The effect of physical training on workload, upper leg muscle function and muscle areas in patients with chronic heart failure

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Abstract

Objective

To investigate the effect of physical training (PTr) on upper leg muscle area, muscle strength and muscle endurance expressed as upper leg muscle function (ULMF) in relation to exercise performance in CHF.

Design

Randomised to a training (TG) or control group (CG). Setting: Outpatient cardiac rehabilitation centre of community hospital. Patients: 77 CHF patients (59 men and 18 women), NYHA class II/III, age 59.8±9.3 years, LVEF 27±8%. Sixteen patients dropped out during the intervention period, 61 patients (M/F:46/15) completed the study. Intervention: PTr (combined strength and endurance exercises) four times per week, twice supervised and twice at home, during 26 weeks.

Main outcome measures

LVEF, body composition, daily physical activity, exercise performance, upper leg muscle area and isokinetic leg muscle variables.

Results

Workload and peak oxygen consumption decreased in the CG (−4.1% and −4%) but increased in the TG (+5% and +4%) following PTr (p<0.05, ANOVA repeated measures). Hamstrings area decreased in the CG and did not change in the TG (p<0.05, ANOVA repeated measures). ULMF improved in the TG, but remained unchanged in the CG (+13.0% and 0.0, respectively, p<0.05; ANOVA repeated measures). At baseline and after intervention nearly 60% of the variance in maximal workload was explained by ULMF and quadriceps muscle area (multiple regression analysis).

Conclusions

In CHF patients, home-based training in conjunction with a supervised strength and endurance training program is safe, feasible and effective and does not require complex training equipment. Physical training prevented loss of hamstrings muscle mass and improved exercise performance by enhancing muscle strength and endurance.

Introduction

Not too long ago physical exercise was discouraged in patients with decreased left ventricular function, cardiac enlargement and heart failure [1]. It was feared that the additional workload placed on the left ventricle would lead to accelerated disease progression. In 1988, a non-randomised study by Sullivan et al. demonstrated that physical training induced several important peripheral adaptations that contributed to improved exercise performance [2]. The paradigm shift continued when Coats et al. documented that training increased exercise duration and peak oxygen consumption in a randomised controlled cross-over trial [3]. Several randomised studies followed that corroborated the finding that physical training in heart failure patients improves exercise performance expressed either as maximal power, exercise time or peak oxygen consumption and showed training to be safe. Nowadays, training has been fully accepted as adjunct therapy for CHF patients. In addition to significant reduction in symptoms[4], [5], [6], skeletal muscle strength and muscle endurance have been reported to improve in CHF patients after a period of training [7], [8], [9], [10], [11].

In a previous study we reported that almost 60% of the variance of maximum workload (as measure of exercise performance) in CHF could be ascribed to quadriceps muscle area, as measured by CT scan, and upper leg muscle function (a composite variable of isokinetic strength and endurance) [12].

The relationship between these muscle parameters and improvement in exercise performance after physical training in CHF patients has not yet been elucidated.

The aim of this study was to investigate the effect of physical training on upper leg muscle area, muscle strength and muscle endurance in relation to exercise performance in CHF.

Section snippets

Patient selection

Seventy-seven patients (59 men and 18 women) with CHF (NYHA class II/III, age 59.8±9.3 years) participated. They had been clinically stable for at least 3 months, received optimal medical therapy (see Table 1), and were physically able to visit the outpatient clinic. The present study is part of the study project “Training, insulin sensitivity and anabolic/catabolic balance in chronic heart failure”.

Additional inclusion criteria were: a history of CHF longer than 6 months classified as NYHA

Results

At baseline the study population consisted of 77 patients, including 10 cross-over patients. LVEF and left ventricular end diastolic diameter of 65.1 (9.5) mm were characteristic for systolic dysfunction. Sixteen patients were lost to follow up because of the following reasons: six died (not related to intervention), seven stopped for personal reasons and three could not be reassessed for medical reasons (progressive heart failure, aneurysm of the aorta and muscle injury in the leg) not related

Discussion

In the present study several important findings emerged:

  • 1.

    A 26 week outpatient exercise program was effective in preventing disease associated reduction of muscle mass as indicated by stable upper leg muscle cross-sectional areas; and

  • 2.

    The training intervention improved objective parameters of peripheral muscle function such as upper leg muscle function (i.e. muscle strength and muscle endurance).

Conclusion

A training program of simple strength and endurance exercises partly supervised and partly executed at home is feasible, safe and effective with a high compliance and low drop-out rate.

Physical training prevented ongoing muscle wasting and improved muscle strength and endurance. The relation between muscle parameters (muscle strength, muscle endurance and muscle area) and exercise performance did not change after training, indicating that improvement of muscle strength and endurance is

Acknowledgements

This study was funded by the Netherlands Heart Foundation (grant 98.125), Sorbo Heart Foundation, Foundation: Wetenschappelijk Onderzoek Hart-en Vaatziekten Amersfoort and Stichting Bijstand Algemeen Christelijk Ziekenhuis Eemland (Amersfoort, The Netherlands).

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