u003e1. Phase 1: Warm-up (10 minutes): Mobilisation of large muscle groups by means of flexion, extension, lateralisation and rotation exercises at the cervical, upper limb, trunk and lower limb levels. Each exercise was repeated approximately 5 times.\u003c/p\u003e\n\u003cp\u003e2. Phase 2: Aerobic Exercise (35 minutes): Performed on cycloergometers or treadmills, with intensity adjusted according to the Maximum Heart Rate Frecuancy (HRF) obtained in the stress test, using the Karvonen formula (Karvonen and Vuorimaa 1988; Mj 1957) During the first third of the sessions, work was performed at 50% of the MHRF, increasing to 60% in the second third and 80% in the last third (Alemán et al. 2014; Mezzani et al. 2013; Swain and Franklin 2006). In patients evaluated by ergospirometry, the intensity was established to achieve the heart rate obtained between the first and second ventilatory threshold (Alemán et al. 2014; Gaskill et al. 2001). In general, so-called continuous training was initiated, seeking an objective heart rate at a sustained exercise intensity. Subsequently, the patient was switched to an interval regime based on the results of the Conconi Test(Conconi et al. 1982).\u003c/p\u003e\n\u003cp\u003e3. Phase 3: Strength Training (2 times per week): Focused on large muscle groups, using 1-2 kg weights and performing 4-5 repetitions per exercise. Emphasis was placed on proper technique and controlled breathing, exhaling during exertion and inhaling during relaxation.\u003c/p\u003e\n\u003cp\u003e4. Phase 4: Stretching and Flexibilisation (5-10 minutes): Static stretching and balancing exercises to improve flexibility and facilitate the return to calm.\u003c/p\u003e\n\u003cp\u003eRecognizing the importance of psychological well-being in cardiac rehabilitation, the program included group or individual psychological therapy sessions, depending on the patient's needs, led by a clinical psychologist on a biweekly basis. In addition, relaxation workshops were offered by a physiotherapist, lasting 20-30 minutes, focused on diaphragmatic breathing techniques and progressive muscle relaxation. In addition, weekly one-hour educational talks were held, addressing topics such as heart-healthy diet, understanding of cardiovascular disease, related pharmacology, physical exercise and sexual activity, cardiovascular risk factors and strategies for smoking cessation.\u003c/p\u003e\n\u003cp\u003eBefore each session, vital parameters such as blood pressure and heart rate were recorded. Abdominal circumference and body weight were measured weekly. Patients requiring additional support were referred to the Smoking Unit, Clinical Psychology or Mental Health, as appropriate. \u003c/p\u003e\n\u003cp\u003eThree months after completion of the CRP (post-test) a new data collection was carried out. The data were then entered into a database for further statistical analysis. At the same consultation, the importance of maintaining the lifestyle changes achieved during the program was reinforced.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3. Instruments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHRQoL is measured with the 36-item RAND 36-Item Health Survey (RAND-36). It is originally derived from the Short Form 36 Health Survey (SF-36) which was originally developed to be a generic instrument, applicable to a wide range of health conditions and populations (Hays et al. 1993). The RAND-36 scale differs from the SF-36 in the coding of some items and in the handling of missing data (McHorney et al. 1993) For the calculation of the RAND-36 scores, the scores of each item are recoded and for the calculation of the dimensions an average of the items answered in each dimension is taken. The dimensions of the RAND-36 are physical functioning (PF), role limitations due to physical health (RP), pain (BP), general health (GH), energy/fatigue (VT), social functioning (SF), role limitations due to emotional problems (RE), emotional well-being (MH); in addition, item number 2 referring to reported health transition is scored separately (Hays et al. 1993).\u003c/p\u003e\n\u003cp\u003eAnxiety and depression are measured with the Goldberg Anxiety and Depression Scale (GADS). The GADS is a short and simple questionnaire that includes two distinct subscales, one for anxiety and one for depression (García et al. 2001). In the anxiety subscale, four questions are asked initially, and if the patient responds affirmatively to two or more, five additional questions are asked. The cut-off point for identifying possible significant anxiety is 4 or more points on the total scale. In the depression subscale, if the patient responds affirmatively to at least one of the initial questions, the rest of the questionnaire is continued, and a score of 2 or more indicates possible significant depression (Montón Franco et al. 1993).\u003c/p\u003e\n\u003cp\u003eThe scale has been shown to have a sensitivity of 83.1 % and a specificity of 81.8 %, which makes it suitable for correctly identifying those patients with psychiatric morbidity and ruling out those without relevant disorders (Montón Franco et al. 1993) making it an effective screening tool. In addition, the EADG allows estimating the severity of the pathology, as higher scores correlate with higher levels of impairment (García et al. 2001).\u003c/p\u003e\n\u003cp\u003eIn this research, total anxiety and depression scores are used as quantitative variables, but cut-off points that establish dichotomous categorical variables (yes/no anxiety or depression) are also used.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.4. Statistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe IBM-SPSS V.25.0 program was used for statistical analysis.\u003c/p\u003e\n\u003cp\u003eFirst, a descriptive analysis of the variables was carried out. Quantitative variables are described with the mean and standard deviation and qualitative variables with the distribution of frequencies and percentages.\u003c/p\u003e\n\u003cp\u003eTo check whether the CRP based on physical exercise and promotion of healthy habits improves anxiety, depression and HRQoL in patients with cardiac pathology, Student's t-statistical analysis was performed for related samples. In order to check whether the presence of anxiety and/or depression at the beginning of the rehabilitation treatment influences the HRQoL achieved after said treatment, the ANCOVA statistic was used in which the dependent variable was the differential HRQoL score (obtained from the T2-T1 transformed scores for each dimension of the RAND-36 scale following its scoring rules), the covariate was the pretest score of the HRQoL dimensions in each case and the fixed factor was the presence or absence of anxiety or depression.\u003c/p\u003e"},{"header":"3.