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Published on in Vol 14 (2026)

Preprints (earlier versions) of this paper are available at https://preprints.jmir.org/preprint/95689, first published .
Woman practicing tai chi at home following an online fitness class on laptop.

Home-Based, Digitally Assisted Dyadic Tai Chi Intervention for Patients With Chronic Heart Failure and Their Caregivers: Development of an Intervention and Pilot Randomized Controlled Trial

Home-Based, Digitally Assisted Dyadic Tai Chi Intervention for Patients With Chronic Heart Failure and Their Caregivers: Development of an Intervention and Pilot Randomized Controlled Trial

Authors of this article:

Yan Zhang1, 2 Author Orcid Image ;   Fei Wan Ngai2 Author Orcid Image ;   Lihua Cao1 Author Orcid Image ;   Xiaohong Lu1 Author Orcid Image ;   Wenzhong Zhang1 Author Orcid Image ;   Lili Wei3 Author Orcid Image ;   Yao Jie Xie2, 4, 5 Author Orcid Image
Article Authors Cited by Tweetations Metrics

    Original Paper

    1Department of Cardiology, Affiliated Hospital of Qingdao University, Qingdao, Shandong, China

    2School of Nursing, Hong Kong Polytechnic University, Hong Kong, China

    3Office of the Dean, Affiliated Hospital of Qingdao University, Qingdao, Shandong, China

    4Research Centre for Chinese Medicine Innovation, Hong Kong Polytechnic University, Hong Kong, China

    5Joint Research Centre for Primary Health Care, Hong Kong Polytechnic University, Hong Kong, China

    Corresponding Author:

    Yao Jie Xie, PhD

    School of Nursing

    Hong Kong Polytechnic University

    No. 11 Yuk Choi Road, Hung Hom, Kowloon

    Hong Kong

    China

    Phone: 852 34003798

    Email: grace.yj.xie@polyu.edu.hk


    Background: Chronic heart failure (CHF) imposes a dual and dynamically interrelated burden on patients and family caregivers, whose health and illness management behaviors are interdependent. Exercise interventions that actively engage the patient-caregiver dyad as the unit of rehabilitation in the home setting remain underdeveloped.

    Objective: This study aimed to develop a home-based, digitally assisted, dyadic tai chi (HDTC) intervention and evaluate its feasibility, acceptability, safety, and preliminary effects among dyads of patients with CHF and their caregivers.

    Methods: This sequential, multiphase study comprised intervention development followed by a single-center, assessor-blinded, parallel-group pilot randomized controlled trial. Phase 1 integrated literature review, theoretical frameworks, and stakeholder focus group interviews to develop and refine the HDTC intervention. In phase 2, eligible adults with CHF (aged 18-75 years; New York Heart Association class I-III) and their primary caregivers were recruited from a tertiary medical center in Qingdao, China, from October 14 to November 12, 2024, and followed for 12 weeks. Forty dyads were allocated 1:1 to the 12-week HDTC intervention plus usual care or usual care alone (n=20 per group). Outcome assessors and the data analyst were blinded to group allocation. Feasibility, acceptability, and safety were the primary focus of the pilot trial. Patient, caregiver, and dyadic health outcomes were preliminarily explored at baseline and 4 and 12 weeks. All 40 randomized dyads were included in the intention-to-treat analyses.

    Results: The HDTC intervention comprised an online educational seminar, nurse-led dyadic coaching, preliminary face-to-face tai chi training, and supervised HDTC practice. The recruitment rate was 83.3% (40/48), mean session attendance was 73.7% (SD 8.6%), and 70% (14/20) of participants achieved high adherence rate (≥75% attendance). All intervention dyads rated the intervention as acceptable. No intervention-related adverse events were identified. Exploratory generalized estimating equation analyses suggested greater improvements from baseline to 12 weeks in the intervention group than in the control group in functional capacity (β=38.858; P=.001), together with greater reductions in Minnesota Living With Heart Failure Questionnaire scores (β=−1.850; P=.002), sedentary time (β=−1.025; P=.01), and fear of activity (β=−6.550; P=.01). Caregiver burden also decreased (β=−4.350; P<.001), while mutuality improved more for both patients (β=10.508; P<.001) and caregivers (β=6.450; P<.001).

    Conclusions: The HDTC intervention was feasible and acceptable, with preliminary improvements across patient, caregiver, and dyadic outcomes. By integrating shared patient-caregiver participation with digitally supported home-based tai chi, the HDTC intervention extends patient-centered rehabilitation toward a dyad-oriented model. If confirmed in a fully powered trial, this approach may offer a practical strategy for expanding home-based cardiac rehabilitation.

    Trial Registration: ClinicalTrials.gov NCT06876441; https://clinicaltrials.gov/study/NCT06876441

    JMIR Mhealth Uhealth 2026;14:e95689

    doi:10.2196/95689

    Keywords

    heart failure; caregivers; home-based rehabilitation; tai chi; dyadic intervention 


    Heart failure (HF) remains a prevalent and burdensome chronic condition worldwide [1,2]. Patients with HF commonly exhibit high levels of sedentary behavior, which are associated with increased risks of hospitalization and mortality [3]. Although exercise-based cardiac rehabilitation is recommended to improve functional outcomes and prognosis [4], participation in center-based programs remains low because of travel, scheduling, and service capacity barriers [5]. Digitally supported home-based exercise rehabilitation offers a potential alternative, although evidence regarding its safety, feasibility, and effects in HF remains limited [6].

    Within the home setting, exercise is embedded in the family context, with caregivers often providing encouragement, safety monitoring, scheduling support, and reinforcement of continued participation [7]. Meanwhile, caregivers experience substantial caregiving burden that can adversely affect their own physical and psychological health [8,9], which may in turn influence patient outcomes [10]. This reciprocal influence supports conceptualizing the patient-caregiver dyad, rather than the patient alone, as a target of intervention [11,12]. However, dyadic intervention research in HF remains limited [13], and existing interventions have focused primarily on self-care and psychosocial support, with relatively little attention to structured exercise jointly undertaken by patients and caregivers [14,15].

    Dyadic exercise extends conventional patient-centered rehabilitation by engaging both members of the dyad in a shared health behavior [16]. Consistent with the theory of dyadic illness management, which emphasizes reciprocal influences within the dyad [17], this approach moves beyond targeting patient behavior alone. It also differs from caregiver-supported self-care, in which caregivers primarily facilitate patient disease management; shared exercise actively involves both members and may benefit both while strengthening mutual support and dyadic relationship quality [11].

    Tai chi, a moderate-intensity aerobic exercise, is recommended as an adjunctive therapy in international HF management guidelines [18,19]. Prior studies suggest that it may enhance exercise capacity, psychological well-being, and quality of life (QoL) in patients with chronic HF (CHF) [20,21], but practical barriers, including travel demands, time constraints, self-discipline challenges, and limited access to qualified masters, hinder patients’ access to center-based practice [22], underscoring the need for home-based, digitally assisted tai chi. Previous evidence has revealed that digitally assisted tai chi, in which all components are delivered through an online platform without face-to-face instruction, is feasible and effective among other frail populations [23]. To date, however, the integration of tai chi into dyadic management models remains largely unexplored.

    To address these gaps, this study aimed to systematically develop a home-based, digitally assisted, dyadic tai chi (HDTC) intervention for patients with CHF and their family caregivers. Then, a pilot randomized controlled trial (RCT) was conducted to evaluate its feasibility, acceptability, and safety and explore preliminary effects on patient, caregiver, and dyadic outcomes.


