RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
KARNATAKA, BANGALORE
Annexure II
Preformat for Registration of Subject for Dissertation
1. / Name of the candidate and Address (In Block letters) / ANUP AVENUVIHAR NEAR SHETTY ICECREAM
SUBHASH CHANDRA NAGARA
KULAI MANGALORE
2. / Name of institution: / CITY COLLEGE OF PHYSIOTHERAPY MANGALORE
3. / Course of study and Subject: / MASTER OF PHYSIOTHERAPY (MPT) 2 YEARS DEGREE COURSE
CARDIORESPIRATORY DISORDER AND INTENSIVE CARE
4. / Date of Admission to course: / 30/06/2012
5. / Title of the topic: / A COMPARATVE STUDY BETWEEN THE EFFECT OF COMBINED ENDURANCE-RESISTANCE TRAINING VERSUS AEROBIC INTERVAL TRAINING IN CHF PATIENTS
6. / Brief resume of the intended work:
6.1) Introduction and need of the study
Heart failure does not mean the heart has stopped working. Rather, it means that the heart's pumping power is weaker than normal. With heart failure, blood moves through the heart and body at a slower rate, and pressure in the heart increases 1.
As a result, the heart cannot pump enough oxygen and nutrients to meet the body's needs. The chambers of the heart may respond by stretching to hold more blood to pump through the body or by becoming stiff and thickened. This helps to keep the blood moving, but the heart muscle walls may eventually weaken and become unable to pump as efficiently. As a result, the kidneys may respond by causing the body to retain fluid (water) and salt 4, 5. If fluid builds up in the arms, legs, ankles, feet, lungs, or other organs, the body becomes congested, and congestive heart failure is the term used to describe the condition. There are many causing factor CHF like coronary artery disease ,high blood pressure (hypertension), longstanding alcohol abuse, disorders of the heart valves unknown (idiopathic) causes, such as after recovery from myocarditis. It is possible to develop congestive heart failure with or without the risk factor 6.
However, the more risk factors you have, the greater your likelihood of developing congestive heart failure. The following medical conditions put you at increased risk for developing CHF: Hypertension (high blood pressure), Coronary artery disease, Diabetes, Obesity, Hyperthyroidism Severe emphysema, Previous history of heart disease, Valvu-lar heart disease lifestyle factors such as Excessive alcohol consumption, and smoking, long-term use of anabolic steroid 5. CHF is most common in people who are older; most people who have CHF are age 65 or older.
Recent studies suggest that peak exercise oxygen uptake (V˙ O2peak), a measure of cardiopulmonary exercise capacity, strongly predicts prognosis in CHF, exhibiting a higher positive correlation with mortality than clinical indexes, including pulmonary capillary wedge pressure and left ventricular ejection fraction. In addition, improvement in V˙O2peak is associated with enhanced survival in patients awaiting cardiac transplantation 9.
Need of the study
Congestive heart failure (CHF), or heart failure, is a condition in which the heart cannot pump enough blood to the body's other organs. The heart keeps working but it does not work as efficiently as it should. As a result, the body’s needs for oxygen and nutrients are not met. As blood moves through the heart and body less efficiently, pressure in the heart increases. The heart’s chambers stretch to hold more blood to pump throughout the body. Over time the heart muscle walls weaken and cannot pump as strongly. The kidneys often respond by causing the body to retain fluid or water and sodium (salt). The fluid builds up in the arms, legs, feet, ankles, lungs or other organs and causes swelling. The body becomes congested. Chronic heart failure exhibits an impaired exercise tolerance that severely limits their functional capacity and quality of life.
Endurance and resistance training is generally used to seek further health benefits or enhanced physical performance and combined endurance and resistance training--increasing both aerobic capacity and maximal strength simultaneously.
Interval training is an excellent way to burn more calories, build endurance quickly and make workouts more interesting. Interval training involves alternating high intensity exercise with recovery periods and there are a variety of ways to set up interval workouts. One option is measured periods of work followed by measured periods of rest. An example would be 1 minute of high intensity work (such as a sprint), followed by 2 minutes of low intensity exercise (e.g., walking) and alternating that several times for 15-30 minutes.
