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European Journal of Heart Failure 2002 4(5):627-634; doi:10.1016/S1388-9842(02)00090-9
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© 2002 European Society of Cardiology

Exercise and muscle strength training and their effect on quality of life in patients with chronic heart failure{star}

Andrea Radzewitz, Eckart Miche*, Gert Herrmann, Mirella Nowak, Uta Montanus, Ulrike Adam, Ylva Stockmann and Maria Barth

Herz-Kreislauf-Zentrum Gernsbach/Schwarzwald Langer Weg 3, 76593 Gernsbach, Germany

* Corresponding author. Tel.: +49-7224-992-501; fax: +49-7224-992-444. E-mail address: cardiol{at}hkz-gernsbach.de


   Abstract
Top
 Notes
 Abstract
1. Introduction
 2. Methods
 3. Results
 4. Discussion
 References
 
Background: There is now evidence that moderate training plays an important role in the treatment of chronic heart failure. No clear instructions exist to date as to how such training programs should be carried out.

Aim: to assess the efficiency of a training program including bicycle ergometer training, moderate muscle strength training and the 6-min walk test and their influence on quality of life, anxiety and depression.

Methods and results: Patients (67 male, 21 female) underwent a standardized 4-week training program. Baseline data: LVEF=31±8%; LVEDD=143±59 ml; peak VO2=13.9±4.6 kg/ml. No adverse side effects could be observed. At discharge LVEF was 37±9%, (P=0.001); LVEDD=131±44ml (P=0.01); and peak VO2=15.4±5.0 kg/ml. Quality of life improved significantly in nearly all domains and in summary score. There were no significant changes in anxiety and depression. There is a negative correlation between the initial workload and changes in physical health (r=–0.42, P=0.001) and only a weak correlation between age and positive changes in physical health (r=0.26, P=0.05).

Conclusions: A standardized training program including moderate muscle strength training could be performed safely and demonstrated improvement in clinical parameters and quality of life.

Key Words: Chronic heart failure • Quality of life • Exercise • Muscle strength training • Oxygen uptake

Received August 15, 2001; Revised October 24, 2001; Accepted January 11, 2002


   1. Introduction
Top
 Notes
 Abstract
 1. Introduction
2. Methods
 3. Results
 4. Discussion
 References
 
Heart failure will be one of our greatest medical challenges over the next few decades and is already accounting for a large proportion of hospital admissions. Treatments for acute events occurring as a result of heart failure are contributory, as is the treatment of chronic heart failure. As populations in many countries become older, an increase in incidence may be observed [1]. Approximately 20% of all Europeans aged 70 suffer from the symptoms of heart failure. Of all admissions to medical hospitals, 70% can be attributed to the symptoms of heart failure [2]. The reasons for this are, on the one hand, improved treatment of acute coronary artery disease events and, on the other hand, increased life expectancy [3]. Various drug regimes have become established for the treatment of patients with heart failure. A reduction in mortality could be proven in conjunction with ACE inhibitors [4–6]. Therapy with beta-blockers has become an established part of standard therapy programs [7,8]. The blocking of aldosterone receptors with spironolactone in patients with significantly reduced left-ventricular function also leads to reduced mortality. The role of digitalis therapy is not completely clear [9–11]. In addition to criteria like prevalence, incidence, mortality, hospitalization and socioeconomic costs, quality of life and psychological well being of patients with heart failure is also an important issue. That is why not only medical drug therapy must be taken into account, but also quality of life and improvement of functional capacity [12]. Training programs carried out with patients suffering from chronic heart failure have been proven to be effective [13,14]. Yet no clear instructions exist to date as to how such training programs should be carried out. Training programs particularly have to take into account peripheral muscle wasting, a frequent occurrence [15–18]. The aim of our study was to point out the importance of a reproducible training program especially combined with muscle strength training in order to improve quality of life, psychological well being and clinical parameters in patients with chronic heart failure.