    Study Design and Setting

    This sequential multimethod study guided by the Medical Research Council framework comprised 2 stepwise phases [24]. Phase 1 developed the HDTC intervention for dyads through (1) iterative evidence synthesis (literature review, systematic review of digitally assisted interventions, and scoping review of caregiver roles), (2) application of theoretical frameworks to inform a stage transition model for sustained dyadic exercise, and (3) focus group interviews with key stakeholders (physicians, nurses, patients with CHF, caregivers, and tai chi master) to refine the digital implementation of the intervention. Phase 2 was a prospective, 2-arm pilot RCT conducted at a tertiary medical center in Qingdao, China, evaluating the feasibility, acceptability, and preliminary effects of the HDTC intervention. This pilot RCT was reported in accordance with the CONSORT (Consolidated Standards of Reporting Trials) 2010 extension for randomized pilot and feasibility trials [25] (Multimedia Appendix 1).

    Phase 1: Development of the HDTC Intervention

    The intervention was developed through 3 sequential steps. First, an iterative evidence synthesis via literature review identified key components informing the HDTC intervention protocol: sedentary behavior, digital health interventions, home-based tai chi, dyadic tai chi, and caregiver roles. Second, 2 theoretical frameworks guided the transition from sedentary behavior to sustained tai chi exercise: the information-motivation–behavioral skills model and theory of dyadic illness management. The information-motivation–behavioral skills model was used primarily to structure the initial transition from sedentary behavior to exercise participation (tai chi motivation stage) [26,27]. The educational seminar addressed exercise-related information, the dyadic coaching session explored motivation and shared goals, and introductory tai chi training was used to develop the behavioral skills required for safe home practice. The theory of dyadic illness management informed the subsequent maintenance phase (tai chi maintenance stage) [17]. In this phase, patients and caregivers were encouraged to view exercise as a shared rehabilitation task, coordinate participation and support, monitor progress, and address exercise-related challenges collaboratively. Digital communication, shared reminders, and professional feedback were incorporated to support continued dyadic engagement. Third, focus group interviews were conducted with key stakeholders, comprising 2 dyads (2 patients and their respective caregivers), 2 cardiologists and 2 nurses with more than 5 years of experience in HF management, and 1 tai chi master with 11 years of teaching experience from the Yang Style Tai Chi Association. The interview guide was designed based on the nonadoption, abandonment, scale-up, spread, and sustainability framework (Multimedia Appendix 2) to enhance the practicality and adaptability of the digital intervention [28]. The intervention was subsequently refined based on stakeholder feedback. The flow diagram of the intervention development is shown in Figure 1.

    ‎
    Figure 1. The home-based, digital-assisted, dyadic tai chi (HDTC) was systematically developed through 3 steps: literature review, theory-guided intervention design, and stakeholder consultation. CHF: chronic heart failure; HF: heart failure; RCT: randomized controlled trial.

    Phase 2: Pilot-Testing of the HDTC Intervention

    Participants and Sample Size

    A convenience sample of 40 dyads of patients with CHF and their caregivers was recruited from the Affiliated Hospital of Qingdao University. The inclusion criteria for patients with CHF were (1) age of 18 to 75 years with a diagnosis of CHF [29]; (2) New York Heart Association class I, II, or III and 6-minute walk test distance of more than 150 m [29]; (3) ability to perform the prescribed tai chi movements without physical assistance, as assessed during pre-enrollment screening; (4) smartphone ownership; and (5) voluntary participation and informed consent. Exclusion criteria were as follows: planned surgery within 6 months; severe comorbidities such as cancer, liver or kidney failure, and diagnosed psychiatric disorders; planned relocation to care facilities; regular exercise in the prior 3 months; or concurrent trial participation. Caregiver inclusion criteria were age of 18 years or older, being primary caregivers for patients with CHF [30], ability to practice tai chi without help, and voluntary participation and informed consent.

    On the basis of pilot trial recommendations, at least 15 participants per group were required to detect a medium effect size assuming a 90% power with a 2-sided 5% significance level [31]. Accounting for 20% attrition, 18 dyads per group were targeted.

    Recruitment of Dyads of Patients With CHF and Their Caregivers

    Potential patients with CHF were recruited through electronic advertisements with QR codes displayed in the HF clinic and cardiology department and via electronic questionnaires disseminated to 30 WeChat groups of discharged patients. After initial prescreening, eligible patients underwent a comprehensive assessment followed by screening of their caregivers. Informed consent was obtained from all dyads prior to enrollment.

    Randomization, Allocation Concealment, and Blinding

    Randomization was performed by an independent individual using the Sealed Envelope online tool [32]. Allocation used a 1:1 ratio with stratification by New York Heart Association class (I, II, and III) and block sizes of 4 and 6. Allocation concealment was ensured through sequentially numbered, opaque, sealed envelopes opened only after baseline assessments. Owing to the nature of the behavioral intervention, blinding of intervention providers and participants was not feasible [33]; only outcome assessors and the data analyst were blinded to group allocation.

    Interventions
    HDTC Intervention

    Dyads in the intervention group participated in the HDTC intervention plus usual care. The intervention was delivered over 12 weeks, consistent with the duration commonly used in previous tai chi studies among patients with CHF [16]. The contents of the intervention are detailed in the Results section.

    Control Group

    Dyads in the control group received usual care, including online comprehensive education and nurse-led telephone consultations. Consultations addressed symptom management, medication adherence, dietary and exercise suggestions, psychosocial support, and regular follow-ups. Caregivers served as both partners and facilitators, assisting patients with CHF in implementing these recommendations.

    Intervention Fidelity

    The Behavior Change Consortium framework was adopted to guide fidelity assurance [34]. First, the initial HDTC protocol was developed through a rigorous 3-stage process to ensure design integrity. Second, a tai chi master received standardized training from a cardiac rehabilitation nurse on intervention delivery, safety protocols, and participant characteristics, with ongoing researcher supervision throughout all sessions to maintain protocol adherence. Third, all tai chi sessions were delivered by a single master from the Qingdao Yang Style Tai Chi Association with 11 years of teaching experience. The master was scheduled to deliver all sessions throughout the 12-week intervention to ensure consistency in intervention delivery. If the master was unavailable, the affected session was rescheduled to maintain continuity of the intervention. Upon completion of the tai chi form learning, the master assessed participants’ skill mastery. Additionally, all online classes were recorded, with an independent expert conducting a random audit of 20% of recorded classes to evaluate intervention fidelity.

    Outcomes

    Assessments were conducted at baseline (T0) and 4 weeks (T1), and 12 weeks (T2) of the intervention to evaluate the feasibility, acceptability, and preliminary effects of the HDTC intervention.

    Feasibility

    Feasibility was assessed through the recruitment period, recruitment rate, attendance rate, adherence rate, and attrition rate. Adherence was calculated as the proportion of completed tai chi classes to total prescribed classes, with high adherence defined as attendance to at least 75% of classes, consistent with previous studies [35].

    Acceptability

    Acceptability was assessed after the intervention using separate patient and caregiver questionnaires based on the theoretical framework of acceptability, covering affective attitude, burden, ethicality, perceived effectiveness, intervention coherence, self-efficacy, opportunity costs, and overall acceptability [36]. Each domain was rated using domain-specific ordered response options. Responses were dichotomized as favorable or unfavorable according to the positive response categories for each domain; for overall acceptability, “acceptable” and “completely acceptable” were classified as favorable. The intervention was considered acceptable if 80% or more of the participants provided a favorable overall rating [37].

