Effects of Rehabilitation in Patients With Stable Chronic Heart Failure

Study Overview
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Brief Summary
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Heart failure (HF) is a major public health problem. This is the first cause of hospitalization and mortality of about 65 years old. This syndrome is characterized by a poor prognosis and a high cost of care. Thus, new strategies for treatment and prevention of the HF are among the major challenges facing health sciences today. The management of HF requires multimodal approach it involves a combination of non-pharmacological and pharmacological treatment, Besides improvements in pharmacological treatment, supervised exercise programs are recommended for all patients with HF as part of a non-pharmacological management but many questions regarding exercise training in HF patients remain unanswered. Even simple questions such as the best mode of training for these patients are unclear. The aim of this study First, to characterize the physiological functions involved in the genesis of exercise intolerance and dyspnea especially muscle function (respiratory and skeletal), and cardiopulmonary patients suffering from chronic HF. Second, to study and compare the effects of different rehabilitation programs and prove the superiority of the combination of three training modalities program: aerobic training (AT), resistance training (RT) and inspiratory muscle training (IMT). These modalities are: Aerobic Training: It has been proven effective in improving muscle abnormalities on changing the ventricular remodeling, dyspnea, functional capacity, increasing the maximum performance and reducing hospitalization in subjects suffering HF. Resistance Training: It has been proven effective in improving skeletal muscle metabolism and angiogenesis; increasing capillary density and blood flow to the active skeletal muscles, promoting the synthesis and release of nitric oxide, and decreasing oxidative stress. Selective Inspiratory Muscle Training: It has been proven effective in improving the strength and endurance of the respiratory muscles and reduction of dyspnea during daily activities.

Detailed Description
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The Heart failure is the major cause of mortality and morbidity especially in elderly subjects. The main feature of heart failure is exercise intolerance, which is always associated with fatigue and dyspnea in exercises of low intensity. Harrigton et al in 1997 demonstrated the existence of a dysfunction of skeletal muscles. But it is likely that these changes are not limited to the musculature of the lower limbs but are widespread and may affected the respiratory muscles. Thus, this dysfunction of the respiratory and skeletal muscles associated with dyspnea can contribute to the genesis of fatigue and impaired physical performance in turn reducing the autonomy of individuals. The guidelines recommend no pharmacologic strategies by specific exercises to relieve symptoms, improve exercise tolerance and quality of life and reduce the rate of hospitalization. The supervised exercise programs are recommended for all patients who have CHF as part of a non-pharmacological management. Thus, the exercise remains the pioneer of cardiac rehabilitation programs. The effectiveness of the training of the skeletal muscles against resistance (RT) and aerobic training (AT) in the rehabilitation HF has been well documented. However, selective training of respiratory muscles (IMT) is a relatively new technique in the field of the ICC. In 1995, Mancini et al. were the first to publish a report on the advantage of selective training of respiratory muscles in HF patients. Another study showed the superiority of a high-intensity training, 60% of maximal inspiratory pressure (PI max) on another 15% of PImax by increasing muscle strength and inspiratory muscle endurance, improved exercise capacity, reduction of dyspnea and quality of life. While the above studies have investigated the benefits of inspiratory muscle training alone in CF patients, the question to ask is If the benefit of the inspiratory muscle training was added to that observed with aerobic training for the whole body.  Laoutaris in 2013 showed that the combination of AT with RT and IMT could result in a significant improvement in peripheral muscle and respiratory function with significant improvement in exercise capacity, dyspnea and quality of life compared to that of the 'single AT. However, this study has several limitations. These limits are: Patients in the combined group suffer longer exercise sessions of 20 minutes compared to patients alone aerobic group. Thus, the difference in the time to exercise between the 2 groups may have influenced the results of the study. Furthermore, the authors compared three different modalities of exercising against a modality which affects so the quality of the study. In addition, the extent to which the resistance training or selective training of respiratory muscles contributed to greater improvements in the combined group was not assessed in this study as this would take several modalities groups different exercises and a control group. Till now, There are no randomized, controlled, double blinding studies that compares different modalities of exercises to each other and to a control group in patients who have CHF. Moreover, It is not known until now what combination of exercises modalities is the most effective and more secure, and If there are additional benefits by combining multiple training modalities by comparing it with other modalities in patients with stable chronic heart failure (CHF). In this study, the investigators examined the hypothesis of the efficiency of a combined program of three modalities: aerobics, resistance, and selective respiratory muscle on: Heart and lung function, Heart and lung structure, The function of skeletal and respiratory muscles, Functional capacity, Dyspnea, and quality of life. The main objectives of this project are defined: To characterize the physiological functions involved in the genesis of exercise intolerance and dyspnea. Comparative study of all therapeutic modalities with a control group and each other. To study muscle function: respiratory and skeletal in HF patients in different training groups. To study the muscular structures: respiratory and skeletal. To study the structure and heart function. See the influence of these three training modalities on functional capacity, dyspnea and quality of life. To state the guidelines for heart failure. Methodology and research requirements Protocol All subjects must sign an informed consent form. Patients will submit a physical examination, and electrocardiographic measurements by a cardiologist. Approximately 60 patients are divided randomly by investigators who are not involved in the implementation of the project to eight different groups. Before and after the intervention were evaluated all the tests mentioned above by a physiotherapist who do not know the distribution of patients to different interventions. Groups All types of training sessions are individualized and are carried in Beirut Cardiac Institute. Patients are exerted for twelve weeks at a rate of three times per week, for one hour. Any missed session will be added to the end of the program, so that the 36 sessions will be realized. All sessions must be supervised at all times by a physiotherapist and a cardiologist. Group 1 (n = 10): Aerobic training (30mn) Group 2 (n = 10): Inspiratory muscle training (20mn) Group 3 (n = 10): Resistance Training (20mn) Group 4 (n = 10): Aerobic Training (30 min) + Inspiratory muscle training (20mn) Group 5 (n = 10): Aerobic Training (30 min) + Inspiratory muscle training (20minutes) + Resistance training (20 minutes) Group 6 (n = 10) Control