   2. Methods
Top
 Notes
 Abstract
 1. Introduction
 2. Methods
3. Results
 4. Discussion
 References
 
2.1. Study population
Eighty-eight patients with stable chronic heart failure, 67 men and 21 women (76 and 24%, respectively), took part in a training program. The patients were aged between 39 and 79 years, mean age 65.8±8.2 years. The cause of heart failure was coronary artery disease in 68 patients (77%) and valvular heart disease in eight patients (9%). In 12 patients (14%), there were other causes. Important comorbidities were high blood pressure in 68% of patients, diabetes mellitus in 27% and hyperlipoproteinemia in 66%. Pre-existing medication was continued during the training program and pharmacological treatment was altered if necessary. Medication is detailed in Table 1. The main criterion for inclusion in our study was stable heart failure with a 45% left ventricular ejection fraction. In addition, maximum peak oxygen uptake had to be below 20 ml/kg. Exclusion criteria were: severe pulmonary diseases; cognitive disorders; and patients with physical limitations which would have prevented them from taking part in our training program. Patients who were unable to answer questions about health-related quality of life and psychological well being adequately were also excluded.


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  		Table 1 Medication

 
2.2. Study design
Patients underwent a standardized 4-week training program. All tests were performed before (entry) and at the end (discharge) of the training program. Patients were examined prior to the training program to ensure that the criteria for inclusion were fulfilled. Data were collected from an echocardiographic examination to determine left ventricular ejection fraction, cardiopulmonary exercise test and a measurement of walking range using the 6-min walk test. In order to record psychosocial factors, patients were questioned about their health-related quality of life and psychological well being. During the training program, training-related symptoms like dyspnea, pulse and blood pressure were controlled. All patients received advance information in writing about the form of the training program and the necessary examinations on entry and discharge. Data were recorded using the methods described below.

2.3. Echocardiography
Two-dimensional echocardiography (Acuson Aspen) was used to analyse left ventricular function on entry and on discharge according to the recommendations of the American Society of Echocardiography [19]. Left ventricular end-diastolic volume (LVEDD) and left ventricular end-systolic volume (LVESD) were obtained from the apical 4- and 2-chamber views. The left ventricular ejection fraction was calculated using Simpson's formula [20].

2.4. Cardiopulmonary exercise test
The cardiopulmonary exercise data were collected on a bicycle ergometer (Ergoline 900, Marquette/Hellige). The gas exchange parameters and peak oxygen uptake (peak VO2) were collected using an automated breath-by-breath system (Ganshorn, Ergoscope). We carried out a ramp-like test on the bicycle ergometer. An initial warm-up of 3 min without workload was followed by an initial level of 25 watts. Workload levels were increased by 10 watts every 2 min. This guaranteed that even patients with considerable muscle wasting were able to perform well enough on the ergometer to produce the exercise test data we required. Blood pressure was measured automatically by an oscillometric instrument every 2 min. Exercise test data were monitored during the 3-min recovery time. Cardiopulmonary exercise test was performed symptom-limited by dyspnea, physical exhaustion and fatigue. In addition, premature stopping criteria for exercise tests were adhered to.

2.5. Psychosocial factors
Health-related quality of life was assessed using the German version of the Short Form 36 Health Survey (SF-36) [21]. Quality of life is a multidimensional construction characterized by four essential components: psychological well being; physical functioning; social relations; and functional competence. The measure assesses eight dimensions, the sums of which describe physical and psychical health. For each item, patients were required to select the answer closest to their own experience. The types of answer possible varied from item to item, from yes/no answers to answers on a scale of 1–6.

In addition to health-related quality of life, anxiety and depression were also measured using the German version of the Hospital Anxiety and Depression Scale (HADS-D) [22]. This is a descriptive screening procedure used in the field of psychosomatic medicine in order to assess anxiety and depression as mental limitations. The questionnaire consisted of 14 items examining in equal parts (seven items each) the subscales of anxiety and depression. Answers were on a scale of 1–4 and in changing key directions.