    Adverse Events

    Consistent with the CONSORT Harms statement [38], adverse events were defined as any possible adverse consequences attributable to the intervention. Potential adverse events, including dyspnea, palpitations, chest pain, arrhythmia, myocardial infarction, falls, and other unexpected symptoms, were recorded by a nurse and subsequently assessed by a physician to determine their relationship to the intervention.

    Preliminary Effects

    Outcomes of Patients With CHF

    The functional capacity of patients with CHF was assessed using the 6-minute walk test through the Walker Doctor Intelligent 6-Minute Walk Test Monitoring and Analysis System [39,40]. Sedentary behavior and fear of activity were evaluated using the International Physical Activity Questionnaire–Short Form [41] and Fear of Activity in Patients With Chronic Heart Failure [42], respectively. Confidence in exercising was assessed using the Self-Efficacy for Exercise Scale [43]. The Minnesota Living With Heart Failure Questionnaire was used to measure patients’ health-related QoL [44].

    Outcomes of Caregivers

    The Chinese version of the Zarit Caregiver Burden Interview was used to measure caregivers’ perceived caring burden [45], and their QoL was assessed using the Chinese Family Caregiver Quality of Life Scale [46].

    Outcomes of Dyads

    Mutuality, the relationship between patients with CHF and their caregivers, was measured using the Chinese Mutuality Scale [47], with higher scores denoting better mutuality.

    Data Analysis

    Statistical analyses were performed using SPSS Statistics (version 26; IBM Corp). Descriptive statistics summarized participant characteristics and assessed feasibility and acceptability outcomes. Normality was evaluated using the Shapiro-Wilk test. Preliminary effects were examined using 2-tailed paired t tests or Wilcoxon signed-rank tests for within-group comparisons and independent t tests or Mann-Whitney U tests for between-group comparisons. Generalized estimating equation models with an independence working correlation structure and robust SEs were used to assess between-group differences across multiple time points. Missing data were assessed using the Little missing completely at random (MCAR) test to evaluate the missingness pattern. All analyses followed the intention-to-treat principle. Effect sizes were calculated using the Cohen d (small effect size: d≤0.2; medium effect size: d≤0.5; large effect size: d≥0.8) [48].

    Ethical Considerations

    This study was approved by the ethics committees of Hong Kong Polytechnic University (HSEARS20240904005) and the Affiliated Hospital of Qingdao University (QYFYWZLL29400). Written informed consent was obtained from all participating patients and caregivers before enrollment. To protect participants’ privacy and confidentiality, study data were deidentified and stored securely, with access restricted to authorized research personnel. Participants received no financial compensation for taking part in the study. No identifiable images of participants are included in the manuscript or supplementary materials.


    HDTC Intervention Protocol

    Intervention Components and Delivery

    The HDTC intervention was informed by multiple sources: a systematic review on digital health interventions for sedentary behavior [49], a scoping review of caregiver roles and engagement levels [50], and focus group interviews with stakeholders (Multimedia Appendix 3). The final intervention comprised 4 components delivered in a structured sequence: an online educational seminar and a nurse-led online dyadic coaching session in week 1, an introductory face-to-face training session of 24-form Yang-style tai chi in week 2, and nurse-supervised HDTC classes (Figure 2). The tai chi sessions were delivered by a master from the Qingdao Yang Style Tai Chi Association with 11 years of teaching experience. During weeks 2 to 4, dyads attended live online tai chi classes, with the frequency and duration progressively increasing from two 30-minute sessions to three 50-minute sessions per week. During weeks 5 to 12, dyads participated in 2 master-led online sessions and 1 video-guided group practice session each week, with each session lasting 50 minutes. During supervised online sessions, a cardiac nurse monitored participants’ exercise-related symptoms and heart rate and provided safety guidance as needed.

    ‎
    Figure 2. Protocol for the home-based, digital-assisted, dyadic tai chi intervention. The intervention comprised 4 components delivered across 2 stages: the motivation stage and the maintenance stage. Digital support included real-time heart rate monitoring, instructional videos, live online classes, WeChat-based support, and goal tracking. CHF: chronic heart failure; SB: sedentary behavior.
    Digitally Assisted Features

    The HDTC intervention was supported by a multifunctional digital infrastructure. Synchronous live video sessions and an on-demand video library delivered structured, progressive tai chi instruction. Real-time heart rate monitoring enhanced safety by enabling continuous oversight of patients during home-based practice. Asynchronous communication via WeChat offered ongoing access to nursing support and peer interaction, thereby reinforcing adherence. Meanwhile, digital goal-tracking features, such as shared progress updates and reminders in the online community via WeChat group, fostered shared accountability and motivation within the dyad. Together, these digitally enabled components created a supportive and interactive remote environment that effectively extends clinical supervision into the home and enhances both engagement and safety.

    Feasibility, Acceptability, and Effects of the Intervention

    Baseline Characteristics of the Dyads

    The dyads were recruited from a tertiary medical center in Qingdao, China, from October 14 to November 12, 2024. A total of 85 patients (62 online; 23 in person) were referred to this study. During initial screening, 37 patients were excluded. Of the 48 eligible dyads, 8 declined participation due to scheduling conflicts (caregivers: n=4; patients with CHF: n=2) or lack of interest (n=2). The remaining 40 dyads were randomly assigned to the intervention or control group. All dyads completed the 4-week assessment. However, 3 dyads (1 in the intervention group and 2 in the control group) did not complete the 12-week follow-up because of perceived recovery, lack of interest, or returning to work (Figure 3) [51]. No item-level missing data were identified among completed questionnaires. The Little MCAR test was not statistically significant (χ216=13.1; P=.66), providing no evidence against the MCAR assumption. Baseline characteristics of dyads were comparable between groups (Table 1).

    ‎
    Figure 3. CONSORT (Consolidated Standards of Reporting Trials) 2025 flow diagram of recruitment, randomization, follow-up, and analysis in the pilot randomized controlled trial [51]. GEE: generalized estimating equations; HDTC: home-based, digital-assisted, dyadic tai chi.
    Table 1. Baseline characteristics of patients with chronic heart failure (CHF) and caregivers (N=40).
    CharacteristicsTotalIGa (n=20)CGb (n=20)χ2/t testP value
    Patients with CHF

    		Age (y), mean (SD)61.43 (8.55)60.65 (9.71)62.20 (7.39)0.568c.57

    		Sex,n (%)1.129d.29


    		Male29 (72.5)13 (65)16 (80)



    		Female11 (27.5)7 (35)4 (20)


    		Educational level,n (%)0.128d.94


    		Elementary school2 (5)1 (5)1 (5)



    		Secondary school27 (67.5)13 (65)14 (70)



    		College or higher11 (27.5)6 (30)5 (25)


    		Family monthly income (CN¥; CN¥ 1=US $0.15 as of October 16, 2026), n (%)2.349d.50


    		<300015 (37.5)8 (40)7 (35)



    		3000-500018 (45)7 (35)11 (55)



    		5000-10,0004 (10)3 (15)1 (5)



    		>10,0003 (7.5)2 (10)1 (5)


    		Time since diagnosis(mo), n (%)1.933d.38


    		≤628 (70)12 (60)16 (80)



    		6-123 (7.5)2 (10)1 (5)



    		>129 (22.5)6 (30)3 (15)


    		NYHAe class, n (%)1.010d.60


    		I12 (30)7 (35)5 (25)



    		II13 (32.5)7 (35)6 (30)



    		III15 (37.5)6 (30)9 (45)


    		Etiology of HFf, n (%)2.371g.67


    		Coronary artery disease30 (75)14 (70)16 (80)



    		Cardiomyopathies2 (5)1 (5)1 (5)



    		Hypertension21 (52.5)8 (40)13 (65)