\tResults","content":"\u003cp\u003eThe sample consisted of 189 patients, 157 (83.1%) were male and 32 (16.9%) were female; 145 (76.7%) reside in the locality where the rehabilitation program takes place, 23 (12.2%) patients at a distance of less than 60 km from this locality and 21 (11.2%) at a distance of more than 60 km. The mean age of the participants was 60.68 years with a maximum of 84 and a minimum of 15.\u003c/p\u003e\n\u003cp\u003eThe descriptive statistics of the quantitative variables anxiety, depression and quality of life in the pretest and posttest are shown in table 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eDescriptive statistics of anxiety, depression and health related quality of life.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"605\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMinimum\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaximum\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eAnxiety pretest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e2.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e3.13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eAnxiety posttest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e2.77\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eDepression pretest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e2.27\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eDepression posttest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1.81\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eRAND_PF pretest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e4.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e37.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e19.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e6.44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eRAND_PF posttest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e6.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e42.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e18.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e6.78\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eRAND_RP pretest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e29.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e37.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eRAND_RP posttest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e46.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e42.21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eRAND_BP pretest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e68.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e24.23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eRAND_BP posttest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e71.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e25.79\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eRAND_GH pretest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e5.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e90.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e53.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e17.25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eRAND_GH posttest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e5.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e58.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e19.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eRAND_VT pretest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e10.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e90.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e57.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e16.18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eRAND_VT posttest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e10.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e90.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e63.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e16.10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eRAND_SF pretest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e77.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e23.60\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eRAND_SF posttest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e84.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e21.60\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eRAND_RE pretest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e55.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e44.92\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eRAND_RE posttest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e63.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e42.92\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eRAND_MH pretest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e16.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e88.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e64.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e16.41\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eRAND_MH posttest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e20.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e88.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e66.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e15.69\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eRAND_2 pretest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e40.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e23.48\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003eRAND_2 posttest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e67.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e26.88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSD: standard deviation. RAND: RAND 36-Item Health Survey; PF: Physical Functioning; RP: Role limitations due to physical health; BP: Pain; GH: General Health; VT: Energy/Fatigue; SF: Social Functioning; RE: Role limitations due to emotional problems; MH: Emotional Well-being; RAND_2: Reported health transition item.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe results of the pre- and post-intervention comparisons for the variables assessed, including anxiety, depression and HRQoL dimensions, are presented below (Table 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u0026nbsp;\u003c/strong\u003eT-test results for paired samples\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"510\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 103px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean Difference (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e\u003cstrong\u003et-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 103px;\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e0.93 (0.44, 1.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e3.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eDepression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 215px;\"\u003e\n \u003cp\u003e0.62 (0.26, 0.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e3.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eRAND_PF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e.90 (.11, -1.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e1.