Transcript et al - Novel Physiotherapies

LAGOS UNIVERSITY TEACHING HOSPITAL/COLLEGE OF MEDICINE,
LAGOS NIGERIA
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Introduction
Aims of the study
Materials and Methods
Data Analysis
Results
Discussion
Conclusion
References
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Fig. 1A: Longitudinal section of the Human Heart showing
the heart chambers and the major vessels (Guyton & Hall,
2005)
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Heart Failure (HF) is characterized by the inability
of heart muscle to pump adequate volume of blood
to meet tissue energy demand

results in symptoms of fatigue or dyspnoea initially
on exertion and then later on progressing to
dyspnoea at rest
(Conraads et al., 2007; Elahi et al., 2010; Conraads
et al., 2013).
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CVD is one of the major causes of death and
suffering both in the developed and developing
countries
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9.5 million individuals died of cardiovascular
disease in 2005.

This highlights the urgent need for developing
effective means of preventing and treating heart
disease.
(Kannel 2000; Stewart et al. 2002, 2006; Silwa et al. 2005).
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Heart failure:
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an endemic syndrome
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constitutes an important public health problem
around the world

high mortality rate (20%),
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poor prognosis
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only 15% of patients are still alive after 12 years
(Hunt et al., 2009)
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Heart failure:
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common and disabling syndrome
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a final pathway for a number of cardiac conditions

It is the most prevalent cardiovascular disease and
the leading cause of sudden cardiac death in Nigeria
(Adedoyin & Adesoye, 2005, Selig & Hare, 2007, Hunt et al., 2009).
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in developed countries 1% - 2% in the adult
population rises to ≥10% in individuals > 70 yrs
(Mosterd & Hoes, 2007 ).
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most prevalent CVD and the leading cause of
sudden cardiac death in Nigeria representing 35% of
CVD
(Adedoyin and Adesoye, 2005).
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3rd commonest non communicable cause of
admission in UPTH
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(Agomouh & Unachukwu 2007)
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Prevalence – 5 million
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Approx 2% of total US population
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Incidence – 550,000
Close to 1/100 for those over age 65yrs
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Overall lifetime risk – 1/5 > 40yrs age
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HTN is most common risk factor, seen in 75% of cases
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50-75% excess rate of HF in blacks
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Younger age with more advanced disease at initial
presentation
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More rapid progression from asymptomatic to
symptomatic
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May be related to divergence in etiology (HTN CM
in blacks and ICM in whites).
JACC 2002;39(10:60
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Statement of the Problem
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Despite remarkable progress in HF management,
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fatigue,
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Breathlessness,
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exercise intolerance and
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muscle wasting remain the hallmarks of the disease.
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impaired quality of life and
capacity for activities of daily living (ADLs)
(Selig and Hare 2007, Fulster et al.,2013).
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Kengne et al. 2005, Mayosi 2007
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In SSA/Nigeria, the use of ET in HF management
has not been widely accepted by health care
providers
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bc of the possibility that the failing hearts may have
a negative response to the increased workload and
stress of exercise.
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Evidence from studies reporting severe cardiac
events and an increase mortality with exercise
(Jetté et al., 1991).
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Most patients with HF seek medical attention with
complaints of a reduction in their effort tolerance due to
dyspnoea and/or fatigue which may occur at rest or during
exercise (Hunt et al., 2009).
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Bi-ventricular failure (BVF) occurs when the right and left
ventricles are unable to pump adequate blood from the heart
to the lung and other parts of the body respectively.
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enormous impact on the prognosis and lifestyle of
patients,
a chronic condition without a “cure” (Green et al., 2000).
goals of its management are:
preventing further disease progression (mortality,
hospitalizations and deterioration of left ventricular
function)
and alleviating patient suffering.
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Muscle wasting is a frequent co-morbidity.
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Patients with muscle wasting present with reduced
exercise capacity and muscle strength, and advanced
disease (Fulster et al.,2013).