    		Valvular heart disease6 (15)4 (20)2 (10)



    		Arrhythmias7 (17.5)2 (10)5 (25)


    		Comorbidity types, n (%)<0.001d>.99


    		04 (10)2 (10)2 (10)



    		1-216 (40)8 (40)8 (40)



    		≥320 (50)10 (50)10 (50)

    Caregivers

    		Age (y), mean (SD)54.80 (10.25)54.15 (9.99)55.45 (10.71)0.397c.69

    		Sex,n (%)<0.001d>.99


    		Male12 (30)6 (30)6 (30)



    		Female28 (70)14 (70)14 (70)


    		Educational level,n (%)0.451g.80


    		Elementary school3 (7.5)1 (5)2 (10)



    		Secondary school28 (70)14 (70)14 (70)



    		College or higher9 (22.5)5 (25)4 (20)


    		Caregiver type, n (%)3.584d.06


    		Spouse31 (77.5)18 (90)13 (65)



    		Child9 (22.5)2 (10)7 (35)


    		Caring h per d, mean (SD)3.18 (1.89)3.20 (1.51)3.15 (2.25)−0.082c.94

    aIG: intervention group.

    bCG: control group.

    cIndependent t test.

    dPearson chi-square test.

    eNYHA: New York Heart Association.

    fHF: heart failure.

    gLikelihood ratio.

    Feasibility Outcomes

    Of the 85 patients referred for screening (average recruitment rate: 2.8 dyads per day; n=85, 100% response rate), 48 were eligible, and 40 dyads were enrolled and randomized, corresponding to a recruitment rate of 83.3% (40/48). Among interested patients (n=85), primary motivators for participation were perceived benefits (68/85, 80%), convenience of home-based delivery (47/85, 55.3%), and insufficient postdiagnosis exercise knowledge (38/85, 44.7%; Table S1 in Multimedia Appendix 4). Retention rates were 100% (40/40) at 4 weeks and 92.5% (37/40) at 12 weeks. Mean attendance to online tai chi classes was 80.6% (SD 14.9%) at 4 weeks and 73.7% (SD 8.6%) at 12 weeks, with 70% (14/20) of participants demonstrating high adherence (≥75% attendance).

    Acceptability Outcomes

    The detailed responses from the dyadic perspective were shown in Table S2 in Multimedia Appendix 4. Notably, dyads reported positive appraisals of the HDTC intervention. Overall, 100% (20/20) of dyads rated the intervention as acceptable, with 60% (12/20) deeming it completely acceptable.

    Safety of the Intervention

    During each tai chi class, the dyads’ physiological responses were closely monitored and documented by a cardiology nurse. Classes began with warm-up exercises and concluded with cooldown stretches to minimize musculoskeletal injury risk. No intervention-related adverse events were reported during the 12-week intervention, suggesting that it was well tolerated in this pilot sample.

    Preliminary Effects of the HDTC Intervention
    Effects of the HDTC Intervention for Patients With CHF

    Compared to the control group, patients with CHF in the intervention group exhibited significant improvement in 6-minute walk test distance at both 4 weeks (β=12.300, 95% CI 8.733-15.867; P<.001) and 12 weeks (β=38.858, 95% CI 15.691-62.025; P=.001; Table S3 and Figure S1 in Multimedia Appendix 4). Significant reductions were observed in sedentary time (T1: β=−0.975, 95% CI −1.338 to −0.612; P<.001; T2: β=−1.025, 95% CI −1.617 to −0.433; P=.01), fear of activity (T1: β=−2.050, 95% CI −3.865 to −0.235; P=.03; T2: β=−6.550, 95% CI −11.548 to −1.552; P=.01), and Minnesota Living With Heart Failure Questionnaire scores (T2: β=−1.850, 95% CI −3.045 to −0.655; P=.002). Effect sizes for these outcomes ranged from moderate to large (Table 2).

    Table 2. Patient, caregiver, and dyadic outcome comparisons at baseline (T0), 4 weeks (T1), and 12 weeks (T2; N=40).
    Outcomes and time pointsIGa (n=20), mean (SD)CGb (n=20), mean (SD)Effect size, Cohen dt test (df)P value
    Patients with CHFc

    		6MWTd (m)


    		T0415.35 (94.18)413.70 (81.76)—e−0.059 (38).95


    		T1435.95 (93.38)422.00 (79.80)0.16−0.508 (38).62


    		T2474.16 (75.52)433.65 (74.50)0.54−1.719 (38).09

    		Exercise self-efficacy(0-90)


    		T041.50 (12.34)39.95 (13.28)—−0.383 (38).70


    		T145.00 (10.88)40.75 (12.13)0.37−1.167 (38).25


    		T249.45 (10.27)41.05 (11.61)0.77−2.423 (38).02

    		Sedentary time (h)


    		T09.30 (1.67)9.40 (1.25)—0.215 (38).83


    		T18.28 (1.37)9.35 (1.13)0.852.710 (38).01


    		T27.58 (0.80)8.70 (1.07)1.183.770 (38).001

    		Fear of activity(0-60)


    		T032.35 (7.85)32.80 (7.90)—0.181 (38).86


    		T127.30 (7.80)29.80 (9.06)0.300.935 (38).36


    		T222.50 (8.31)29.50 (9.74)0.772.370 (38).02

    		MLHFQf (0-105)


    		T059.05 (9.59)60.05 (12.14)—0.289 (38).77


    		T150.85 (10.51)56.80 (11.98)0.531.670 (38).10


    		T240.70 (10.76)53.05 (11.99)1.083.428 (38).001

    		Mutuality(0-60)


    		T037.45 (5.87)37.05 (8.24)—−0.177 (38).86


    		T143.05 (9.45)36.95 (7.70)0.71−2.239 (38).03


    		T248.16 (8.90)37.25 (7.59)1.32−4.124 (38)<.001
    Caregivers

    		Care burden(0-88)


    		T026.35 (7.76)26.10 (7.69)—0.102 (38).92


    		T124.25 (7.22)25.75 (7.89)0.20−0.627 (38).54


    		T222.60 (6.27)26.70 (6.45)0.64−2.039 (38).048

    		Personal burden(0-48)


    		T09.50 (3.58)9.95 (3.14)—−0.423 (38).68


    		T18.90 (3.11)9.70 (3.37)0.25−0.780 (38).44


    		T28.25 (2.40)9.90 (2.79)0.63−2.004 (38).05

    		Role burden(0-36)


    		T016.85 (5.20)16.15 (5.39)—0.418 (38).68


    		T115.35 (5.01)16.05 (5.34)0.14−0.428 (38).67


    		T214.35 (4.51)16.80 (5.00)0.51−1.627 (38).11

    		Quality of life(16-80)


    		T049.75 (6.08)47.60 (4.56)—−1.266 (38).21


    		T152.50 (5.52)49.55 (3.25)0.60−2.059 (38).048


    		T252.55 (5.03)49.10 (3.13)0.82−2.605 (38).01

    		Mutuality(0-60)


    		T037.75 (10.28)37.40 (10.28)—−0.109 (38).91


    		T142.50 (12.01)38.30 (9.14)0.39−1.245 (38).22


    		T244.95 (12.43)38.20 (7.35)0.66−2.090 (38).04

    aIG: intervention group.

    bCG: control group.

    cCHF: chronic heart failure.

    d6MWT: 6-minute walk test.

    eNot applicable.

    fMLHFQ: Minnesota Living With Heart Failure Questionnaire.