Official Title
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Functional Characterization of Respiratory Muscles and Effects of Rehabilitation in Patients With Stable Chronic Heart Failure

Conditions
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Heart Failure, Aerobic Exercise, Quality of Life, Respiratory Muscle Training, Strength Training, Exercise Intolerance, Cardiac Rehabilitation

Intervention / Treatment
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* Other: Aerobic training
* Other: Inspiratory muscle training
* Other: Resistance Training
* Other: Aerobic and Inspiratory training
* Other: Combined


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria Congestive heart failure (CHF) due to ischemic or dilated cardiomyopathy. Left ejection fraction ≤ 45%. NYHA functional class II and III. A patient with a diagnosis of CHF for six months including no admission to the hospital or change in medications over the previous 3 months. IMW <70% of predicted Exclusion criteria Pulmonary limitation (forced expiratory volume in 1 s and/or vital capacity of less than 60% of predicted value). History of significant cardiac arrhythmia. History of myocardial infarction or cardiac surgery (6 months). Orthopedic or neurologic disease. Non echogenic, Unstable. Poorly controlled blood pressure. End-Stage HF (on the waiting list for transplantation or LVAD).

Ages Eligible for Study
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Minimum Age: 40 Years
Maximum Age: 75 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Prevention
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Interventions Aerobic exercise training Patients follow an alternating aerobic training using a treadmill at an intensity of 60% of maximum heart rate, 3 mn and 3 mn working off an alternative way.To ensure progressive overload appropriate, we adjust moderate intensity aerobic exercise every two weeks with an overall 5% increase in heart rate. Inspiratory muscle training The inspiratory muscle training involves a high intensity endurance training to 60% of PI, max. We recalculate the individual SPImax and PImax in each training session. Patients use the driving tool inspiratory muscle. Resistance training The resistance should be measured on 1 RM (Repetition Maximum) for each muscle group. The exercises are performed in three sets of ten repetitions of exercises at 60% of 1RM intensity recalculated every two weeks training.
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Aerobic training<br>Patients follow an alternating aerobic training using a treadmill at an intensity of 60% of maximum heart rate, 3 mn and 3 mn working off an alternative way.To ensure progressive overload appropriate, we adjust moderate intensity aerobic exercise every two weeks with an overall 5% increase in heart rate. | Other: Aerobic training<br> <br> |
| Experimental: Inspiratory muscle training<br>The inspiratory muscle training involves a high intensity endurance training to 60% of PI, max. We recalculate the individual SPImax and PImax in each training session. Patients use the driving tool inspiratory muscle. | Other: Inspiratory muscle training<br> <br> * Other names: Respiratory Training;|
| Experimental: Resistance training<br>The resistance should be measured on 1 RM (Repetition Maximum) for each muscle group. The exercises are performed in three sets of ten repetitions of exercises at 60% of 1RM intensity recalculated every two weeks training. | Other: Resistance Training<br> <br> * Other names: Strength training;|
| No Intervention: Control<br>The control group patients were allocated to a non-training time period, during which they were told to continue their life as before enrollment. | |
| Experimental: Aerobic and Inspiratory training<br>Note that the Aerobic and Inspiratory group participant undergone same protocols of inspiratory and aerobic training stated above, with almost a 5 minutes rest in between. | Other: Aerobic and Inspiratory training<br> <br> |
