Teffaha D. Relevance of Water ...

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//-->Journal of Cardiac Failure Vol. 17 No. 8 2011Relevance of Water Gymnastics in Rehabilitation Programs inPatients With Chronic Heart Failure or Coronary Artery DiseaseWith Normal Left Ventricular FunctionDALINE TEFFAHA, PhD,1LAURENT MOUROT, PhD,2PHILIPPE VERNOCHET, MD,3FAWZI OUNISSI, MD,3JACQUES REGNARD, MD, PhD,2CATHERINE MONPERE, MD,1,3AND BENOIT DUGUE, PhD1Poitiers, Besancon, and Ballan-Mir, France¸eABSTRACTBackground:Exercise training is included in cardiac rehabilitation programs to enhance physical capac-ity and cardiovascular function. Among the existing rehabilitation programs, exercises in water are in-creasingly prescribed. However, it has been questioned whether exercises in water are safe andrelevant in patients with stable chronic heart failure (CHF), coronary artery disease (CAD) with normalsystolic left ventricular function. The goal was to assess whether a rehabilitation program, includingwater-based gymnastic exercises, is safe and induces at least similar benets as a traditional land-based training.Methods and Results:Twenty-four male CAD patients and 24 male CHF patients with stable clinicalstatus participated in a 3-week rehabilitation. They were randomized to either a group performing thetraining program totally on land (CADl, CHFl; enduranceþcallisthenic exercises) or partly in water(CADw, CHFw; land enduranceþwater callisthenic exercises). Before and after rehabilitation, left ven-tricular systolic and cardiorespiratory functions, hemodynamic variables and autonomic nervous activitieswere measured. No particular complications were associated with both of our programs. At rest, signi-cant improvements were seen in CHF patients after both types of rehabilitation (increases in stroke volumeand left ventricular ejection fraction [LVEF]) as well as a decrease in heart rate (HR) and in diastolic ar-_terial pressure. Signicant increases in peaksVO2, HR, and power output were observed in all patientsafter rehabilitation in exercise test. The increase in LVEF at rest, in HR and power output at the exercisepeak were slightly higher in CHFw than in CHFl.Conclusions:Altogether, both land and water-based programs were well tolerated and triggered improve-ments in cardiorespiratory function. (JCardiac Fail 2011;17:676e683)Key Words:Cardiac disease, cardiovascular system, exercise training, rehabilitation, water-basedexercises.Physical exercise has been proven to be relevant incardiac rehabilitation programs in patients with coronaryartery disease (CAD) and chronic heart failure (CHF). Itinduces improvements in cardiac performance as leftventricular ejection fraction and maximal cardiac output,skeletal muscle, metabolic adaptations, and endothelialFrom the1Universit de Poitiers, Laboratoire des Adaptations Physiolo-eegiques aux Activits Physiques, Poitiers, France;2Universit de FrancheeComt, Explorations Fonctionnelles-Physiologie, CHU Besancon,e¸eBesancon, France and3Centre de Radaptation Cardiovasculaire Bois¸Gibert, Ballan-Mir, France.eManuscript received January 4, 2010; revised manuscript received April7, 2011; revised manuscript accepted April 11, 2011.Reprint requests: Benoit Dugu, PhD, UFR Sciences du Sport de l’Uni-eversit de Poitiers et Laboratoire des Adaptations, Physiologiques auxeActivits Physiques (EA 3813), 8, alle Jean Monnet, 86000 Poitiers,eeFrance. Tel:þ33549454040;Fax:þ33549453396.E-mail:benoit.dugue@univ-poitiers.frfunction as well as a marked reduction in subsequentmajor cardiac morbidity and mortality.1e7Physical exer-cises in rehabilitation programs can easily be performedin thermoneutral water, and such practices are more andmore commonly used in cardiac centers (in France,around 27 % of cardiac rehabilitation centers haveFunded by grants from the Syrian Ministry of Higher Education (D.T.),the French Ministry of National Education of Research and of Technology(EA 3813 and EA3920), the Fdration Francaise de Cardiologie, and thee e¸Fondation de l’Avenir.Conict of Interest: None.See page 682 for disclosure information.1071-9164/$ - see front matterÓ2011 