    Effects of the HDTC Intervention for Caregivers

    Caregivers in the intervention group demonstrated significant reduction in Zarit Caregiver Burden Interview scores compared to controls at both 4 weeks (β=−1.750, 95% CI −2.499 to −1.001; P<.001) and 12 weeks (β=−4.350, 95% CI −5.765 to −2.935; P<.001), with effect sizes ranging from small to moderate (Table 2). However, no significant between-group differences were observed in Family Caregiver Quality of Life scores (β=1.300, 95% CI −1.644 to 4.244; P=.39; Table S3 and Figure S2 in Multimedia Appendix 4).

    Effects of the HDTC Intervention for Dyads

    Both patients with CHF and caregivers in the intervention group showed significant improvements in mutuality scores at 4 weeks (patients with CHF: β=5.700, 95% CI 1.126-10.274; P=.02; caregivers: β=3.850, 95% CI 1.961-5.739; P<.001) and 12 weeks (patients with CHF: β=10.508, 95% CI 5.534-15.482; P<.001; caregivers: β=6.450, 95% CI 3.652-9.248; P<.001; Table S3 and Figure S3 in Multimedia Appendix 4).


    Principal Findings

    The potential therapeutic benefits of tai chi have been increasingly investigated [52,53], but dyadic tai chi interventions among patients with CHF and their caregivers remain under-studied [13]. This study developed and evaluated an HDTC intervention that engaged patients and caregivers as active participants in a shared rehabilitation process, thereby extending conventional patient-centered exercise toward a dyad-oriented model. The intervention demonstrated satisfactory recruitment, retention, attendance, and acceptability, providing initial evidence that this approach is feasible in the home setting. No intervention-related adverse events were reported during the 12-week intervention, although the small sample size limits conclusions regarding safety. Exploratory analyses also indicated preliminary improvements across patient, caregiver, and dyadic outcomes. However, this study was not powered to establish clinical effectiveness. If confirmed in a fully powered trial, this model may offer a practical strategy for expanding home-based cardiac rehabilitation while addressing the needs of both patients and caregivers.

    Feasibility of the HDTC Intervention Among Dyads

    The HDTC intervention demonstrated encouraging recruitment, with enrollment completed within 1 month. The overall recruitment rate was 83.3% (40/48), comparable to the 75.1% reported in a previous dyadic study [14]. Although dyadic interventions often face recruitment challenges because of the need to coordinate participation by both members [54,55], recruitment in this study may have been facilitated by multiple recruitment pathways and close collaboration with the Department of Cardiology at the Affiliated Hospital of Qingdao University.

    Notably, the relatively low refusal rate may have been due to nurses’ extensive experience with patients with CHF [54], stakeholder-informed tailoring of the intervention, and its home-based delivery [56]. Participant feedback also suggested that dyads perceived the intervention as beneficial, and more than half valued the home-based convenience. Feasibility was further supported by complete retention at 4 weeks and a satisfactory retention rate at 12 weeks. Free access, convenient home-based practice, and social support from caregivers and nurses may have contributed to sustained engagement and retention [57]. Mean attendance was consistent with findings from a previous tai chi study [58], while adherence was comparable to that reported in a previous home-based cardiac rehabilitation study (14/20, 70% vs 73%) [59]. Collectively, these findings support the feasibility and acceptability of the HDTC intervention in this pilot setting.

    Acceptability of the HDTC Intervention Among Dyads

    All dyads in the intervention group rated the HDTC intervention as acceptable, with 60% (12/20) rating it as completely acceptable. This high acceptability may reflect the intervention’s dyadic tailoring and home-based delivery, which may also have promoted participant engagement and adherence [60]. Findings align with evidence that tai chi has been reported to be feasible and well tolerated among patients with frailty [61-62]. Its acceptability may have been further enhanced by caregiver involvement, which could provide encouragement and reinforce patients’ motivation to engage in regular exercise [63].

    Regarding engagement, 45% (9/20) of patients with CHF reported that the intervention required substantial effort, whereas 70% (14/20) of caregivers described it as moderately effortful. Informal telephone follow-up suggested that difficulties in learning tai chi forms contributed to the perceived effort, a challenge also reported in previous studies involving older adults [64]. This highlights the need for refinements in a full-scale RCT. Suggested strategies include (1) enhanced instructional support with clearer, more detailed demonstrations; (2) incremental learning of new forms; and (3) pretraining videos coupled with regular review sessions. Together, these approaches aim to ease skill acquisition, foster independent practice, and support long-term retention.

    Preliminary Effects of the HDTC Intervention

    For patients with CHF, the intervention showed favorable preliminary effects on exercise tolerance, sedentary time, fear of activity, exercise self-efficacy, and health-related QoL, generally consistent with previous evidence on tai chi and home-based rehabilitation [21,49]. These changes may reflect the gradual, low-impact nature of tai chi and the intervention’s emphasis on replacing sedentary behavior with structured home exercise, while supervised practice and progressive skill acquisition may also have supported confidence and reduced fear of activity [65,66]. Given the pilot design, these findings should be interpreted as preliminary signals rather than definitive evidence of efficacy.

    For caregivers, the intervention was associated with reduced caregiver burden, whereas QoL did not show a significant improvement, possibly because broader QoL is influenced by multiple factors, including caregiving distress and competing social and family demands, and may therefore be less responsive over a short intervention period [13,67,68]. At the dyadic level, both patients and caregivers showed improved mutuality, which may reflect the intervention’s emphasis on joint decision-making, shared exercise participation, and mutual encouragement, in contrast to dyadic interventions focused primarily on patient self-care [69]. These findings suggest that dyadic exercise may influence not only individual outcomes but also the relational processes within the patient-caregiver pair.

    Strengths and Limitations

    A key strength of this study was its explicit focus on dyads of patients with CHF and their caregivers throughout intervention conceptualization, development, and evaluation, addressing an important gap in previous research [13]. The HDTC intervention was developed through an evidence-based approach incorporating a comprehensive literature review, theoretical frameworks, and stakeholder consultation, thereby enhancing its conceptual foundation and contextual relevance.

    Several limitations should be considered. First, the pilot sample was small and was not powered for definitive between-group testing of clinical outcomes; consequently, effect estimates are imprecise and exploratory. Second, the 12-week follow-up does not establish whether engagement or outcome changes are sustained after intervention completion. Third, participants were recruited from a single tertiary medical center and through voluntary recruitment pathways, which may limit generalizability to other health care settings and may have preferentially enrolled dyads who were more motivated to exercise or use digital technology. Fourth, requiring both members of the dyad to participate may have further selected families with greater caregiver availability and relational capacity. Fifth, although both patient and caregiver outcomes were measured, the small sample limited the ability to reliably estimate dyadic interdependence. Finally, feasibility estimates such as recruitment and adherence are context dependent and require confirmation in larger, multicenter settings.

    Conclusions

    The HDTC intervention demonstrated feasibility and acceptability among dyads, with preliminary evidence suggesting potential to improve dyadic health outcomes. These findings support further evaluation of this dyad-oriented, digitally supported home rehabilitation model in a sufficiently powered multicenter RCT with longer follow-up.

    Acknowledgments

    The authors express their sincere gratitude to the physicians and nurses of the Department of Cardiology, Affiliated Hospital of Qingdao University, for their professional support and to the tai chi master for providing expert instruction. They further extend their deep appreciation to the patients with chronic heart failure and caregivers for their participation in this study. The authors declare the use of generative AI in the manuscript preparation and revision process. According to the Generative AI Delegation Taxonomy (2026), the following tasks were delegated to generative AI tools under full human supervision: proofreading and editing, adapting and adjusting emotional tone, and reformatting. The generative AI tool used was ChatGPT (GPT-6; OpenAI). Responsibility for the final manuscript lies entirely with the authors. Generative AI tools are not listed as authors and do not bear responsibility for the final outcomes.