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Hand Grip strength (HGS) is a general indicator of
muscle strength
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low hand grip strength has been linked with
premature mortality in the middle and elderly
subjects
(Metter et al., 2002. Takata et al., 2007 )
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Earlier studies also suggested that HGS may be
controlled by multiple physiological systems and
this may be associated with a number of chronic
diseases (Sayer et al., 2007, Oken et al., 2008).
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It is a common conception that HGS is related
mainly to the muscular strength (Filho et al., 2010;
Cheung et al., 2012).
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Cheung et al.,(2013) reported that HGS was
associated with multiple chronic diseases after
controlling for co-morbidity.
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Exercise training(ET) in patients with CHF is a
relatively recent development, and studies to date
have generally been limited to Caucasians (Kengne et
al., 2005, Mayosi 2007).
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Blacks and other racial minorities with HF are
under-represented in most of these clinical trials of
HF.
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This compromises the extrapolation of results from
major clinical trials to ethnic sub-group populations
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aetiology in Caucasians populations has been
reported to be mostly ischaemic (Mayosi 2007).
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evidence based studies in SSA especially in
Nigeria among HF population had shown that
aetiology its mostly non-ischaemic (Kengne et al.,
2005).
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ET has been recommended as an adjunctive
therapy but its role in CHF has not been
explored in Nigeria.
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The aim of this study was therefore to investigate
the effects of aerobic and resistance exercise
training on:
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the sub-maximal walking capacity,
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grip strength of individuals with BVF.
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Subjects Selection
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66 individuals with BVF (30-71yrs)
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Classes ll and lll (NYHA functional classification).
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Maximal pharmacological treatment in Cardiology
Unit of LUTH, Idi-Araba Lagos.
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randomized into 2 groups, EG & CG;
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A randomized controlled trial design
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A randomization list was computer generated
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random-number sequence in blocks of 10 was
adopted for consistent patients’ distribution.
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199 met inclusion criteria
119 declined
80 gave consent
8 did not turn up
72 turned up
3 showed signs of
decompensation
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66
randomized to 2 groups
33 to Control group
23 turned up for
post test
assessment
23 completed 12
weeks of study
randomized to 2 groups
33 to Exercise group
10 were lost
to follow up
28 completed
at least 80%
attendance
5 could not meet
80% attendance
28 subjects completed the exercise
training with atleast 80% attendance
Figure 3: Flow chart showing patients’ responses during the study
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Protocol was approved by the Health Research and
Ethics Committee of LUTH, Idi-Araba, Lagos.
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Written consent was also obtained from subjects
before enrolment into the study.
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standiometer
(Seradon, England) (height and
weight)
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Omron BP monitor - Omron HEM-712C digital
(SBP, DBP and HR).
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6MWT (6MWD).
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Duke Activity Status Index (DASI) questionnaire
(estimate peak oxygen consumption).
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Polar heart rate monitor (heart rate)
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Veteran’s Specific Activity Questionnaire
(VSAQ) (activity level)
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Hand dynamometer (grip strength)
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dumb- bell/bar-bell (1RM).
Modified Borg’s scale (intensity).
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EG - 12 weeks combined aerobic and resistance
training (CART)
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CG had no exercise intervention.
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Both groups were monitored on their drug therapy
throughout the study.
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Both groups also received 3 sessions of health
education /counselling.
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Fig. 4: Subjects in EG performing aerobic exercise on the motorized
ergometer
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The modified Borg’s rate of perceived exertion was
used as a check tool
to exercise at moderate
 intensity range
 at point 3 – 4 of the scale which
 denoted “somewhat hard”.
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Borg, 1982
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EXERCISE TRAINING PROTOCOL
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Exercise training:
3 times/week for 12wks
Composition:
 10 min. warm-up,
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20 min. cycling (20Watts),
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20 min. resistance training
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10 minutes of cool- down exercises.
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The resistance exercise:
3 sets at 50% of 1RM/10 rep. from
1st to 6th week followed by
60% of 1RM for 10 repetitions per
set from 7th to 12th week.
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The loading on the ergo. progressed
by 5Watts individually depending
on their responses to treatment.
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Six minute walk test was used to determine
6MWD
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Duke Activity Status Index (DASI) questionnaire
was used to estimate peak oxygen consumption.