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e.041\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eRAND_RP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e-16.57 (-22.79, -10.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e-5.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eRAND_BP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e-3.07 (-6.67, .54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e-1.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e.048\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eRAND_GH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e-4.67 (-6.81, -2.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e-4.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eRAND_VT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e-5.85 (-7.94, -3.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e-5.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eRAND_SF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e-6.60 (-10.00, -3.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e-3.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eRAND_RE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e-7.57 (-14.29, -.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e-2.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e.014\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eRAND_MH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e-2.63 (-4.60, -.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e-2.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e.005\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eRAND_2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e-27.08 (-31.34, -22.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 88px;\"\u003e\n \u003cp\u003e-12.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eCI: Confidence Interval; RAND: RAND 36-Item Health Survey; PF: Physical Functioning; RP: Role limitations due to physical health; BP: Pain; GH: General Health ; VT: Energy/Fatigue; SF: Social Functioning ; RE: Role limitations due to emotional problems; MH: Emotional Well-being; RAND_2: Reported health transition item.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3 shows that the presence of anxiety at the beginning of the rehabilitation program influences the improvement in the Role limitations due to physical health, Pain and Emotional Well-being dimensions of HRQoL achieved after treatment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u0026nbsp;\u003c/strong\u003eANCOVA analysis between anxiety at the beginning and non-anxiety at the beginning groups related to HRQoL improvements.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"103%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTreatment group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean difference\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 19px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eObserved power\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 11px;\"\u003e\n \u003cp\u003eRAND_PF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e-1.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e7.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e.902\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 19px;\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eNon-anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e7.29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 11px;\"\u003e\n \u003cp\u003eRAND_RP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e12.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e42.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e.047\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 19px;\"\u003e\n \u003cp\u003e.028\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eNon-anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e17.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e44.77\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 11px;\"\u003e\n \u003cp\u003eRAND_BP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e-2.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e28.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e.035\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 19px;\"\u003e\n \u003cp\u003e.032\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eNon-anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e2.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e21.56\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 11px;\"\u003e\n \u003cp\u003eRAND_GH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e4.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e15.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e.466\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 19px;\"\u003e\n \u003cp\u003e.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eNon-anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e3.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e12.59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 11px;\"\u003e\n \u003cp\u003eRAND_VT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e6.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e16.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e.121\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 19px;\"\u003e\n \u003cp\u003e.017\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eNon-anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e5.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e13.96\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 11px;\"\u003e\n \u003cp\u003eRAND_SF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e11.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e24.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e.130\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 19px;\"\u003e\n \u003cp\u003e.016\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eNon-anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e3.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e20.29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 11px;\"\u003e\n \u003cp\u003eRAND_RE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e18.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e42.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e.109\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 19px;\"\u003e\n \u003cp\u003e.018\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eNon-anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e2.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e45.78\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 11px;\"\u003e\n \u003cp\u003eRAND_MH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e3.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e15.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e.004\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 19px;\"\u003e\n \u003cp\u003e.059\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eNon-anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e1.