    Funding

    This work was supported by the General Research Fund, Research Grants Council of the University Grants Committee of Hong Kong (grant 15100822); the Affiliated Hospital of Qingdao University (grant QDFY+X2024206); and Shandong Province Traditional Chinese Medicine Science and Technology Project (grant M20244004).

    Data Availability

    The data that support the findings of this study are available from the corresponding author on reasonable request.

    Generative AI Use

    The generative AI tool used was ChatGPT (GPT-6; OpenAI). Responsibility for the final manuscript lies entirely with the authors.

    Authors' Contributions

    Conceptualization: YZ, FWN, YJX

    Formal analysis: YZ

    Methodology: YZ, LC, XL, YJX

    Project administration: YZ, LC, XL, WZ

    Supervision: FWN, WZ, LW, YJX

    Validation: YJX

    Writing—original draft: YZ

    Writing—review and editing: YZ, FWN, LC, LW, YJX

    Conflicts of Interest

    None declared.

    Multimedia Appendix 1

    CONSORT-eHEALTH checklist.

    PDF File (Adobe PDF File), 3062 KB
    Multimedia Appendix 2

    Interview guide for the focus group interviews.

    DOCX File , 13 KB
    Multimedia Appendix 3

    Results of the focus group interviews.

    DOCX File , 22 KB
    Multimedia Appendix 4

    Supplementary analyses and longitudinal changes in patient, caregiver, and dyadic outcomes.