Majority of training studies have used aerobic modalities, which improve cardiorespiratory fitness but are not specifically targeted at skeletal muscle. Because skeletal muscle abnormalities are an important limitation to exercise tolerance in CHF patients, and muscular strength impacts their capacities to perform daily tasks. This study aims to improve both endurance and strength to make them more confident and physical active through combined endurance resistance training24.
Research question
Will there be any improvement in endurance and strength in CHF patients who are treated with combined endurance and resistance training.
Hypothesis
Hypothesis –There will be statistically significant improvement in endurance and strength in CHF patients who are treated with combined endurance resistance training and aerobic interval training.
Null hypothesis-There is no statistically significant improvement in endurance and strength in CHF patients who are treated with combined endurance resistance training and aerobic interval training.
6.2) REVIEW OF LITERATURE.
1. Haskell W.L., et al. (2000) evaluated that Impact of home-based walking and resistance training program on quality of life in patients. Obtained results show that quality of life improved more markedly in AIT subjects than in other groups.
2. Camargo MD et al., (2007) compared that the effect of the aerobic training and the circuit weight training up on morphological and functional cardiac adaptations. Results concluded that aerobic training and circuit weight training improved strength in the lower limbs and only circuit weight training resulted in improvement of strength of upper limb.
3. Rognmo O et al.,(2004) compared that High intensity aerobic interval exercise is superior to moderate intensity exercise for increasing aerobic capacity
4. Clin Rehabil et al., (2012) evaluated that Aerobic interval training increases peak oxygen uptake more than usual care exercise training in myocardial infraction patients. The results obtained is peak oxygen uptake increased more than after usual rehabilitation in subjects to whom AIT given.
5. Robert D. (2008) points out that both resistance and aerobic exercise mitigated fatigue in men with PCa receiving radiotherapy. Resistance exercise generated longer-term improvements and additional benefits for strength, triglycerides, and body fat
6. Drummond, M.J et al., (2005).conducted a study on Aerobic and resistance exercise sequence affects excess post exercise oxygen consumption. Concluded that the Excess post-exercise oxygen consumption (EPOC) levels returned to pre-exercise values within 40 minutes of all 4 exercise sessions, thus confirming previous research which shows that the prominent effect of the exercise after-burn is within the first 2 hours of exercise.
7. Mandic S et al., (2009) compared combined aerobic and resistance training significantly improved upper extremity strength and muscular endurance compared with aerobic training .Quality of life was improved in the aerobic group only.
8. Loennechen JP et al., (2007) compared superior cardiovascular effect of aerobic interval training versus moderate continuous training in heart failure patients. Study revealed that VO2peak increased more with aerobic interval training than moderate continuous training. Improvement in brachial artery flow-mediated dilation (endothelial function) was greater with aerobic interval training, and mitochondrial function in lateral vastus muscle increased with aerobic interval training only.
9. Rochester C.L et al., (2003) conducted a study that the skeletal muscle dysfunction is a major factor which contribute to exercise intolerance in COPD Both resting and exercise muscle metabolism are impaired and patients develop lactic acidosis at lower exercise workloads than healthy person. This leads to an increased ventilator requirement and early onset of muscle fatigue.
10. Nilsson BB et al., (2008) reported that Group-based aerobic interval training in patients with chronic heart failure and concluded that our exercise model significantly improved functional capacity and quality of life compared with the control group in patients with CHF. Improvements in quality of life were significantly related to functional capacity.
11. Moholdt,TT et al.,(2006) compared Group exercise verses myocardial infraction patients .The outcome of this study was treadmill aerobic interval training was more effective in improving vo2 max than usual cardiac rehabilitation program.
12. Gosker H.R et al., (2000) states that low exercise tolerance has a large influence on health status in chronic obstructive pulmonary disease and chronic heart failure. In both diseases, muscular impairment is multifactor ally determined; hypoxia, oxidative stress, disuse, medication, nutritional depletion, and systemic inflammation may contribute to the observed muscle abnormalities and each factor has its own potential for innovative treatment approaches.