2.6. Training program
The training program consisted of muscle strength training and bicycle ergometer training as well as the 6-min walk test as a training unit. Our overall weekly training program comprised muscle strength training (two to three times), bicycle ergometer training (three times) and the 6-min walk test as a training unit (twice).

Muscle strength training (MST) was initiated in order to train the lower limb muscles. A warm-up phase on the bicycle ergometer at a low workload was followed by a session on a shuttle exercising device. By stretching their legs against an individually adjustable resistance, patients moved up and down a track in a semi-prostrate position (Fig. 1). The level of resistance was determined by the number of rubber bands used. The number of rubber bands and the distance covered on the shuttle defined the necessary effort, expressed in kilograms per path (repeat unit). One training unit consisted of several consecutive series of repeat units. This enabled effort in kilograms to be calculated, referred to below as muscle strength training units (MST). For example, five series of 15 repeat units using three rubber bands (24 kg) over a distance of 26 cm would equal 1.8 MST (5x15x24 kg=1.8x103 kg or 1.8 MST).


Figure 1
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  		Fig. 1 Muscle strength training by a shuttle.

 
Bicycle ergometer training was carried out in standardized conditions. The maximum workload for bicycle ergometer training was defined by cardiopulmonary exercise test results. It corresponded to the heart rate measured at 60–80% of the maximum peak oxygen uptake. An initial warm-up of 5 min at 15 watts was followed by continuous training for a further 15–20 min. The maximum performance possible per training unit was achieved individually and symptom-limited.

The 6-min walk test was used following standardized instruction. Patients were asked to walk briskly down a set path for a period of 6 min. The distance covered was measured in meters. Standardized measuring of the distances covered was facilitated through markings on the floor of a gymnasium. Reproducibility was guaranteed by using a strictly standardized procedure for the test and performed by a constant room temperature of 22 °C and a room humidity of 68%.

2.7. Statistical analysis
The data collected during the tests were evaluated using the statistics software StatView (Version II) for Macintosh. Descriptive values were found to illustrate variables. Results on entry and discharge of the study period were compared. Normal distribution was tested out using the Kolmogorov–Smirnov Goodness of Fit Test. The class of the collected data indicates the adequate test procedure [23]. Test data for the individual scales in the SF-36 questionnaire were calculated in z-values, anxiety and depression in t-values. The t-tests for dependent random samples were carried out in order to ascertain differences. An alpha error of 5% was established for all tests. Using correlation calculations, we examined the extent to which the factors: age; maximum peak oxygen uptake; maximum ergometer performance; and left ventricular ejection fraction were related to changes in physical and psychical health. In order to measure training-related changes and changes in physical and psychical health, a new difference variable was taken from the data collected on entry and on discharge from the program. The Kolmogorov–Smirnov Goodness of Fit Test was performed in order to test the normal distribution of the variables.


   3. Results
Top
 Notes
 Abstract
 1. Introduction
 2. Methods
 3. Results
4. Discussion
 References
 
All patients took part in the training program and adhered to it to the end. None of the patients showed any immediate adverse cardiac response to the training program. No severe long-term adverse events occurred either.

3.1. Echocardiography
The left ventricular end-diastolic volume (LVEDD) was 143±59 ml on entry (T1) and 131±44 ml on discharge (T2) (P=0.01). The left ventricular end-systolic volume (LVESD) was 99±52 ml at T1 and 83±34 ml at T2 (P=0.01). The resulting left-ventricular ejection fraction (LVEF) increased from 31±8 to 37±9% (P=0.001).

3.2. Training-related effects
On entry the maximum symptom-limited, bicycle ergometer performance was 76±40 workload and on discharge it was 85±36 workload (P=0.001). The rate–pressure product sank not significantly from 15519±5183 to 15110±4962 (P=0.919). Maximum peak oxygen uptake, the 6-min walk test and muscle strength training results are listed in Table 2.