    DOCX File , 418 KB
    1. Savarese G, Becher PM, Lund LH, Seferovic P, Rosano GM, Coats AJ. Global burden of heart failure: a comprehensive and updated review of epidemiology. Cardiovasc Res. Jan 18, 2023;118(17):3272-3287. [FREE Full text] [CrossRef] [Medline]
    2. Wang H, Liu Y, Yang J. Epidemiology of heart failure. J Clin Cardiol. 2023;39(4):243-247. [CrossRef]
    3. Chen MF, Ke SR, Liu CL, Wu TC, Yu YM, Chiou AF. Associated factors and impacts of sedentary behaviour in patients with heart failure: a longitudinal study. Eur J Cardiovasc Nurs. Oct 2020;19(7):609-618. [FREE Full text] [CrossRef] [Medline]
    4. Dibben GO, Faulkner J, Oldridge N, Rees K, Thompson DR, Zwisler AD, et al. Exercise-based cardiac rehabilitation for coronary heart disease: a meta-analysis. Eur Heart J. Feb 07, 2023;44(6):452-469. [FREE Full text] [CrossRef] [Medline]
    5. Molloy C, Long L, Mordi IR, Bridges C, Sagar VA, Davies EJ, et al. Exercise-based cardiac rehabilitation for adults with heart failure. Cochrane Database Syst Rev. Mar 07, 2024;3(3):CD003331. [CrossRef] [Medline]
    6. Hwang HF, Tseng KC, Chen SJ, Yu WY, Chen CY, Lin MR. Effects of home-based computerized cognitive training and Tai Chi exercise on cognitive functions in older adults with mild cognitive impairment. Aging Ment Health. 2023;27(11):2170-2178. [CrossRef] [Medline]
    7. Buck HG, Howland C, Stawnychy MA, Aldossary H, Cortés YI, DeBerg J, et al. Caregivers' contributions to heart failure self-care: an updated systematic review. J Cardiovasc Nurs. 2024;39(3):266-278. [FREE Full text] [CrossRef] [Medline]
    8. Jackson JD, Cotton SE, Bruce Wirta S, Proenca CC, Zhang M, Lahoz R, et al. Burden of heart failure on caregivers in China: results from a cross-sectional survey. Drug Des Devel Ther. Jun 08, 2018;12:1669-1678. [FREE Full text] [CrossRef] [Medline]
    9. Dirikkan F, Baysan Arabacı L, Mutlu E. The caregiver burden and the psychosocial adjustment of caregivers of cardiac failure patients. Turk Kardiyol Dern Ars. Dec 2018;46(8):692-701. [FREE Full text] [CrossRef] [Medline]
    10. Suksatan W, Tankumpuan T, Davidson PM. Heart failure caregiver burden and outcomes: a systematic review. J Prim Care Community Health. 2022;13:21501319221112584. [FREE Full text] [CrossRef] [Medline]
    11. Yu DS, Qiu C, Li PW, Lau J, Riegel B. Effects of dyadic care interventions for heart failure on patients' and caregivers' outcomes: a systematic review, meta-analysis and meta-regression. Int J Nurs Stud. Sep 2024;157:104829. [CrossRef] [Medline]
    12. Di Maio S, Villinger K, Knoll N, Scholz U, Stadler G, Gawrilow C, et al. Compendium of dyadic intervention techniques (DITs) to change health behaviours: a systematic review. Health Psychol Rev. Sep 2024;18(3):538-573. [FREE Full text] [CrossRef] [Medline]
    13. Bidwell JT, Conway C, Babicheva V, Lee CS. Person with heart failure and care partner dyads: current knowledge, challenges, and future directions: state-of-the-art review. J Card Fail. Aug 2023;29(8):1187-1206. [FREE Full text] [CrossRef] [Medline]
    14. Yang W, Sun L, Hao L, Zhang X, Lv Q, Xu X, et al. Effects of the family customised online FOCUS programme on patients with heart failure and their informal caregivers: a multicentre, single-blind, randomised clinical trial. EClinicalMedicine. Feb 12, 2024;69:102481. [FREE Full text] [CrossRef] [Medline]
    15. Zhao Y, Zhang S, Lu M, Zhen Q, Shi X. Patient and informal caregiver-centered nursing interventions for adults with heart failure: a systematic review and meta-analysis. Intensive Crit Care Nurs. Jun 2025;88:103943. [CrossRef] [Medline]
    16. Doyle KL, Toepfer M, Bradfield AF, Noffke A, Ausderau KK, Andreae S, et al. Systematic review of exercise for caregiver-care recipient dyads: what is best for spousal caregivers-exercising together or not at all? Gerontologist. Aug 13, 2021;61(6):e283-e301. [FREE Full text] [CrossRef] [Medline]
    17. Lyons KS, Lee CS. The theory of dyadic illness management. J Fam Nurs. Feb 2018;24(1):8-28. [FREE Full text] [CrossRef] [Medline]
    18. Chow SL, Bozkurt B, Baker WL, Bleske BE, Breathett K, Fonarow GC, et al. Complementary and alternative medicines in the management of heart failure: a scientific statement from the American Heart Association. Circulation. Jan 10, 2023;147(2):e4-30. [FREE Full text] [CrossRef] [Medline]
    19. Professional Committee of Cardiovascular Prevention and Rehabilitation of Chinese Rehabilitation Medical Association. Expert consensus on cardiac rehabilitation for chronic heart failure in China [Article in Chinese]. Zhonghua Nei Ke Za Zhi. Dec 01, 2020;59(12):942-952. [CrossRef] [Medline]
    20. Huang J, Qin X, Shen M, Xu Y, Huang Y. The effects of Tai Chi exercise among adults with chronic heart failure: an overview of systematic review and meta-analysis. Front Cardiovasc Med. Mar 18, 2021;8:589267. [FREE Full text] [CrossRef] [Medline]
    21. Hui J, Wang Y, Zhao J, Cong W, Xu F. Effects of Tai Chi on health status in adults with chronic heart failure: a systematic review and meta-analysis. Front Cardiovasc Med. Sep 9, 2022;9:953657. [FREE Full text] [CrossRef] [Medline]
    22. Du Y, Roberts P, Liu W. Facilitators and barriers of Tai Chi practice in community-dwelling older adults: qualitative study. Asian Pac Isl Nurs J. Jan 23, 2023;7:e42195. [FREE Full text] [CrossRef] [Medline]
    23. Teo JL, Bird SR, Wang X, Zheng Z. Using telehealth to deliver Qi Gong and Tai Chi programs: a mixed-methods systematic review on feasibility, acceptability and participant engagement factors. Arch Gerontol Geriatr. Feb 2024;117:105203. [FREE Full text] [CrossRef] [Medline]
    24. Skivington K, Matthews L, Simpson SA, Craig P, Baird J, Blazeby JM, et al. Framework for the development and evaluation of complex interventions: gap analysis, workshop and consultation-informed update. Health Technol Assess. Sep 2021;25(57):1-132. [FREE Full text] [CrossRef] [Medline]
    25. Eldridge SM, Chan CL, Campbell MJ, Bond CM, Hopewell S, Thabane L, et al. CONSORT 2010 statement: extension to randomised pilot and feasibility trials. BMJ. Oct 24, 2016;355:i5239. [FREE Full text] [CrossRef] [Medline]
    26. Ferrari M, Speight J, Beath A, Browne JL, Mosely K. The information-motivation-behavioral skills model explains physical activity levels for adults with type 2 diabetes across all weight classes. Psychol Health Med. Mar 2021;26(3):381-394. [CrossRef] [Medline]
    27. Fisher WA, Fisher JD, Harman J. The information-motivation-behavioral skills model: a general social psychological approach to understanding and promoting health behavior. In: Suls J, Wallston KA, editors. Social Psychological Foundations of Health and Illness. Oxford, UK. Blackwell Publishing; Jan 01, 2003.
    28. Greenhalgh T, Abimbola S. The NASSS framework - a synthesis of multiple theories of technology implementation. Stud Health Technol Inform. Jul 30, 2019;263:193-204. [CrossRef] [Medline]
    29. Chinese Society of Cardiology‚ Chinese Medical Association, Chinese College of Cardiovascular Physician, Chinese Heart Failure Association of Chinese Medical Doctor Association, Editorial Board of Chinese Journal of Cardiology. Chinese guidelines for the diagnosis and treatment of heart failure 2024 [Article in Chinese]. Zhonghua Xin Xue Guan Bing Za Zhi. Mar 24, 2024;52(3):235-275. [CrossRef] [Medline]
    30. Castro AR, Arnaert A, Moffatt K, Kildea J, Bitzas V, Tsimicalis A. "Informal caregiver" in nursing: an evolutionary concept analysis. ANS Adv Nurs Sci. 2023;46(1):E29-E42. [CrossRef] [Medline]
    31. Whitehead AL, Julious SA, Cooper CL, Campbell MJ. Estimating the sample size for a pilot randomised trial to minimise the overall trial sample size for the external pilot and main trial for a continuous outcome variable. Stat Methods Med Res. Jun 2016;25(3):1057-1073. [FREE Full text] [CrossRef] [Medline]
    32. Sealed Envelope. URL: https://www.sealedenvelope.com/ [accessed 2026-10-19]
    33. Boutron I, Tubach F, Giraudeau B, Ravaud P. Blinding was judged more difficult to achieve and maintain in nonpharmacologic than pharmacologic trials. J Clin Epidemiol. Jun 2004;57(6):543-550. [CrossRef] [Medline]
    34. Bellg AJ, Borrelli B, Resnick B, Hecht J, Minicucci DS, Ory M, et al. Enhancing treatment fidelity in health behavior change studies: best practices and recommendations from the NIH Behavior Change Consortium. Health Psychol. Sep 2004;23(5):443-451. [CrossRef] [Medline]
    35. Lackinger C, Grabovac I, Haider S, Kapan A, Winzer E, Stein KV, et al. Adherence is more than just being present: example of a lay-led home-based programme with physical exercise, nutritional improvement and social support, in prefrail and frail community-dwelling older adults. Int J Environ Res Public Health. Apr 15, 2021;18(8):4192. [FREE Full text] [CrossRef] [Medline]
    36. Sekhon M, Cartwright M, Francis JJ. Acceptability of healthcare interventions: an overview of reviews and development of a theoretical framework. BMC Health Serv Res. Jan 26, 2017;17(1):88. [FREE Full text] [CrossRef] [Medline]