Elsevier Inc. All rights reserved.doi:10.1016/j.cardfail.2011.04.008676Water Gymnastics in Cardiac RehabilitationTeffaha et al677a swimming pool). Exercise in water, because of buoy-ancy, is well known to improve mobility, strength, andcan easily be performed even by patients with reducedmobility.3,8e13However, such procedures have not been thoroughlyevaluated. It has even been argued that water-based gym-nastic exercise and swimming could be dangerous for car-diac disease patients because of a sudden and largeincrease in the preload.14,15Initially, it has been arguedthat the volume shift, induced by water hydrostatic pres-sure, might overstrain the cardiovascular adaptive mecha-nisms in patients with heart failure and may lead to leftventricular decompensation.15Recent works showed thatin patients with heart failure, acute thermoneutral water im-mersion could be well tolerated and may lead to a numberof benecial physiological responses.8,16e18However, thelong-term effect of repetitive exercise training sessions inwater has not been studied so far, especially in heart failurepatients.Therefore, the aim of this study was to assess whethera rehabilitation program including water-based gymnasticexercises at a thermoneutral temperature is safe andwhether it could induce at least similar or additional bene-ts in cardiorespiratory and cardiovascular functions com-pared with a traditional land-based training in patientswith stable chronic heart failure or coronary artery diseasewith normal left ventricular function.Subjects and MethodsSubjectsForty-eight men participated in this study; 24 patients had sta-ble CHF, and 24 patients had CAD with normal left ventricularfunction. Baseline characteristics of patients are presented inTable 1.CAD patients had normal left systolic function with anejection fraction higher than 50% and no history or symptomsof heart failure. They were referred for cardiac rehabilitation afteran acute coronary syndrome with or without ST segment eleva-tion. CHF patients had left ventricular systolic dysfunction denedas ejection fraction equal to or lower than 40%. Heart failure re-sulted from ischemic or idiopathic dilated cardiomyopathy. A cor-onary angiogram was performed in all patients. The patients wereclinically stable for at least 2 weeks and were on a stable treat-ment regimen, except for diuretics where the titration could bemodied if needed. They had not previously participated in a com-parable study. Exclusion criteria were water phobia, cutaneous in-fection, urinary incontinence, disabling disease that might haveinterfered with the exercise protocol, and all the contraindicationsto exercise test or training sessions. The study protocol compliedwith the declaration of Helsinki and was reviewed and acceptedby the ethical committee of Tours (France). All subjects were in-formed about the study procedure and gave their written informedconsent.Within each disease population, the patients were randomizedto either a group performing the training program totally onland (enduranceþcallisthenic exercises) or partly in water(land enduranceþwater callisthenic exercises). Allocationto each group was determined by computer-generated randomnumbers.Rehabilitation ProgramsThe study was conducted at the Centre of Cardiovascular Reha-bilitation of Bois Gibert, Ballan Mir, France. The patients wereeinvolved in a 3-week rehabilitation program 5 times per week.The rehabilitation program of each participant comprised aerobicexercises performed on land on a cycle ergometer (30 minutes perday, 5 times per week, at an individualized target intensity heartrate recorded at the ventilatory threshold during the rst exercisetolerance test). In addition, gymnastic (callisthenic) sessions of50 minutes per day were performed on land (CADl and CHFlgroups) or in immersed condition (CADw and CHFw groups)5 times per week, at an intensity based on the target heart rateas previously dened. Water-based gymnastic exercises were per-formed in the swimming pool of the Cardiac Rehabilitation CentreBois Gibert at a constant water depth of 1.30 meters and with a sta-ble water temperature of 30 to 32C