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e12.49\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 11px;\"\u003e\n \u003cp\u003eRAND_2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e26.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e28.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e.459\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 19px;\"\u003e\n \u003cp\u003e.004\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eNon-anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e24.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e31.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSD: Standard Deviation; RAND: RAND 36-Item Health Survey; PF: Physical Functioning; RP: Role limitations due to physical health; BP: Pain; GH: General Health ; VT: Energy/Fatigue; SF: Social Functioning ; RE: Role limitations due to emotional problems; MH: Emotional Well-being; RAND_2: Reported health transition item.\u003c/p\u003e\n\u003cp\u003eTable 4 shows that the presence of depression at the beginning of the rehabilitation program influences the improvement in the Social Functioning and Emotional Well-being dimensions of HRQoL achieved after treatment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4.\u0026nbsp;\u003c/strong\u003eANCOVA analysis between depression at the beginning and non-depression at the beginning groups related to HRQoL improvements.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"103%\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 20px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTreatment group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean difference\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 17px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eObserved power\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 11px;\"\u003e\n \u003cp\u003eRAND_PF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eDepression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e-1.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e7.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 19px;\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eNon-depression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e7.49\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 11px;\"\u003e\n \u003cp\u003eRAND_RP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e21.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e39.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 19px;\"\u003e\n \u003cp\u003e.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eNon-anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e11.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e46.76\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 11px;\"\u003e\n \u003cp\u003eRAND_BP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e3.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e28.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 19px;\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eNon-anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e-1.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e20.81\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 11px;\"\u003e\n \u003cp\u003eRAND_GH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e5.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e15.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 19px;\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eNon-anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e2.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e12.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 11px;\"\u003e\n \u003cp\u003eRAND_VT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e8.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e17.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 19px;\"\u003e\n \u003cp\u003e.009\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eNon-anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e3.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e12.65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 11px;\"\u003e\n \u003cp\u003eRAND_SF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e7.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e26.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 19px;\"\u003e\n \u003cp\u003e.046\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eNon-anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e4.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e18.54\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 11px;\"\u003e\n \u003cp\u003eRAND_RE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e14.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e43.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 19px;\"\u003e\n \u003cp\u003e.025\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eNon-anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e3.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e46.77\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 11px;\"\u003e\n \u003cp\u003eRAND_MH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e3.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e15.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e.02\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 19px;\"\u003e\n \u003cp\u003e.036\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eNon-anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e1.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e11.73\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 11px;\"\u003e\n \u003cp\u003eRAND_2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e30.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e29.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 19px;\"\u003e\n \u003cp\u003e.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003eNon-anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e20.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e29.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSD: Standard Deviation; RAND: RAND 36-Item Health Survey; PF: Physical Functioning; RP: Role limitations due to physical health; BP: Pain; GH: General Health ; VT: Energy/Fatigue; SF: Social Functioning ; RE: Role limitations due to emotional problems; MH: Emotional Well-being; RAND_2: Reported health transition item.\u003c/p\u003e"},{"header":"4.\tDiscussion","content":"\u003cp\u003eThe results demonstrate that the objectives of this study were achieved, as the participating patients with cardiac pathology experienced significant improvements in anxiety, depression, and HRQoL after completing a CRP focused on physical exercise and the promotion of healthy habits, thereby confirming the primary hypothesis. Furthermore, consistent with the secondary objective, the findings revealed that baseline levels of anxiety and/or depression significantly influenced the magnitude of improvement in specific HRQoL dimensions, such as emotional well-being and social functioning. These results support the secondary hypothesis, highlighting the importance of addressing psychological factors at the start of rehabilitation to optimize outcomes.