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  		Table 2 Exercise-related data on entry (T1) and on discharge (T2)a

 
3.3. Psychosocial factors
Significant changes occurred in the scales for physical functioning, role-physical, bodily pain, general health, vitality, role-emotional and mental health. The greatest increases were recorded for the scales physical functioning (z at T1=–1.38, z at T2=–0.89) and role-physical (z at T1=–1.2, z at T2=–0.26). There were no significant changes in the answers relating to anxiety and depression between entry and discharge. Scale-related patient answers are listed in Table 3. Correlation calculations to ascertain relations between age, maximum peak oxygen uptake, maximum workload and left ventricular ejection fraction (T1) on the one hand and changes in physical and psychical health on the other are listed in Table 4. There is a negative correlation between the initial workload and changes in physical health (Fig. 2). There is also a weak correlation between age and positive changes on the SF-36 scale pertaining to physical health (r=0.26, P=0.05). Initial workload and training-related increase in muscle strength training units are positively correlated (r=0.33, P=0.01). The remaining variables showed no significant correlations.


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  		Table 3 Psychosocial data on entry (T1) and on discharge (T2)a

 


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  		Table 4 Patient characteristics and their relationship to exercise-related data and quality of lifea

 


Figure 2
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  		Fig. 2 Correlation between maximal exercise workload and difference of physical health on entry and on discharge.

 

   4. Discussion
Top
 Notes
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
References
 
These results for patients with chronic heart failure from our training program, comprising muscle strength training, bicycle ergometer training and the 6-min walk test as a training unit reveal both an improvement in cardiopulmonary exercise-related data and a subjective improvement in quality of life, assessed using the SF-36 questionnaire. Anxiety and depression were not influenced (HADS-D questionnaire).

In the patient group we examined, no serious events occurred. This underlines the executability and safety of a training program in patients with chronic heart failure, as recommended by the Working Group on Cardiac Rehabilitation and Exercise Physiology and the Working Group on Heart Failure of the European Society of Cardiology [24] and from the Board of the German Society for Cardiology, Cardiac and Cardiovascular Research [25]. The type and extent of such training programs are still under discussion, however, and require further evaluation. Our training program comprised a combination of bicycle ergometer training, the 6-min walk test as a training unit and special muscle strength training. This combination permits both static and dynamic exercising. Comparable to other controlled studies, the safety of such a training program in patients with chronic heart failure could be confirmed. Undesirable side effects due to a moderate shuttle training did not occur, although we included a significantly older group of chronic heart failure patients (mean age=65.8±8.2 years). The mean age in other comparable studies ranged from 52±2 to 61.8±1.5 years [26,27]. Even in our older group we were able to show positive effects with regard to an increase in maximum peak oxygen uptake, in line with the studies by Hambrecht and Schuler [12], Belardinelli et al. [13] and Coats et al. [26]. In contrast to the above mentioned studies, the mean ejection fraction (31.4±8%) of our older patients on entry was slightly higher and increased significantly on discharge (37.6±9%). Such a positive effect on left ventricular ejection fraction could not be observed by others and may be explained by increased doses of beta-blockers [13].

The 6-min walk test seems to be a very simple alternative for measuring exercise capacity of patients with chronic heart failure [28]. The reproducibility of the test has been shown by replicate measurements without great differences in the walking distance [29]. There is, however, no clear link between the maximum distance walked and cardiac function [30]. There is a significant relation between the distance walked and mortality as well as peak VO2. The 6-min walk test does appear to be an alternative method of risk determination in patients with chronic heart failure. A walking range of less than 300 meters corresponded to a 1-year mortality of 50%. When the range was more than 450 meters, 1-year mortality was just a few percent [31]. The extent to which physical exercise leading to a major walking distance within 6 min relativizes these statements is not clear. Training leads to an increase in the 6-min walk test distance, and results improve the worse the function limitations are [32].