6.3) OBJECTIVES OF THE STUDY
1. To study the efficacy of Combined aerobic and resistance exercise training in improving endurance and strength in CHF.
2 To study the efficacy of aerobic interval training in improving endurance and strength in CHF.
3 To compare the efficacy of Combined aerobic and resistance exercise training verses Aerobic interval training in improving endurance and strength in CHF.
7. / MATERIAL AND METHODS
7.1. STUDY DESIGN
The study design adopted is a pre and posttest comparison between combined endurance -resistance training verses aerobic interval training.
7.2. SOURCE OF DATA
Patients who were diagnosed with chronic heart failure will be recruited in the study after exercise testing referred to Physiotherapy department of city hospital Mangalore.
7.2(I) Definition of study subjects
Patients with CHF aged between 40 -50 years.
7.2 (II) Inclusion and Exclusion criteria
INCLUSION CRITERIA
· Chronic heart failure patients will be recruited in this study
· Age group of 40 -50 years.
· Male patients who have ceased smoking at least before six months.
· Patients with same drug regimen.
· Patients who were willing for the study
EXCLUSION CRITERIA
· Patients with other lung pathologies.
· Patients with neurological impairments.
· Patients with renal impairment
· Cognitive and mental impairments
· Patients with orthopedic handicap such as limb deformities, muscular paralysis and weakness..
· Patients with visual and hearing impairments.
· History of seizures.
· Non co-operative patients.
7.2 (III) STUDY SAMPLING DESIGN, METHOD AND SIZE:
SAMPLE – DESIGN
METHOD OF COLLECTION OF DATA
Patients fulfilling the inclusive and exclusive criteria would only be recruited.
SAMPLE – SIZE
The sample consists of 50 patients with CHF satisfying the inclusion and exclusion criteria and referred to the physiotherapy department.
7.2(IV) Follow Up
Pre test evaluation was done on the first day prior to treatment and post treatment evaluation was done on the last day of treatment.
7.2(V) Parameters and statistical tests used.
Statistical test used Fisher exact test and t’ test
(VI) Duration of study
The study will be conducted over duration of 6 months.
.
7.2 (VII) Methodology
Group A received aerobic interval training which consist of first warm up by walking comfortably at 6mph on treadmill for 3minutes then cycle ling at 6mp for 10 minute and Interval 1-3min and again walk on treadmill for 5 minute at 7mph and cycle for 5min at 7mph Interval 2-3 minute and continue this for 30 minutes by keeping interval of 3 min in between.
Group B received Combined Endurance and resistance exercise training.
Which involves gravity or elastic forces It involves start with shorter rest time and lighter weight that is combined with cycling doing shoulder curls with minimum weights starting with 2 kgs this is done for 30 minutes elastic band can also be used while doing shoulder curls.
Pre test evaluation was done on the first day of treatment and the post test evaluation on the last day. Duration of the study was 6months. The total treatment had been given for 5 days per week for 4 weeks during which patient were advised to continue all medications as prescribed by the Pulmonologist or Physician.
Outcome measures
ASTRAND 6MIN CYCLE TEST-VO2 MAX test on a static cycle (endurance test)
1RM TEST(Strength test)
7.3 Does the study require any investigation to be conducted on patients or other human or Animal? If so, please describe briefly.
Yes
7.4 Has ethical clearance been obtained from your institution in case of 7.3
Yes
LIST OF REFERENCES
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2. Hurley, B. F., J. M. Hagberg, A. P. Goldberg, D. R. Seals, A. A. Ehsani, R. E. Brennan, and J. O. Holloszy Sports Exercise 20: 150–154, 1988.. Resistive training can reduce coronary risk factors without alteringV˙ O2max or percent body fat. Med. Sci.
3. MacDougall, J. D., G. R. Ward, D. G. Sale, and J. R. Sutton J. Appl. Physiol. 43: 700–703, 1977. Biochemical adaptations of human skeletal muscle to heavy resistance training and immobilization.