\u003c/p\u003e\n\u003cp\u003eThe relationship between anxiety and cardiovascular health has garnered increasing attention in recent research. Anxiety disorders are prevalent among patients with coronary heart disease (CHD) and have been linked to poorer clinical outcomes, including increased mortality and new cardiac events (L. Wang et al. 2021). Consistent with this evidence, our study found that participation in a CRP significantly reduced anxiety levels among patients, highlighting the effectiveness of exercise-based rehabilitation programs in alleviating psychological distress. These findings align with a meta-analysis demonstrating that exercise therapy can significantly alleviate anxiety symptoms in cardiac patients (Bethge et al. 2023). Research highlights the role of anxiety in accelerating the development of cardiovascular disease risk factors as studies have shown that ongoing stress and anxiety can lead to the adoption of poor lifestyle behaviors, such as smoking and physical inactivity, which further compromise cardiovascular health (Abdul Manan et al. 2024). By addressing anxiety through structured interventions, including physical exercise and psychological support, CRPs not only improve psychological well-being, as demonstrated in our results, but may also enhance overall physical health outcomes. This underscores the importance of routinely assessing and addressing anxiety levels in cardiac rehabilitation settings, as done in this study using the Goldberg Anxiety and Depression Scale (GADS), which effectively identified changes in anxiety pre- and post-intervention. These results emphasize the need for a collaborative approach between healthcare professionals and patients to optimize both mental and cardiovascular health. The cumulative evidence suggests that addressing anxiety through structured interventions, including exercise therapy, not only improves psychological well-being but may also enhance overall physical health outcomes (Abdul Manan et al. 2024).\u003c/p\u003e\n\u003cp\u003eThe prevalence of depression among patients undergoing cardiac rehabilitation is significantly higher than that in the general population, with estimates ranging from 15% to 45% following acute cardiac events (Child et al. 2010). In a recent study, depressive tendencies were observed in 47.6% of patients at the 9-month evaluation, with 40.5% of participants exhibiting type D personality traits (Ibrahim et al. 2025). These comorbidities, including depression and anxiety, are known to exacerbate health outcomes and reduce quality of life. Consistent with this context, our findings highlight the importance of addressing psychological factors like depression in cardiac rehabilitation to optimize recovery and improve patients\u0026rsquo; overall well-being.\u003c/p\u003e\n\u003cp\u003eA comparison of baseline characteristics between patients with and without depressive tendencies revealed that 72.5% of those who were depressed at the 9-month mark had also shown depressive symptoms at baseline, compared to only 40.9% of the non-depressed group (p = 0.004) (Ibrahim et al. 2025). Similarly, our study found that baseline depression significantly influenced improvements in HRQoL dimensions, such as social functioning (RAND-SF: p = 0.01) and emotional well-being (RAND-MH: p = 0.02), underscoring the lasting impact of initial depressive symptoms on rehabilitation outcomes. Additionally, patients with depressive tendencies were more likely to utilize maladaptive coping strategies, such as \u0026quot;abandonment or resignation,\u0026quot; which is associated with a higher likelihood of ongoing depressive symptoms (p = 0.033) (Ibrahim et al. 2025). Conversely, those who engaged in adaptive coping strategies, like \u0026quot;planning\u0026quot; and \u0026quot;positive interpretation,\u0026quot; were less likely to exhibit depressive tendencies at follow-up (p = 0.007 and p = 0.018, respectively) (Ibrahim et al. 2025). These findings align with our results, emphasizing the need for psychological support within CRPs to foster adaptive coping strategies and optimize recovery trajectories, particularly for patients with high baseline depression.\u003c/p\u003e\n\u003cp\u003eThe efficacy of various treatment modalities in addressing depression among cardiac patients remains inconsistent. For instance, cognitive-behavioral therapy has shown short-term improvements in depressive symptoms and social support, yet these benefits were not sustained at 30 months post-intervention (Child et al. 2010). Similarly, studies have indicated that antidepressant treatments did not result in significant long-term improvements in depression or cardiac prognosis following myocardial infarction (Child et al. 2010).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResearch highlights a strong correlation between psychological health and cardiovascular disease risk. Chronic stress and negative mental states, such as anxiety and depression, are linked to the accelerated development of cardiovascular risk factors, which can lead to adverse health outcomes (Abdul Manan et al. 2024). In line with these findings, our study demonstrated significant reductions in anxiety and depression after the CRP, emphasizing the critical role of addressing psychological health in cardiac rehabilitation. These improvements align with the American Heart Association\u0026apos;s emphasis on the necessity for integrated approaches that target both psychological and physical well-being in cardiac care (Abdul Manan et al. 2024). Furthermore, our results highlight the importance of tailoring interventions to address baseline psychological conditions, as patients with higher initial levels of anxiety and depression showed differential improvements in HRQoL dimensions. Promoting awareness and proactive management of mental health, as evidenced by the outcomes in this study, is essential for enhancing the overall recovery and quality of life of cardiac patients.\u003c/p\u003e\n\u003cp\u003eThe impact of CRPs on HRQoL is significant, as these programs aim to enhance patients\u0026apos; overall well-being and functional capacity following cardiac events. The World Health Organization (WHO) defines quality of life as an individual\u0026apos;s perception of their situation within their cultural context and belief systems, emphasizing the multidimensional nature of this concept (Levine et al. 2021). HRQoL assessment is increasingly utilized in clinical settings to evaluate how patients perceive their health status and the limitations imposed by chronic diseases, particularly cardiovascular conditions (Levine et al. 2021).