and an outside temperature of25 to 26C.The callisthenic sessions were performed upright whether theywere on land or aquatic. They began with a 5-minute warmingup period (slow-pace walk, segmental movements at low speed,stretching). The core of the session lasted 25 minutes and com-prised exercises involving muscle groups of the lower and theupper limbs and torso with a progressive increase in intensity(increased number of repetitions and velocity). The sessionended with 5 minutes of recovery while seated where the patientonly performed abdominal respiratory movements. During thesession, the patients scheduled their inspiration and expirationwithin each segmental movement. All training sessions wereconducted under supervision of a physical therapist with heartrate monitoring (Polar Electro Oy, Kempele, Finland) to main-tain the exercise intensity at the target heart rate during thecore of the session.In addition to exercise training programs, all the patients at-tended a comprehensive rehabilitation program focused on sec-ondary cardiovascular prevention, educational sessions, andpsychosocial and vocational managements if needed (eg, stressmanagement, nutritional education program, smoking cessationconsultation).Experimental DesignAll patients were investigated before and after 3 weeks of therehabilitation program. Cardiopulmonary stress test, echo-Doppler cardiography, noninvasive hemodynamic measurements,and assessment of autonomic functioning were performed beforeand after completion of the training program. All investigationsstarted 2 hours after a light meal and at the beginning of the after-noon. First, the patients underwent an echocardiography measure-ment in supine posture during 30 minutes. Afterwards,cardiovascular evaluations (noninvasive hemodynamic measure-ments and evaluation of autonomic nervous system) were per-formed at rest in a supine posture during 15 minutes (after20 minutes of rest) and then during an exercise tolerance testand during 2 minutes of recovery. All evaluations were organizedon land (dry ambiance) in a quiet, dimly lit room with a stableambient temperature (22 to 25C).Echocardiography MeasurementsEchocardiographic measurements were calculated using anAcuson Sequoia C-256 (Siemens, New York, NY) machine witha 3.5-MHz transducer employing harmonic imaging (3V2 Cs) in678Journal of Cardiac Failure Vol. 17 No. 8 August 2011Table 1.Patient Characteristics before RehabilitationChronic Heart Failure Patients (n524)Land-basedRehabilitation (n512)Age (y)Height (cm)Weight (kg)BMI (kg$mÀ2)LVEF (%)_VO2peak (ml$minÀ1$kgÀ1)Etiology of heart failureIschemic heart diseaseDilated cardiomyopathyNYHAMedicationb-blockersVasodilators*DiureticsAnti-aldosteroneDigitalis53.3169.876.126.428.918.26666664.21.32.10.82.21.6Coronary Artery Disease Patients (n524)Land-basedRehabilitation (n512)53.2174.484.927.957.824.16666662.90.82.50.81.41.3Water-basedRehabilitation (n512)51.7175.378.625.630.220.06666663.62.12.50.82.02.1Water-basedRehabilitation (n512)51.6171.174.225.259.227.76666663.11.54.51.31.71.775II (n52)III (n510)121187e84II (n51)III (n511)119622eeII (n512)12111eeeeII (n512)87eee_BMI5body mass index; LVEF5left ventricular ejection fraction;VO2peak: oxygen consumption at peak exercise tolerance test; NYHA5New YorkHeart Association Functional Class.*Angiotensin-converting enzyme inhibitors and angiotensin receptors-II antagonists.all patients at baseline and at the end of rehabilitation. Two-dimensional transthoracic echocardiography was performed withpatients in the left lateral decubitus position in the parasternalshort and long axes, taking apical 4- and 2-chamber views. Leftventricular diameters (end-diastolic diameter [LVEDD] and endsystolic diameter [LVESD]) and left ventricular ejection fraction(LVEF; assessed according to modied Simpson method) werecalculated.Doppler echocardiography was performed in the apical 4-chamberview, and the left ventricular diastolic lling pressure pattern wasassessed from measurements of peak velocity of the early rapid ll-ing wave (E), peak ow velocity of atrial contraction (A), decelera-tion time of mitral valve, early peak velocity