# Exercise as it relates to Disease/Getting Fit with Heart Failure - a waltz in the park
## Background

Chronic heart failure is a reduction in the capability of the heart muscle to pump blood around the body. It can be caused by an acute myocardial infarct, hypertension, ischemic heart disease or cardiomyopathies. Symptomatic heart failure presents as shortness of breath, fatigue, weakness and lower limb oedema. Initial treatments focus on education for lifestyle changes, including weight loss and physical activity to manage risk factors and comorbidities. In Australia, the Heart Foundation have developed a ‘Heartmoves’ exercise class that can be adapted for patients in all stages of disease progression.
Previous research into cardiovascular diseases and exercise has shown that physical activity decreases the risk of a another cardiovascular event and slows the deterioration of pre-existing conditions. Moderate intensity aerobic exercise improves function and quality of life in patients with normal or depressed cardiovascular function. The Australian National Heart Foundation physical activity guidelines recommend 30 minutes of moderate intensity activity 5 times a week.  (Physical Activity Recommendations)

## Introduction

The article “Waltz Dancing in Patients With Chronic Heart Failure: New Form of Exercise Training” was published in 2008 in the ‘Circulation: Heart Failure - AHA’ journal. The study is a randomised control trial that looked into the difference between traditional exercise interventions and waltz dancing. They measured initial function and quality of life, and reassessed with an 8 week and 2 year follow up. This was a moderate quality study scoring 6/10 on the PEDro scale.

## Methods

The study was conducted between September 2001 to November 2003. There were 130 participants with stable chronic heart failure, class 2 or 3 (New York Heart Association) that were randomised into ‘control’ ‘exercise’ and ‘dance’ groups. Participants were excluded if they had recent acute coronary events, coronary investigations, renal insufficiency, liver abnormality, uncontrolled hypertension and orthopaedic or neurological limitations.
The control group remained sedentary and did not participate in either of the exercise groups. The exercise group completed cycling or treadmill walking at 70% of VO2max for 30 minutes 3 times a week for 8 weeks. The dance protocol alternated between fast and slow waltz’s, accumulating 21 minutes dance time. Both exercise groups completed a 10 minute calisthenics warm up, and 10 minute stretching cool down.
All groups completed cardiovascular function testing, including blood chemistry (cholesterol, blood glucose), anaerobic threshold (estimation of VO2peak), cardiac ultrasound imaging (ejection fraction) and brachial artery vasomotor function. Quality of life was measured using the Minnesota Living With Heart Failure Questionnaire (MHFLQ), which looks at the physical, emotional and socioeconomic effects of heart failure.

## Results

At the 8 week follow up all participants were required to repeat their physiological and quality of life testing. The results are as follows:
Physiological Changes
| | Peak HR (bpm) | HDL Cholesterol mg/dL | Resting BGL's (g/dL) | Peak VO2 | Ejection Fraction (%) |
| Control | ↑ 1 | No change | No change | ↓ 0.3 | ↑ 1 |
| Exercise | ↑ 6 | ↑ 4 | ↓ 10 | ↓ 3.1 | ↑ 4 |
| Waltz | ↑ 7 | ↑ 4 | ↓ 10 | ↓ 2.7 | ↑ 3 |
Peak HR increased in the exercise groups, but was not statistically significant. Blood testing showed no change in LDL cholesterol, but an increase in HDL cholesterol in both exercise groups. This suggests that there has been a positive change in body composition and improvement in blood cholesterol transport. There was a decrease in resting blood glucose for both exercise groups, suggesting improved glucose regulation and transport in the blood. Peak VO2 decreased and ejection fraction increased slightly in all groups. The clinical implications of these results suggest that both exercise groups had an improved fitness, because they were using less of their VO2max and had an increased ejection fraction when working at the same intensity. The blood markers show improved hormonal control of some health markers, such as cholesterol and glucose. Cumulatively, this shows that the participants in the exercise groups were physiologically fitter and healthier, whereas there were no positive changes in the control group.
Quality of Life Changes
| | MHFLQ-Physical | MHFLQ-Emotional | MHFLQ-Socioeconomic | Total |
| Control | ↓ 2 | ↓ 1 | No change | ↓ 3 |
| Exercise | ↓ 8 | ↓ 3 | ↓ 2 | ↓ 13 |
| Waltz | ↓ 8 | ↓ 6 | ↓ 3 | ↓ 17 |
A different score of 5 points or more indicates a clinically significant change in quality of life. As above, both exercise groups had a positive improvement, but the waltz group had a greater change. This means that exercise improve quality of life in heart failure patients, but dancing had a greater improvement.
Lastly, adherence to the protocols (percentage of sessions attended) was significantly better in the waltz group (90%) than the exercise group (77%). The high adherence in the dance group suggests that people are more likely to participate in activities that are social and fun whilst challenging both physical and cognitive skills.

## Conclusions & Recommendations

Previous research into treating heart failure has concluded that exercise is beneficial for physiological and quality of life changes (Belardinelli, 2008). This study was particularly interested in how waltz dancing compared to traditional exercise programs. Once again, the exercise groups had a significant positive change in all physiological and quality of life measures, when compared to the control group. However, dancing had a significantly greater impact on quality of life than traditional exercise. This was also reflected in attendance rates. We can conclude that exercise is beneficial for treating heart failure patients, but the social aspects of dancing in a group is much better for quality of life and adherence to exercise. Treating heart failure is just a waltz in the park.

## References

* ↑ The Heart Foundation Chronic heart failure - the facts [Internet]. The Heart Foundation. 2017 [cited 19 September 2017]. Available from: https://www.heartfoundation.org.au/your-heart/heart-conditions/chronic-heart-failure-the-facts
* ↑ Belardinelli R, Lacalaprice F, Ventrella C, Volpe L, Faccenda E. Waltz Dancing in Patients With Chronic Heart Failure New Form of Exercise Training. Circulation-Heart Failure. 2008 Jul;1(2):107-14. PubMed PMID: WOS:000266127600005. English.
* ↑ Romualdo Belardinelli FL, chiara Ventrella, Loretta Volpe, Ernesto Faccenda. Waltz Dancing in Patients With Chronic Heart Failure: New Form of Exercise Training. American Heart Failure. 2008;108:107-14.
* ↑ Physiotherapy Evidence Database, [Internet]. Pedro.org.au. 2017 [cited 20 September 2017]. Available from: https://www.pedro.org.au
* ↑ Morcillo C, Aguado O, Delás J, Rosell F. Utility of the Minnesota Living With Heart Failure Questionnaire for Assessing Quality of Life in Heart Failure Patients. Revista Española de Cardiología (English Edition). 2007;60(10):1093-6.