\u003c/p\u003e\n\u003cp\u003eVarious instruments are employed to measure HRQoL, including generic utility measures such as Quality-Adjusted Life Years (QALYs), which offer a single score reflecting the patient\u0026apos;s evaluation of their health (Levine et al. 2021). The EQ-5D-5L, recommended by the UK National Institute of Health and Care Excellence for economic evaluations, is one such tool used to estimate health benefits in clinical trials (McPhillips et al. 2021). The RAND 36-Item Health Survey (RAND-36) is a prominent tool for assessing HRQoL designed to be user-friendly and applicable across various health contexts, playing a crucial role in evaluating the impact of cardiovascular diseases on patients\u0026apos; quality of life (Garc\u0026iacute;a-S\u0026aacute;nchez et al. 2024; Orwelius et al. 2018). The inclusion of HRQoL as a variable in clinical trials is essential, as it serves not only to monitor treatment efficacy but also to predict patient responses to therapy and aid in future care planning (Levine et al. 2021).\u003c/p\u003e\n\u003cp\u003eEvidence suggests that participation in CRPs leads to substantial improvements in HRQoL among patients with heart disease. Consistent with this evidence, our study found significant improvements in multiple HRQoL dimensions after the CRP, such as role limitations due to physical health, social functioning, and emotional well-being. Additionally, previous research indicates that physical activity post-rehabilitation can reduce cardiovascular mortality by up to 35% and enhance functional capacity and quality of life (Levine et al. 2021). Furthermore, improvements in functional capacity and quality of life are often observed, with higher rates of return to work reported among those who undergo CRPs (Levine et al. 2021). Similarly, our results emphasize the importance of CRPs in addressing both physical and psychological dimensions of health, as improvements in HRQoL were accompanied by reductions in anxiety (mean difference = 0.93, p \u0026lt; .001) and depression (mean difference = 0.62, p \u0026lt; .001). For patients with advanced heart failure or severe cardiac conditions, these findings underscore the value of prioritizing quality of life as a key treatment outcome (Levine et al. 2021). By focusing on HRQoL, healthcare providers can gain insights into the patient\u0026apos;s subjective experience, which may include psychological aspects such as anxiety and depression that are commonly associated with cardiac conditions (Levine et al. 2021; Thomas 2024).\u003c/p\u003e\n\u003cp\u003eGenerally, research in this field faces several limitations that can affect the validity and generalizability of findings. Many studies report small sample sizes, resulting in reduced statistical power and fewer participants available for long-term follow-ups. Furthermore, disparities in gender representation can lead to biases in outcomes, particularly when studies primarily include male participants (Yamaguchi et al. 2025). The varying methodologies employed to measure psychological outcomes, such as different psychometric scales, introduce additional complexity in comparing results across studies. Additionally, inconsistencies in intervention durations and follow-up periods can attenuate observed effects, further complicating the analysis of CR interventions (de la Cuerda et al. 2012; Yamaguchi et al. 2025).\u003c/p\u003e\n\u003cp\u003eAnother significant challenge is the low adherence rates observed in cardiac rehabilitation programs. Factors contributing to treatment discontinuation may include patient motivation, interest levels, and the perceived relevance of psychological support methods, such as relaxation training and stress management techniques (Candelaria et al. 2024; de la Cuerda et al. 2012). The overall effectiveness of these interventions can be hindered by these adherence issues, which are commonly observed in clinical practice. Optimizing patient engagement through tailored approaches that address individual preferences may enhance the impact of psychological support within CR settings (de la Cuerda et al. 2012).\u003c/p\u003e\n\u003cp\u003eSocioeconomic disparities also pose a barrier to participation in CR programs. Despite the proven benefits of CR, only about 25% of eligible patients enroll, with even fewer completing the program. Participation disparities are notably influenced by factors such as sex, race, ethnicity, and geographic location (Beatty et al. 2023; Moreira et al. 2024). Future efforts must focus on addressing these barriers and exploring different payment models to enhance access to psychosocial services within CR programs. Improved financial support and resources are essential for comprehensive care and to ensure that all patients can benefit from CR interventions (Bush et al. 2023).\u003c/p\u003e\n\u003cp\u003eThis study has several limitations that should be acknowledged. The absence of a control group limits the ability to definitively attribute the observed improvements in anxiety, depression, and HRQoL solely to the cardiac rehabilitation program. This may inflate the perceived impact, and its magnitude, while difficult to quantify, could be relevant.\u003c/p\u003e\n\u003cp\u003eAdditionally, the predominantly male sample limits the generalizability of the findings to female patients, who are known to experience different psychological and physical responses to cardiac rehabilitation. Furthermore, the reliance on self-reported measures introduces response bias, where participants may overstate improvements due to social desirability or other subjective factors. While this bias is moderate, it highlights the need for complementary objective measures in future studies.\u003c/p\u003e\n\u003cp\u003eDespite these limitations, the study has notable strengths. It provides robust evidence of significant improvements in anxiety, depression, and HRQoL following participation in a iCRP, emphasizing the importance of integrating psychological support into rehabilitation protocols. The longitudinal design allowed for the assessment of changes over time, adding depth to the analysis. Moreover, the use of validated instruments ensures reliability and facilitates comparability with previous research.\u003c/p\u003e\n\u003cp\u003eFuture research should incorporate comparison groups that would allow for more robust causal inferences regarding the intervention\u0026apos;s effectiveness. Additionally, ensuring a more diverse sample, including a balanced representation of genders, would enhance the generalizability of the findings. Studies should also consider adjusting for potential confounders, such as age, comorbidities, and socioeconomic status, to better understand the factors influencing outcomes.\u0026nbsp;\u003c/p\u003e"},{"header":"5.\tConclusions","content":"\u003cp\u003eThis study demonstrates that CRPs based on physical exercise and the promotion of healthy habits significantly reduce anxiety and depression while improving HRQoL in patients with cardiovascular conditions. The findings underscore the importance of addressing psychological factors, such as baseline anxiety and depression, as they play a critical role in determining the extent of HRQoL improvements.