of E wave at the mitralannulus (Ea), pulmonary A wave duration (Ap), and mitral A waveduration (Am). The ratio of the peak velocities waves E and A(E/A) calculated at the level of the transmitral ow, the ratio of thevelocity of the transmitral wave to the mitral annulus (E/Ea) andthe difference between the period of the pulmonary wave and the mi-tral wave (Ap-Am) were also calculated.Noninvasive Hemodynamic MeasurementsHemodynamic variables (systolic and diastolic arterial pres-sures [SAP, DAP], heart rate [HR], stroke volume [SV], cardiacoutput [CO], large [C1] and small [C2] artery compliance indices,systemic vascular resistance [SVR]) were evaluated by applana-tion tonometer with a non-invasive method (HDI/PulseWaveCR-2000 device, Hypertension Diagnostics, Inc., Eagen, MN).This method has been described in detail elsewhere.16,19Evaluation of the Autonomic Nervous SystemThe autonomic nervous system was investigated using heart ratevariability analysis. R-R intervals were obtained continuouslyfrom a standard electrocardiogram and analyzed with special soft-ware (Biomedical Signal Analysis Group, UV. Kuopio, Finland),as previously described.20Power spectral analysis was performedon consecutive 128-second (Â 25256 points) time pointsselected between 15 minutes of recordings in a supine positionat rest. A selection of a 5-minute section free from artefacts ormarked sudden changes in respiration or R-R interval was per-formed for each recording condition. Time domain analysis in-cluded measurements of the mean R-R interval and its standarddeviation. Spectral analysis was performed by fast Fourier trans-formation, and spectral heart rate variability was expressed asa very low frequency band (0 to 0.04 Hz), low-frequency band(LF: 0.04 to 0.15 Hz), and high-frequency band (HF: 0.15-0.40).Mean R-R intervals, LF bands of the spectrum, and HF were mea-sured. Total power of the spectrum and the ratio LF/HF were alsocalculated.Exercise Tolerance TestEach patient performed a symptom-limited cardiopulmonaryexercise test before (at baseline) and after 3 weeks of the rehabil-itation program on an electrically braked cycle ergometer (ERG900, GE Medical System, CASE Exercise Testing System Case,Milwaukee, WI) using a ramp protocol with a 10 watts$minÀ1workload increase until exhaustion. Twelve-lead electrocardio-gram and heart rate were continuously monitored during exerciseand recovery, whereas cuff blood pressure was measured every2 minutes and at exercise peak._Breath-by-breath gas exchange measures (oxygen uptakeVO2,__carbon dioxide productionVCO2, ventilationVE)were performedusing a V Max Spectra System device (Sensor Medics Corpora-tion, Yorba Linda, CA) with the values being averaged every10 seconds. The ventilatory threshold (VT) was determined usingthe V-slope method of Beaver and Wassermann.21The slope of the__relationship betweenVEandVCO2was calculated up to the VT_2/VO2(respiratory exchange ratio; RER) at_point. The ratioVCO40 watts was also calculated.The heart rate recovery (HRR) was estimated as the differencebetween the heart rate measured at the peak exercise tolerance testand that one measured after 1 minute of recovery (HRR5peakHReHR at 1 minute of recovery).22Water Gymnastics in Cardiac RehabilitationStatisticsData are expressed as mean6standard deviation (SD). Statis-tical analyses were performed using STATISTICA AVANCEEprogram version 8 (StatSoft, Maisons Alfort, France). The normal-ity tests of Kolmogorov-Smirnov and Lilliefors was used to exam-ine whether the distribution of the data was Gaussian. In case ofthe non-Gaussian distribution, we used log-transformed sets ofour data.Each disease group was treated separately. Baseline characteris-tics between the land-based and water-based gymnastic groupswere tested with an unpairedt-test.Then, data obtained before and after the training programs inland-based and water-based gymnastic groups were studied with2-way analysis of variance of repeated measurements. APvaluelower than .05 was considered signicant.Besides the interaction in the 2-way analysis of variance for re-peated measurements, the effect size was also calculated