4. Volaklis KA, Tokmakidis SP Sports Med.. 2005;35:1085–1103 Resistance training in patients with heart failure.
5. Hunter GR, Wetzstein CJ, Fields DA, Brown A, Bamman MM, J Appl Physiol. 2000;89:977–984 Resistance training increases total energy expenditure and free-living physical activity in older adults
6. Lind AR, McNicol GW Can Med Assoc J. 1967;96:706 –715
Muscular factors which determine the cardiovascular responses to sustained and rhythmic exercise.
7. American College of Sports Medicine position stands Med Sci Sports Exerc.1990; 22:265–274: the recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness in healthy adults.
8. Parise G, Brose AN, Tarnopolsky MA Exp Gerontol. 2005; 40:173–180.
Resistance exercise training decreases oxidative damage to DNA and I decreases cytochrome oxidase activity in older adults.
9. .Poehlman ET, Denino WF, Beckett T, Kinaman KA, Dionne IJ, Dvorak R, Ades PA. . J Clin Endocrinol Metab. 2002;87:1004 –1009 Effects of endurance and resistance training on total daily energy expenditure in young women: a controlled randomized trial
10. European Heart Failure Training Group Eur Heart J 1998; 19:466–75... Experience from controlled trials of physical training in chronic heart failure: protocol and patient factors in effectiveness in the mprovement in exercise tolerance.
11. Meyer K, Schwaibold M, Westbrook S et al Am Heart J 1997; 133: 447–53.. Effects of exercise training and activity restriction on 6-minute walking test performance in patients with chronic heart failure.
12. Wielenga RP, Huisveld IA, Bol E et al Eur Heart J 1999; 20: 872–9... Safety and effects of physical training in chronic heart failure; results of the chronic heart failure and graded exercise study (CHANGE).
13. Meyer K, Samek L, Schwaibold M et al Med Sci Sports Exec1997; 29: 306–12. Interval training in patients with severe chronic heart failure; analysis and recommendations for exercise procedures.
14. Kavanagh T, Myers MG, Baigrie RS et al. Heart 1996; 75: 42–9.
Quality of life and cardiorespiratory function in chronic heart failure: effects of 12 month’s aerobic training.
15. Coats AJS Circulation 1999; 99: 1138–40 Eur Heart J 1996; 17: 10407... Exercise training for heart failure. Coming of age. Meyer K, Samek L, Schwaibold M et al. Physical responses to different mode of interval exercise in patients with chronic heart failure—application to exercise training.
16. Meyer K, Samek L, Schwaibold M et al Med Sci Sports Exec 1997; 29:306–12.. Interval training in patients with severe chronic heart failure; analysis and recommendations for exercise procedures.
17. Kostis JB, Rosen RC, Cosgrove NM et al Chest 1994; 106: 996–1001. Non pharmacologic therapy improves functional and emotional status in congestive heart failure.
18. Wilson JR, Groves J, Rayos G Circulation 1996; 94: 1567–72... Circulatory status and response to cardiac rehabilitation in patients with heart failure.
19. Meyer K, Westbrook S, Schwaibold M, Hajric R, Lehmann M Clin Cardiol 1996; 19: 944–8. Cardiopulmonary determinants of functional capacity in patients with chronic heart failure compared with normals.
20. Mancini D, Henon D, La Manca J, Donchez L, Levine S.Circulation 1995; 91: 320–9. Benefit of selective respiratory muscle training on exercise capacity in patients with chronic congestive heart failure.
9 / SIGNATURE OF THE CANDIDATE
10 / REMARKS OF GUIDE / Appropriate and feasible study recommended
11 / NAME AND DESIGNATION (in Block Letters)
11.1 GUIDE / LIJESH JOY
ASSISTANT PROFESSOR
11.2 SIGNATURE
11.3 CO GUIDE (If any) / PRINCE THOMAS
ASSISTANT PROFESSOR
11.4 SIGNATURE
11.5 HEAD OF THE DEPARTMENT / NA
11.6 SIGNATURE / ------
12 / 12.1 REMARKS OF THE CHAIRMAN AND PRINCIPAL / TOPIC IS APPROPRIATE AND HAS CLINICAL APPLICATIONS. RECOMMENDED.
12.2 SIGNATURE
1