\u003c/p\u003e\n\u003cp\u003eSpecifically, the presence of anxiety and depression at the start of the rehabilitation program was found to influence key HRQoL dimensions, including emotional well-being, social functioning, and role limitations. These results highlight the need for tailored and integrated interventions that simultaneously address physical and psychological aspects of recovery.\u003c/p\u003e\n\u003cp\u003eFuture research should explore strategies to enhance patient adherence and engagement in CRPs, as well as the long-term sustainability of psychological and HRQoL benefits.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding Declaration:\u0026nbsp;\u003c/strong\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate Declaration:\u003c/strong\u003e Informed consent was obtained from all subjects involved in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics Declaration:\u003c/strong\u003e The study was conducted in accordance with the Declaration of Helsinki, and approved by the Medicines Research Ethics Committee of the Burgos and Soria Health Area (Ref. CEIm 2569) for studies involving humans. \u0026nbsp;\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAbdul Manan, H., Mir, I. A., Humayra, S., Tee, R. Y., \u0026amp; Vasu, D. T. (2024). Effect of mindfulness-based interventions on anxiety, depression, and stress in patients with coronary artery disease: a systematic review and meta-analysis of randomized controlled trials. \u003cem\u003eFrontiers in Psychology\u003c/em\u003e, \u003cem\u003e15\u003c/em\u003e, 1435243.\u003c/li\u003e\n \u003cli\u003eAlem\u0026aacute;n, J. A., de Baranda Andujar, P. S., \u0026amp; Ort\u0026iacute;n, E. J. O. (2014). \u003cem\u003eGu\u0026iacute;a para la prescripci\u0026oacute;n de ejercicio f\u0026iacute;sico en pacientes con riesgo cardiovascular\u003c/em\u003e. Seh-Lelha.\u003c/li\u003e\n \u003cli\u003eBeatty, A. L., Beckie, T. M., Dodson, J., Goldstein, C. M., Hughes, J. W., Kraus, W. E., et al. (2023). 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(2018). 2018 ACC/AHA Clinical Performance and Quality Measures for Cardiac Rehabilitation. \u003cem\u003eJournal of the American College of Cardiology\u003c/em\u003e, \u003cem\u003e71\u003c/em\u003e(16), 1814\u0026ndash;1837. https://doi.org/10.1016/j.jacc.2018.01.004\u003c/li\u003e\n \u003cli\u003eKarvonen, J., \u0026amp; Vuorimaa, T. (1988). Heart rate and exercise intensity during sports activities: practical application. \u003cem\u003eSports medicine\u003c/em\u003e, \u003cem\u003e5\u003c/em\u003e, 303\u0026ndash;311.\u003c/li\u003e\n \u003cli\u003eLevine, G. N., Cohen, B. E., Commodore-Mensah, Y., Fleury, J., Huffman, J. C., Khalid, U., et al. (2021). Psychological Health, Well-Being, and the Mind-Heart-Body Connection A Scientific Statement From the American Heart Association. \u003cem\u003eCirculation\u003c/em\u003e, \u003cem\u003e143\u003c/em\u003e(10), E763\u0026ndash;E783. https://doi.org/10.1161/CIR.0000000000000947\u003c/li\u003e\n \u003cli\u003eMcHorney, C. A., Ware Johne, J. R., \u0026amp; ANASTASIAE, R. (1993). The MOS 36-Item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. \u003cem\u003eMedical care\u003c/em\u003e, \u003cem\u003e31\u003c/em\u003e(3), 247\u0026ndash;263.\u003c/li\u003e\n \u003cli\u003eMcPhillips, R., Capobianco, L., Cooper, B. G., Husain, Z., \u0026amp; Wells, A. (2021). Cardiac rehabilitation patients experiences and understanding of group metacognitive therapy: a qualitative study. \u003cem\u003eOpen Heart\u003c/em\u003e, \u003cem\u003e8\u003c/em\u003e(2), e001708.\u003c/li\u003e\n \u003cli\u003eMezzani, A., Hamm, L. F., Jones, A. M., McBride, P. E., Moholdt, T., Stone, J. A., et al. (2013). Aerobic exercise intensity assessment and prescription in cardiac rehabilitation: a joint position statement of the European Association for Cardiovascular Prevention and Rehabilitation, the American Association of Cardiovascular and Pulmonary Rehabilitation and the Canadian Association of Cardiac Rehabilitation. \u003cem\u003eEuropean journal of preventive cardiology\u003c/em\u003e, \u003cem\u003e20\u003c/em\u003e(3), 442\u0026ndash;467.\u003c/li\u003e\n \u003cli\u003eMj, K. (1957). The effects of training on heart rate: a longitudinal study.\u0026nbsp;\u003cem\u003eAnn med exp biol fenn\u003c/em\u003e, \u003cem\u003e35\u003c/em\u003e, 307\u0026ndash;315.\u003c/li\u003e\n \u003cli\u003eMont\u0026oacute;n Franco, C., P\u0026eacute;rez Echevarr\u0026iacute;a, M. J., Campos, R., Garc\u0026iacute;a Campayo, J., \u0026amp; Lobo, A. (1993). Escalas de ansiedad y depresi\u0026oacute;n de Goldberg: una gu\u0026iacute;a de entrevista eficaz para la detecci\u0026oacute;n del malestar ps\u0026iacute;quico.\u0026nbsp;\u003cem\u003eAtenci\u0026oacute;n primaria\u003c/em\u003e, \u003cem\u003e12\u003c/em\u003e(6), 345\u0026ndash;349.\u003c/li\u003e\n \u003cli\u003eMoreira, J., Bravo, J., Aguiar, P., Delgado, B., Raimundo, A., \u0026amp; Boto, P. (2024). Physical and Mental Components of Quality of Life after a Cardiac Rehabilitation intervention: a systematic review and Meta-analysis. \u003cem\u003eJournal of Clinical Medicine\u003c/em\u003e, \u003cem\u003e13\u003c/em\u003e(18), 5576.\u003c/li\u003e\n \u003cli\u003eOrwelius, L., Nilsson, M., Nilsson, E., Wenemark, M., Walfridsson, U., Lundstr\u0026ouml;m, M., et al. (2018). The Swedish RAND-36 Health Survey-reliability and responsiveness assessed in patient populations using Svensson\u0026rsquo;s method for paired ordinal data. \u003cem\u003eJournal of patient-reported outcomes\u003c/em\u003e, \u003cem\u003e2\u003c/em\u003e, 1\u0026ndash;10.\u003c/li\u003e\n \u003cli\u003ePatel, D. K., Duncan, M. S., Shah, A. S., Lindman, B. R., Greevy Jr, R. A., Savage, P. D., et al. (2019). Association of Cardiac Rehabilitation With Decreased Hospitalization and Mortality Risk After Cardiac Valve Surgery. \u003cem\u003eJAMA Cardiology\u003c/em\u003e, \u003cem\u003e4\u003c/em\u003e(12), 1250\u0026ndash;1259. https://doi.org/10.1001/jamacardio.2019.4032\u003c/li\u003e\n \u003cli\u003eSwain, D. P., \u0026amp; Franklin, B. A. (2006). Comparison of cardioprotective benefits of vigorous versus moderate intensity aerobic exercise. \u003cem\u003eThe American journal of cardiology\u003c/em\u003e, \u003cem\u003e97\u003c/em\u003e(1), 141\u0026ndash;147.\u003c/li\u003e\n \u003cli\u003eThomas, R. J. (2024). Cardiac Rehabilitation\u0026mdash;challenges, advances, and the Road ahead. \u003cem\u003eNew England Journal of Medicine\u003c/em\u003e, \u003cem\u003e390\u003c/em\u003e(9), 830\u0026ndash;841.\u003c/li\u003e\n \u003cli\u003eWang, C.-Y. (2017). Circadian rhythm, exercise, and heart.\u0026nbsp;\u003cem\u003eActa Cardiologica Sinica\u003c/em\u003e, \u003cem\u003e33\u003c/em\u003e(5), 539.