to inves-tigate the rehabilitation effects (before vs. after) in each subgroupof patient results. The effect size (d), dened as the difference be-tween the means divided by standard deviation of either group,was calculated using the following formula: d5(M1-M2)/[((SD1)2-(SD2)2)/2]0.5where M is the mean and SD is the stan-dard deviation. We estimated a small difference when d valueswere#0.2, a moderate difference when d was approximately0.5 and a large difference when d was 0.8 or above.23Teffaha et al679ResultsThe characteristics of the subjects are presented inTable 1.At the beginning of the rehabilitation program, therewere no signicant differences between the groups per-forming the land-based rehabilitation and thoseexperiencing the program that included water-based gym-nastics, both in CHF and CAD patients (Table1).Duringthe gymnastic sessions, the mean heart rate was similar inthe different groups (76.865.6, 73.766.5, 72.166.4,and 67.864.2 beats/min, in CHFl, CHFw, CADl, andCADw, respectively).All the patients were able to complete the 3-week of therehabilitation program, either in CAD or CHF groups, inwater- or land-based groups. Two CHF patients, both allo-cated to water-based gymnastic sessions, had to temporarilyquit the training program for 1 week. This was not linked toimmersion per se but was due to heart failure worsening, in1 patient because of intercurrent bronchopulmonary infec-tion, and in the other one because of inappropriate diureticdosage intake. Both patients resumed the training afterwardwithout any complications.Rest echocardiography completion of the 3-week reha-bilitation program revealed no deleterious effects in anyof the patients. In the two subgroups of CAD patients,left ventricular parameters (LVEDD, LVEF, and measureof diastolic lling pressure) were unchanged after the 3 re-habilitation weeks (Table2, Fig. 1).In CHF patients atbaseline, the diastolic lling pressures remained stablewithin reference interval. No changes in LVEDD and inend diastolic lling pressures were observed.However, LVEF was slightly but signicantly improved(P!.05) after the rehabilitation program in CHF patients(Fig.1).This improvement was slightly higher in CHF pa-tients who were randomized to water program (effect sizeof 0.44 and 0.21 in CHFw and CHFl, respectively).In both CAD and CHF patients, resting DAP was foundsignicantly lower after the completion of the rehabilitationTable 2.Echocardiography Parameters at RestChronic Heart Failure Patients (n524)BeforeLVEDD (mm)LandWaterLVESD (mm)LandWaterE/ALandWaterE/EaLandWaterAp-Am (ms)LandWaterTDM (ms)LandWater66.162.466.862.751.162.950.363.51.661.22.061.411.967.75.662.127.6612.930.1616.9162.6694.3149.0646.0Coronary Artery Disease Patients (n524)Before53.261.853.060.933.861.132.261.21.460.51.260.34.761.44.461.123.0618.718.3610.8176.9630.2197.2630.9After66.561.266.562.450.162.150.162.91.661.51.760.99.466.55.762.421.6612.1*22.6612.5*174.2651.0162.7645.0After52.761.853.360.732.361.530.460.51.260.41.260.34.261.04.561.116.6614.917.2615.0181.8622.3193.0634.3Ap-Am5the difference between the duration of the pulmonary wave and the mitral wave; E/A5the ratio of the peak velocities waves E and A (cal-culated at the level of the transmitral ow); E/Ea5the ratio of velocity of the transmitral wave to the mitral annulus; LVEDD5left ventricular end diastolicdiameter; LVESD5left ventricular end systolic diameter; TDM5deceleration time of mitral wave.Twenty-four chronic heart failure and 24 coronary artery disease patients were studied before and after 3 weeks of rehabilitation performed on land(enduranceþcallisthenic exercises; n512) or partly in water (land enduranceþwater callisthenic exercises; n512).