| Experimental: Combined<br>Note that the Aerobic, Inspiratory and resistance group participant undergone same protocols of inspiratory and aerobic training stated above, with almost a 5 minutes rest in between. | Other: Combined<br>* Aerobic, inspiratory and resistance training<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in Minnesota Living with Heart Failure Questionnaire (MLWHF) | The Quality of life was assessed using the Minnesota Living with Heart Failure Questionnaire (MLWHF). the minimum score is 0 and the maximum score is 105. the total score should decrease to indicate the amelioration of the quality of life. | Baseline and 12 weeks | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in Forced Vital Capacity (FVC) | FVC was assessed to evaluate the lung Function. FVC measurement shows the amount of air a person can forcefully and quickly exhale after taking a deep breath. | Baseline and 12 weeks | 
| Change in Forced Expiratory Muscle Volume in one second (FEV1) | FEV1 was assessed to evaluate the lung Function. FEV1 measurement shows the amount of air a person can forcefully exhale in one second of the FVC test. | Baseline and 12 weeks | 
| Change in Left Ventricular Ejection Fraction (LVEF) | LVED was assessed to evaluate the cardiac function by using echocardiography at rest. LVEF (%) : the total amount of blood in the left ventricle is pumped out with each heartbeat. | Baseline and 12 weeks | 
| Change in Left Ventricular End Systolic and Diastolic Diameter (LVESD and LVEDD) | LVESD and LVEDD was assessed to evaluate the cardiac function by using echocardiography at rest. Evaluation of the Left Ventricule dimensions (mm) and wall thicknesses in end-systolic and end-diastolic. | Baseline and 12 weeks | 
| Change in Maximal Inspiratory Pressure (MIP) | MIP (cm h2o) was assessed to evaluate the strength of inspiratory muscles using Electronic pressure transducer. | Baseline and 12 weeks | 
| Change in Sustained Maximal Inspiratory Pressure [SMIP] | SMIP (Secondes) was used to assess the respiratory muscle endurance where the time was recorded in the period during which a patient can cover maintaining 70% MIP. | Baseline and 12 weeks | 
| Change in Borg scale | The dyspnea was assessed using Borg Scale. the minimum score is 6 and the maximum score is 20. the total score should decrease to indicate the amelioration of the dyspnea. | Baseline and 12 weeks | 
| Change in six-minute walk test (6MWT) | The Functional capacity was assessed by using 6MWT in meters. the distance should increase to indicate the amelioration of the functional capacity. | Baseline and 12 weeks | 
| Change in Exercise time in stress test | Exercise time (secondes) was assessed using Stress test on a treadmill according to the Bruce protocol. the time should increase to indicate the amelioration of the aerobic capacity. | Baseline and 12 weeks | 
| Change in Metabolic Equivalent of a Task (METs) | The assessment of workload is measured by METs during stress test. METs is a unit that estimates the amount of energy used by the body during physical activity, as compared to resting metabolism. The unit is standardized so it can apply to people of varying body weight and compare different activities. | Baseline and 12 weeks | 
| Change in Maximal Voluntary Isometric Force (MVIF) | MVIF (Kg) was assessed to evaluate the function of skeletal muscles using Dynamometer; to assess the strength of the quadriceps muscle. | Baseline and 12 weeks | 
| Change in Isometric endurance time (MT) | MT (secondes) was assessed to evaluate the endurance of the quadriceps muscle. MT was measured when subjects maintained an isometric contraction at 50% of the reported MVIF. | Baseline and 12 weeks | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Heart Failure, Aerobic Exercise, Respiratory Muscle Training, Strength Training