Chronic heart failure is accompanied by considerable changes to the skeletal muscles and can lead to peripheral chemoreceptor hypersensitivity [33]. This loss to the peripheral skeletal muscles seems to be related to significant changes at a neurohumoral and immunologic level [16]. Muscle wasting is characteristic of heart failure and correlates to maximum peak oxygen uptake. In patients with a peak oxygen uptake of below 14 ml, Opasisch et al. [17] were able to ascertain significantly reduced strength in both the respiratory muscles and the muscles of the lower extremities. There is a negative correlation between increased efferent sympathetic nervous activity and maximum peak oxygen uptake [34]. This could be an explanation for peripheral neurogenic limitation in patients with chronic heart failure. Prolonged recovery of cardiac output back to baseline values following maximum exertion seems to be explained by increased systemic vascular resistance [35]. Training the lower limb muscles seems to be particularly significant for the pathophysiology of patients with chronic heart failure. Studies on special strength training for the respiratory muscles exist [36,37]. Muscle strength training in patients with chronic heart failure is still controversial. Only a few studies exist [38–40]. The muscle strength training we performed using a shuttle device can ideally be adapted to individual patient capacity due to its good reproducibility, documentation and dosage. Our proposed method of measuring effort, uniform in its combination of resistance (rubber bands), distance covered on a shuttle device and the number of series and repeat units executed, seems to us to be an ideal way of guaranteeing standardized documentation. The increase in functional capacity achieved during our training program appears to be important, and its significance with regard to pathophysiologic changes in the peripheral skeletal muscles is seemingly underlined.

A training program can have considerable influence on endothelial function [41,42]. Uncertainty arising from lack of standardization, limits the transfer of these results to hospital routines [14,24,43]. Neither have sufficient answers been found to the issue of whether interval training is transferable to hospital routines from a practical point of view, even though myocardial oxygen consumption and lactate reduction are lower than with steady state training [44,45].

Assessing quality of life, anxiety and depression must especially be taken into account since the patients’ own evaluation of their illness plays a significant role in addition to clinical parameter measurements [46]. A standardized training program is preceded by emotional and life threatening events which lead to uncertainty, anxiety and depression [47,48]. Physical inactivity during the acute stage of the disease and convalescence have a negative influence on emotional status and can lead to a complete loss of enjoyment and activity [49]. Measurement of quality of life and psychological well being, plus any measures which can lead to a positive change in these areas appear to merit central significance [50]. Even a short-term program lasting 4 weeks can be accompanied by an increase in functional capacity and in quality of life. The SF-36 questionnaire is well suited to the standardized and practicable documentation of quality of life [21,51]. The questionnaire could even be incorporated in our group of older patients in the form of interviews. Anxiety and depression scales remained unchanged in our patients, this could possibly be explained by their increased age and the high proportion of male patients, as well as the fact that anxiety and depression are particularly multifactorial and may be influenced by psychosocial factors and the underlying disease [52,53].

Taking psychological factors into account seems to have considerable importance in evaluating the effectiveness of training programs for patients with chronic heart failure. It is still unclear, however, how these factors are influenced by hemodynamic parameters [54,55]. We were also unable to provide evidence of a relationship between physical health and clinical parameters. Our results show that the initial workload of our training program is negatively correlated to improvements in physical health. This means that in cases of poor initial performance an improvement over the course of the training program is particularly valuable. As we could demonstrate, left ventricular ejection fraction determined at rest is not significant for the subjective perception of quality of life. This could be due to the assumption that exercise cardiac output response is independent of the ejection fraction measured at rest, but depend on extra cardiac factors.

Chronic heart failure is a challenge requiring practical training programs leading to a reduction in new hospital admissions [56]. Equally important, however, is emotional support, especially for older patients [48]. The standardized training program we propose meets these requirements and is simple to execute.


   Acknowledgements
 
The authors wish to thank Sarah L. Kirkby for her assistance in preparing this manuscript.


   Notes
Top
 Notes
Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 References
 
{star} Presented in part at: Heart Failure 2001, Barcelona, Spain, June 9–12, 2001. Back


   References
Top
 Notes
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 References
 

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