    37. Barr A, Coates E, Kingsley E, de la Cuesta GG, Biggs K, Le Couteur A, et al. A mixed methods evaluation of the acceptability of therapy using LEGO® bricks (LEGO® based therapy) in mainstream primary and secondary education. Autism Res. Jul 2022;15(7):1237-1248. [FREE Full text] [CrossRef] [Medline]
    38. Junqueira DR, Zorzela L, Golder S, Loke Y, Gagnier JJ, Julious SA, et al. CONSORT Harms 2022 statement, explanation, and elaboration: updated guideline for the reporting of harms in randomised trials. BMJ. Apr 24, 2023;381:e073725. [FREE Full text] [CrossRef] [Medline]
    39. Giannitsi S, Bougiakli M, Bechlioulis A, Kotsia A, Michalis LK, Naka KK. 6-minute walking test: a useful tool in the management of heart failure patients. Ther Adv Cardiovasc Dis. 2019;13:1753944719870084. [FREE Full text] [CrossRef] [Medline]
    40. WOCaring. URL: http://www.wocaring.com/ [accessed 2026-10-19]
    41. Macfarlane DJ, Lee CCY, Ho EYK, Chan KL, Chan DTS. Reliability and validity of the Chinese version of IPAQ (short, last 7 days). J Sci Med Sport. Feb 2007;10(1):45-51. [CrossRef] [Medline]
    42. Ozyemisci-Taskiran O, Demirsoy N, Atan T, Yuksel S, Coskun O, Aytur YK, et al. Development and validation of a scale to measure fear of activity in patients with coronary artery disease (Fact-CAD). Arch Phys Med Rehabil. Mar 2020;101(3):479-486. [CrossRef] [Medline]
    43. Liu T, Chan AW, Chair SY. Group- plus home-based Tai Chi program improves functional health among patients with coronary heart disease: a randomized controlled trial. Eur J Cardiovasc Nurs. Aug 29, 2022;21(6):597-611. [FREE Full text] [CrossRef] [Medline]
    44. Mogle J, Buck H, Zambroski C, Alvaro R, Vellone E. Cross-validation of the Minnesota Living With Heart Failure Questionnaire. J Nurs Scholarsh. Sep 2017;49(5):513-520. [CrossRef] [Medline]
    45. Ko KT, Yip PK, Liu SI, Huang CR. Chinese version of the Zarit Caregiver Burden Interview: a validation study. Am J Geriatr Psychiatry. Jun 2008;16(6):513-518. [CrossRef]
    46. Qian H, Wang J, Shen W, Miao A, Yu Y. The Chinese version of the Family Caregiver-Specific Quality of Life Scale: validation among community family caregivers of chronic heart failure patients [Article in Chinese]. J Nurs Sci. 2012;27(21):85-87. [CrossRef]
    47. Dellafiore F, Buck HG, Pucciarelli G, Barbaranelli C, Paturzo M, Alvaro R, et al. Psychometric characteristics of the mutuality scale in heart failure patients and caregivers. Heart Lung. Nov 2018;47(6):553-561. [CrossRef] [Medline]
    48. Sullivan GM, Feinn R. Using effect size-or why the P value is not enough. J Grad Med Educ. Sep 2012;4(3):279-282. [FREE Full text] [CrossRef] [Medline]
    49. Zhang Y, Ngai FW, Yang Q, Xie YJ. Effectiveness of digital health interventions on sedentary behavior among patients with chronic diseases: systematic review and meta-analysis. JMIR Mhealth Uhealth. Jun 24, 2025;13:e59943. [FREE Full text] [CrossRef] [Medline]
    50. Zhang Y, Ngai FW, Liang J, Yang Q, Zhao M, Wei L, et al. Roles and engagement levels of caregivers during dyadic Tai Chi interventions: a scoping review. Complement Ther Med. Jun 2026;98:103350. [FREE Full text] [CrossRef] [Medline]
    51. Hopewell S, Chan AW, Collins GS, Hróbjartsson A, Moher D, Schulz KF, et al. CONSORT 2025 statement: updated guideline for reporting randomised trials. BMJ. Apr 14, 2025;389:e081123. [FREE Full text] [CrossRef] [Medline]
    52. Szabo SM, Whitlatch CJ, Orsulic-Jeras S, Johnson JD. Recruitment challenges and strategies: lessons learned from an early-stage dyadic intervention (innovative practice). Dementia (London). Jul 2018;17(5):621-626. [CrossRef] [Medline]
    53. Gu Q, Wu SJ, Zheng Y, Zhang Y, Liu C, Hou JC, et al. Tai Chi exercise for patients with chronic heart failure: a meta-analysis of randomized controlled trials. Am J Phys Med Rehabil. Oct 2017;96(10):706-716. [CrossRef] [Medline]
    54. Jiao Q, Meng C, He H, Li S, Xu F, Cui W, et al. Safety and effects of a home-based Tai Chi exercise rehabilitation program in patients with chronic heart failure: study protocol for a randomized controlled trial. Front Cardiovasc Med. Nov 29, 2023;10:1237539. [FREE Full text] [CrossRef] [Medline]
    55. Fruhauf C, Schmid A, Prabhu N, Swink L, Portz J, Leach H, et al. Challenges of recruiting caregiver and care receiver dyads for a randomized clinical trial. Innov Aging. Dec 16, 2020;4(Suppl 1):356-357. [CrossRef]
    56. Cheung DS, Tang SK, Ho KH, Jones C, Tse MM, Kwan RY, et al. Strategies to engage people with dementia and their informal caregivers in dyadic intervention: a scoping review. Geriatr Nurs. 2021;42(2):412-420. [CrossRef] [Medline]
    57. Yang Z, Jia H, Zhang F, Huang H, Hao X, Wang A. A behavioural driving model of adherence to home-based cardiac rehabilitation exercise among patients with chronic heart failure: a mixed-methods study. J Clin Nurs. Feb 2024;33(2):531-542. [CrossRef] [Medline]
    58. Yeh GY, McCarthy EP, Wayne PM, Stevenson LW, Wood MJ, Forman D, et al. Tai Chi exercise in patients with chronic heart failure: a randomized clinical trial. Arch Intern Med. Apr 25, 2011;171(8):750-757. [FREE Full text] [CrossRef] [Medline]
    59. Nagatomi Y, Ide T, Higuchi T, Nezu T, Fujino T, Tohyama T, et al. Home-based cardiac rehabilitation using information and communication technology for heart failure patients with frailty. ESC Heart Fail. Aug 2022;9(4):2407-2418. [FREE Full text] [CrossRef] [Medline]
    60. Liang IJ, Francombe-Webb J, McGuigan PM, Perkin OJ, Thompson D, Western MJ. The acceptability of homebased exercise snacking and Tai-Chi snacking amongst high and low function UK and Taiwanese older adults. Front Aging. Aug 1, 2023;4:1180939. [FREE Full text] [CrossRef] [Medline]
    61. Wang C, Schmid CH, Fielding RA, Harvey WF, Reid KF, Price LL, et al. Effect of Tai Chi versus aerobic exercise for fibromyalgia: comparative effectiveness randomized controlled trial. BMJ. Mar 21, 2018;360:k851. [FREE Full text] [CrossRef] [Medline]
    62. Takemura N, Cheung DS, Fong DY, Lin CC. Impact of adherence to exercise interventions on effectiveness in a randomized controlled trial in improving sleep in advanced lung cancer patients: a comparison between aerobic exercise and Tai Chi. Palliat Support Care. Jul 28, 2023:1-9. [CrossRef] [Medline]
    63. van Beurden SB, Cross R, McDonagh ST, Clark L, Thomas C, Greaves CJ, et al. Digital adaptation of the clinically effective REACH-HF home-based cardiac rehabilitation programme for people living with heart failure (D:REACH-HF). Digit Health. Dec 18, 2025;11:20552076251406545. [FREE Full text] [CrossRef] [Medline]
    64. Sadeghian F, Zolaktaf V, Shigematsu R. A comparison between effects of square-stepping exercise and Tai Chi Chuan on functional fitness and fear of falling in older women. Aging Clin Exp Res. Apr 2023;35(4):827-834. [CrossRef] [Medline]
    65. Liu L, Yang Q, Li T, Xie H, Zeng B, Zha L, et al. Prevalence and influencing factors of kinesiophobia in patients with heart disease: a meta-analysis and systematic review. Sci Rep. Aug 15, 2024;14(1):18956. [FREE Full text] [CrossRef] [Medline]
    66. Lüke T, Brandenburg VM, Partetzke TM, Voss F, Spaderna H. Accelerometer-measured daily physical activity in adults with chronic heart failure and associations with fear of physical activity and coping dispositions. J Cardiovasc Nurs. 2026;41(3):165-173. [CrossRef] [Medline]
    67. Piamjariyakul U, Werkowitch M, Wick J, Russell C, Vacek JL, Smith CE. Caregiver coaching program effect: reducing heart failure patient rehospitalizations and improving caregiver outcomes among African Americans. Heart Lung. 2015;44(6):466-473. [CrossRef] [Medline]
    68. Alaei A, Babaei S, Farzi S, Hadian Z. Effect of a supportive-educational program, based on COPE model, on quality of life and caregiver burden of family caregivers of heart failure patients: a randomized clinical trial study. BMC Nurs. Jan 26, 2024;23(1):72. [FREE Full text] [CrossRef] [Medline]
    69. Pucciarelli G, Occhino G, Locatelli G, Baricchi M, Ausili D, Rebora P, et al. The effectiveness of a motivational interviewing intervention on mutuality between patients with heart failure and their caregivers: a secondary outcome analysis of the MOTIVATE-HF randomized controlled trial. J Cardiovasc Nurs. 2024;39(2):107-117. [CrossRef] [Medline]

    ‎
    CHF: chronic heart failure
    CONSORT: Consolidated Standards of Reporting Trials
    HDTC: home-based, digitally assisted, dyadic tai chi
    HF: heart failure
    MCAR: missing completely at random
    QoL: quality of life
    RCT: randomized controlled trial

    Edited by S Brini; submitted 22.Mar.2026; peer-reviewed by Y-J Son, W Cai; comments to author 17.Sep.2026; revised version received 13.Oct.2026; accepted 14.Oct.2026; published 11.Nov.2026.

    Copyright

    ©Yan Zhang, Fei Wan Ngai, Lihua Cao, Xiaohong Lu, Wenzhong Zhang, Lili Wei, Yao Jie Xie. Originally published in JMIR mHealth and uHealth (https://mhealth.jmir.org), 11.Nov.2026.

    This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR mHealth and uHealth, is properly cited. The complete bibliographic information, a link to the original publication on https://mhealth.jmir.org/, as well as this copyright and license information must be included.