\u003c/li\u003e\n \u003cli\u003eWang, L., Sun, Y., Zhan, J., Wu, Z., Zhang, P., Wen, X., et al. (2021). Effects of exercise therapy on anxiety and depression in patients with coronary heart disease: a meta-analysis of a randomized controlled study. \u003cem\u003eFrontiers in Cardiovascular Medicine\u003c/em\u003e, \u003cem\u003e8\u003c/em\u003e, 730155.\u003c/li\u003e\n \u003cli\u003eWells, A., McNicol, K., Reeves, D., Salmon, P., Davies, L., Heagerty, A., et al. (2018). Improving the effectiveness of psychological interventions for depression and anxiety in the cardiac rehabilitation pathway using group-based metacognitive therapy (PATHWAY Group MCT): study protocol for a randomised controlled trial. \u003cem\u003eTrials\u003c/em\u003e, \u003cem\u003e19\u003c/em\u003e, 1\u0026ndash;12.\u003c/li\u003e\n \u003cli\u003eYamaguchi, D., Asano, Y., Kuwahara, K., \u0026amp; Izawa, A. (2025). Coping strategies and changes in type D personality were associated with depressive tendency at 9 months after percutaneous coronary intervention.\u0026nbsp;\u003cem\u003ePloS one\u003c/em\u003e, \u003cem\u003e20\u003c/em\u003e(1), e0316639.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"the-egyptian-heart-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tehj","sideBox":"Learn more about [The Egyptian Heart Journal](https://tehj.springeropen.com)","snPcode":"43044","submissionUrl":"https://submission.springernature.com/new-submission/43044/3","title":"The Egyptian Heart Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cardiac Rehabilitation, Physical exercise, Healthy habits, Anxiety, Depression, Quality of life, Cardiovascular disease","lastPublishedDoi":"10.21203/rs.3.rs-6261651/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6261651/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction:\u003c/strong\u003e The study aimed to evaluate the effects of a cardiac rehabilitation program based on physical exercise and the promotion of healthy habits on anxiety, depression, and health-related quality of life in patients with cardiovascular conditions. Additionally, it sought to analyze the influence of baseline anxiety and depression levels on post-treatment health-related quality of life outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A longitudinal study was conducted with 189 patients who completed a structured cardiac rehabilitation program. Anxiety and depression were assessed using the Goldberg Anxiety and Depression Scale, while health-related quality of life was measured with the RAND-36 survey. Data were collected pre- and post-intervention. Statistical analyses included paired t-tests for pre-post comparisons and ANCOVA to evaluate the impact of initial anxiety and depression on health-related quality of life improvements.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The cardiac rehabilitation program significantly reduced anxiety (mean difference = 0.93, p \u0026lt; .001) and depression (mean difference = 0.62, p \u0026lt; .001), with improvements observed across several health-related quality of life dimensions, including emotional well-being (p = .005) and energy/fatigue (p \u0026lt; .001). Baseline anxiety and depression levels influenced changes in specific health-related quality of life dimensions, such as social functioning and role limitations due to physical health (p \u0026lt; .05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion:\u003c/strong\u003e The findings demonstrate the effectiveness of cardiac rehabilitation programs in reducing anxiety and depression and improving health-related quality of life in patients with cardiovascular conditions. Baseline psychological status plays a key role in determining the magnitude of health-related quality of life improvements, highlighting the need for tailored interventions.\u003c/p\u003e","manuscriptTitle":"Cardiac Rehabilitation Program effect on anxiety, depression and quality of life.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-06 13:59:22","doi":"10.21203/rs.3.rs-6261651/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-24T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-23T23:56:37+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-22T22:33:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-21T21:02:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-10T13:40:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-08T22:23:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-08T15:18:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"288937521127144914798463300555529865840","date":"2025-04-08T14:55:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"98524069317541260751016337765384292248","date":"2025-04-08T03:04:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"173626587072725860161478336263302367196","date":"2025-04-06T15:16:03+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-05T18:03:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"88040126107460569319295370353766407221","date":"2025-04-05T15:27:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"103008673829417984867929872040325342879","date":"2025-04-05T13:27:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"113437842736486461990926012280574330522","date":"2025-04-04T23:57:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"136931176386314038150695870995761888914","date":"2025-04-04T21:57:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-04T06:51:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"305024184985962859751837131056076488844","date":"2025-04-04T06:13:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"225961765032450651599936903210503193904","date":"2025-04-02T22:10:52+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-02T20:45:28+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-26T08:43:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-26T08:41:30+00:00","index":"","fulltext":""},{"type":"submitted","content":"The Egyptian Heart Journal","date":"2025-03-19T12:31:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"the-egyptian-heart-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"tehj","sideBox":"Learn more about [The Egyptian Heart Journal](https://tehj.springeropen.com)","snPcode":"43044","submissionUrl":"https://submission.springernature.com/new-submission/43044/3","title":"The Egyptian Heart Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e5cdeb52-1eb7-4765-87c2-231268d881ba","owner":[],"postedDate":"May 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-06-23T16:02:00+00:00","versionOfRecord":{"articleIdentity":"rs-6261651","link":"https://doi.org/10.1186/s43044-025-00658-8","journal":{"identity":"the-egyptian-heart-journal","isVorOnly":false,"title":"The Egyptian Heart Journal"},"publishedOn":"2025-06-20 15:57:41","publishedOnDateReadable":"June 20th, 2025"},"versionCreatedAt":"2025-05-06 13:59:22","video":"","vorDoi":"10.1186/s43044-025-00658-8","vorDoiUrl":"https://doi.org/10.1186/s43044-025-00658-8","workflowStages":[]},"version":"v1","identity":"rs-6261651","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6261651","identity":"rs-6261651","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}