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Hand Dynamometer
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1RM
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Statistical Package for Social Sciences (SPSS
version-17) was used to analyze the data.
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Analysis of the socio-demographic data was done
using descriptive statistics of mean and standard
error of mean.
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Paired t test was used to compare pre- and post-tests
for variables
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Independent t test was used to compare variables
between EG and CG.
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Level of significance was set at p < 0.05.
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Table 1: Physical Characteristics of subjects in Exercise and Control Groups
Physical
Characteristics
Both Groups
Mean ± SEM
N = 51
Control
Group
Mean ± SEM
N = 23
Exercise
Group
Mean ± SEM
N = 28
Age (years)
54.0 ± 1.6
51.5 ± 2.6
Height (meters)
1.65 ± 0.01
Weight (kilograms)
t-value
p-value
56.1 ± 2.0
1.442
0.156
1.65 ± 0.02
1.65 ± 0.02
- 0.097
0.923
77.0 ± 2.0
75.1 ± 3.4
78.6 ± 2.4
0.867
0.390
Body mass index (kg/m2)
28.6 ± 0.7
27.7 ± 1.3
29.1 ± 0.9
0.969
0.338
Six minute walk distance (m)
409.0 ± 5.8
404.0 ± 6.9
414.1 ± 8.8
0.856
0.397
New York Heart Association
Class
25/2; 26/3
13/2, 10/3
12/2, 16/3
0.462
0.557
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The mean age was comparable with other studies
done in Nigeria
(Adebayo et al., 2009; Onwuchekwa and Asekomeh 2009; Mbakwem et al., 2013).
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Kengne et al., (2005) reported that HF in Africa
occurs mostly between 5th to 6thdecade of life.
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Table 2: Comparison of pre-test and post-test functional walking capacity within and between the control and exercise groups after 12 weeks of
study.
Control
(CG)
Exercise
(EG)
Group
Group
Variables
Pre-test
Post-test
t-value
P-value Pre-test
Post- test
t-value
P- value
PP-value
Mean±
Mean±
Mean
± Mean± SEM
value
SEM
SEM
(a&b)
SEM
(d)
(c&d)
(b&d)
(b)
(c)
(a&c)
(a)
6MWD
404.0 ± 6.9 399.0 ± 12.1 1.482
0.168
414.1 ± 8.8
448.8 ± 6.6
-5.871
< 0.001** 0.397
< 0.001**
(meters)
PVO2-DASI
(ml/kg/min)
12.7 ± 0.2
12.2± 0.2
3.495
0.002*
12.8 ± 0.2
15.0± 0.2
-13.426
< 0.001**
0.952
< 0.001**
PVO2-VSAQ 14.9 ± 0.5
(ml/kg/min)
14.1± 0.5
1.344
0.209
13.8 ± 0.4
21.9 ± 0.5
-16.156
< 0.001**
0.078
< 0.001**
NYHA
CLASS
15/2; 8/3
0.826
0.768
12/2; 16/3
14/1; 13/2; 2/3
-19.457
<0.001**
0.635
< 0.001**
13/2; 10/3
p ≤ 0.001;
p ≤ 0.05
6MWD – six minute walk distance, NYHA class – New York Heart Association class, , PeakVO2- as estimated from CPET, PeakVO2 (DASI) – peak
oxygen consumption as estimated from Duke Activity Status Index questionnaire, PeakVO2 (VSAQ) – Veteran’s Specific Activity Questionnaire.
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The result of this study shows a significant increase in
6MWD (410.9 ± 6.9m vs 447.0 ± 5.2m)
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and estimated peak oxygen uptake (12.7 ±
0.1ml/kg/min vs 15.1 ± 0.2ml/kg/min) in the EG after
12weeks of training.
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This finding shows significant effect of ET in
improving walking capacity of patients in the EG.
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Improvement
partial reversal of physical deconditioning that affects adversely organ systemic changes
that occur in CHF.
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Mechanisms
reversal of peripheral abnormalities such
as endothelial dysfunction, skeletal muscle wasting and
ventilation in- efficiency seen in HF.