*Signicantly different from the data obtained before rehabilitation,P!.05.680Journal of Cardiac Failure Vol. 17 No. 8 August 2011Fig. 1.Individual left ventricular ejection fraction data from 24 chronic heart failure and 24 coronary artery disease patients are reportedbefore and after 3 weeks of rehabilitation performed on land (enduranceþcallisthenic exercises; n512) or partly in water (landenduranceþwater callisthenic exercises; n512). Numbers in the graph indicate the mean value of ejection fraction obtained beforeand after rehabilitation. *5signicant difference from the data obtained before rehabilitation,P!.05; a5higher effect size inwater-based gymnastics than in land-based program; NS5no signicant changes; CAD5coronary artery disease; CHF5congestiveheart failure; LVEF5left ventricular ejection fraction.period (P!.05). In CHF patients, HR signicantly de-creased (P!.05), while SV signicantly increased(P!.05) after the 3-week rehabilitation course (Fig.2).Mean RR intervals was also signicantly increased afterthe rehabilitation (from 1.0060.16 vs 0.9460.15 to1.0660.18 vs 0.9960.09 s, in CHFl and CHFw, respec-tively;P!.05). No signicant changes occurred in otheraspects of heart rate variability and in vascular characteris-tics measured by applanation tonometry neither in CAD norin CHF patients._At maximal exercise test, peaks of power output,VO2and HR were signicantly higher at the end of the rehabil-itation period than before in both CAD and CHF patients(P!.05). The HRR was only increased in CHF patients(Table3).Interestingly, in CHF patients the changes inpeak power output and peak HR were signicantly higherafter the rehabilitation that included water-based gymnasticexercises than in the CHF control group that followed theland-based rehabilitation (signicant interaction,P!.05)(Table3)._ _During the exercise tolerance test, theVE/VCO2ratio atVT and the RER at the workload of 40 W were both signif-icantly lowered in CHF patients after the rehabilitation pro-gram (P!.05), whereas they did not change in CADpatients (Table3).DiscussionThe impact of water-based exercises in cardiac rehabili-tation is not clear so far. In the context of patient safety,such practice has even been questioned. In the presentstudy, we compared the effects of cardiac rehabilitationthat included water-based gymnastic exercises with conven-tional land-based rehabilitation in CHF patients who hada stable clinical status and CAD patients with normal leftventricular function.We found that water-based gymnastic in cardiac rehabil-itation was well-tolerated by all patients, whether they wereCHF or CAD patients. Signicant benets were obtainedregarding cardiorespiratory efciency after 3 weeks of re-habilitation in CAD and CHF patients in both land and wa-ter programs.Considering the trends we observed in the benets ofwater-based versus land-based gymnastic exercises (trendfor a larger increase in LVEF at rest, signicant increasesin peak power output and peak HR during exercise), morepatients should denitely be studied.It has been questioned whether water gymnastic exer-cises are safe for CHF patients as thermoneutral head-outwater immersion could overstrain their cardiovascularadaptive capacities. In water, the hydrostatic pressure re-duces the vascular capacitance and induces a translocationof peripheral blood (about 700 mL) into the abdominal andthoracic vascular beds that lead to a higher preload.17,24,25In healthy subjects, a rise in preload increases the strokevolume and cardiac output according to the Frank-Starling mechanism.25However, there are some limits tothis adaptive mechanism, especially in CHF patients26,27in whom the rise in end diastolic pressure could inducepulmonary congestion.14,15In our study, all patients completed the rehabilitationperiod without any severe complications in both land andwater programs. Both programs were well tolerated inCAD patients with normal left ventricular and in CHF pa-tients despite severe reduction in left ventricular function_(LVEF!40%) and physical capacities (VO2peak!20À1À1ml$min$kg) before the rehabilitation.At rest, no deleterious effect was observed on left ven-tricular remodelling (e.g. no change in left ventricular di-ameters, nor in left ventricular diastolic lling pressures),neither in CAD nor in CHF patients. In both subgroups ofCHF patients, the resting LVEF was signicantly improvedafter completion of the 3-week rehabilitation period. More-over, the improvement magnitude of LVEF seemed slightlyhigher in CHF patients who performed the water-basedexercising. [ Pobierz całość w formacie PDF ]