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Similar results were observed by Maiorana et al (2002),
Bocalini et al., (2008) and Hwang et al (2010)
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CHF is characterized by a myopathy syndrome,
manifested by a loss of strength in mild cases
through to cachexia in severe cases.
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The goal for including resistance (strength) training
is to partially reverse the deficits of muscle wasting
and weakness
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and to improve the capacity for ADLs and quality
of life.
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Table 3: Comparison of upper limbs muscle and grip strength between pre-test and post-test
assessment within the control and exercise groups using paired t test
Variables
Control
Group
Pre-test
Mean±
SEM
(a)
Post-test
Mean±
SEM
(b)
t-value P-value
(a&b)
Exercise
Group
Pre-test
Post- test
Mean
t-value
P- value
± Mean±
SEM
SEM
(c)
(d)
(c&d)
RULS (kg)
13.0 ± 0.6
13.5 ± 0.5 0.170
0.079
13.8 ± 0.6
15.5 ± 0.4
-9.997
< 0.001**
LULS (kg)
12.9 ± 1.5
12.8 ± 1.3
0.270
0.105
12.3 ± 0.7
14.3 ± 0.3
-22.333
< 0.001**
RGS (kg)
28.6 ± 1.8
28.5 ± 1.0
1.182
0.926
28.8 ± 1. 0
32.8 ± 1.2
-4.513
0.001**
LGS (kg)
30.6 ± 2.8
29.7 ± 2-2
1.861
0.873
26.4 ± 1.3
30.9 ± 1.1
-3.548
< 0.001**
RULS – Right upper limb strength; LULS – Left upper limb strength; RGS – Right grip strength; LGS – Left grip strength.
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RULS -Right Upper Limb Strength; LULS – Left Upper Limb Strength; RGS – Right Grip Strength; LGS–
Left Grip Strength.
Figure 6: Comparison of changes in muscle strength and grip strength variables
between subjects in control and exercise groups after 12 weeks of study.
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ET brought about significant increase in the muscle
strength (21.8% and 22.2% in the right and left
upper limb respectively)
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and grip strength (12.7% and 18.3% increase in the
right and left grip respectively).
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CHF is characterized by a myopathy syndrome
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manifested by a loss of strength in mild cases to
cachexia in severe cases.
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Mechanism may be thr. reduction of oxidative
stress and level of fatigue
of:
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partially reverse the deficits of muscle wasting and
weakness
improve the capacity for ADLs and quality of life
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Heamodynamic load during exercise is determined
by the % of muscle mass used,
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therefore ↑ strength of a certain muscle group, the %
of muscle mass solicited to lift a certain weight ↓
cardiovascular load.
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improve aerobic /oxidative capacity partly via
improvements to skeletal muscle mitochondrial ATP
production rates
Selig & Hare 2007
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Activity level (mets)
8
**
7
6
5
4
Pre-test
3
Post-test
2
1
0
CONTROL VSAQ (mets)
EXERCISE VSAQ (mets)
** P < 0.001
Figure 4: Activity Level of subjects at baseline and after 3 months of study.
VSAQMET –Metabolic equivalent as measured by Veteran’s Specific Activity
Questionnaire.
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The increase in strength and potential increased muscle mass
as observed in this study may be translated to improvement in
activity level and their ability to become more physically
active
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and may improve the ability to perform activities of daily
living which may eventually improve the quality of life.
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Safety
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No adverse reactions to the training were reported.
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None of the patients in EG experienced any
worsening of heart failure during the study,
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and none of them were hospitalized, whereas three
of the control patients were hospitalized during the
first 12weeks of study..
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Aerobic and resistance exercise training is safe,
beneficial and have the potential to improve walking
exercise capacity, Muscle strength and grip strength
of individuals with BVF.
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The result of this study also support the concept that
exercise should be part of heart failure treatment
plan in Nigeria,
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Exercise training should be incorporated as part of
the standard treatment of heart failure patients in
Nigeria.
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Cardiac rehabilitation centres should be domiciled
in all the Teaching and Specialist hospitals in
Nigeria..
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THANKS
FOR
YOUR ATTENTION
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