Use of Aquatic Therapy for Adults with Chronic Heart Failure: An Evidence-Based Review

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1 Use of Aquatic Therapy for Adults with Chronic Heart Failure: An Evidence-Based Review Ajay Crittendon, DPTc UCSF/SFSU Graduate Program in Physical Therapy Spring Symposium May 4 th 2013

2 Introduction Chronic Heart Failure (chf) Heart unable to pump enough blood to keep up with body s metabolic demand. (Carvalho & Guimarães, 2010)

3 Definitions Stroke Volume: (stroke volume) Ejection Fraction: Preload/Afterload Cardiac Output: HR X SV

4 Clinical Problem Retain fluids & constrict peripheral vasculature Enlarge chamber size & heart rate Skeletal muscles & lungs suffer Fatigue, SOB, exercise tolerance, QOL, death (Carvalho & Guimarães, 2010)

5 Significance 1 in 5 people die in the first year of diagnosis Prevalence: 6.6 million or ~2.8% Incidence: 15.2/1000 males 8.2/1000 females Age million doctor/ hospital visits Costs: $34.8 billion survival time & prevalence of risk factors Estimated prevalence of 9 million in 2030 ( 25% from 2010) (Rosamond et al, 2008) (Roger et al, 2012)

6 Core Components of Cardiac Rehabilitation in Chronic Heart Failure Treatment of causative factors and management of comorbidities Medication ACE inhibitors, beta blockers, digitalis Counseling and education Lifestyle, diet, self-monitoring Psychosocial support and continuum of care Implementation of a continuing program of physical activity and exercise training (Corra et al, 2005)

7 Relevance to Physical Therapy PTs are integral to cardiac rehabilitation Specialists in exercise prescription for increasing muscle function and cardiovascular training. Develop programming, make recommendations Ensure evidence-based best practice

8 Background: Monitoring Exercise tolerance: Oxygen uptake (VO2) is reliable indication of exercise tolerance in this population (Working Group, 2001) Six-minute walk test (6MWT) Heart Function: Ejection fraction (LVEF) New York Heart Association (NYHA) (AHA 2011) Class I-II mild, III moderate, IV severe Minnesota Living with Heart Failure questionnaire (MLHF) (Rector 2005)

9 Background: Exercise for chf Only since 1990 has exercise been accepted for adults with chf Previously bed rest recommended Various modes: aerobic endurance & resistance training Initial improvements normally seen after 4 weeks Benefits: max physical capacity quality of life morbidity and hospital re-admission Compliance is challenging 28-37% of patients leave cardiac rehab programs (Carvalho & Guimarães, 2010)

10 Background: Aquatic Therapy Skilled physical therapy in aquatic environment Performed upright, submerged to chest level Unique properties of water: buoyancy, resistance, temperature, hydrostatic pressure Reduced loading on joints Safe, supportive environment Exercises for strength, flexibility, and endurance easily applied C (86-93 F) Patients with: Orthopedic/ neurologic issues Obesity High fall risk

11 Background: Water Immersion Water exerts a pressure on the body causing blood to shift from periphery ( pre-load on heart) Warmth of water can cause peripheral vasodilation ( afterload) pre-load and afterload = cardiac output Improved hemodynamic effect (Meyer & Leblanc, 2008) - Shift in blood volume may overload the heart. - Water immersion is contraindicated for decompensated heart failure.

12 Theoretical Construct Reports of maintained feelings of well-being. (Cider 2003) Exercise improves physical capacity and quality of life. Aquatic exercise may have better outcomes for patients with chf than land exercise Patients with comorbidities are able to participate. Water immersion may increase cardiac output.

13 Gap in literature Studies show: Effectiveness of land-based exercise Acute changes with water immersion Effect of water temperature This Review No metaanalysis for long-term outcomes of aquatic exercise No consensus on how aquatic exercise compares to land-based exercise

14 Purpose and Research Questions To search the existing literature to determine: Foreground questions: Primary Secondary Is aquatic exercise a safe and effective for adults with chronic heart failure? Does aquatic therapy provide better functional outcomes and increased heart function compared to land therapy for patients with chronic heart failure?

15 PICO Population Adults with chronic heart failure Intervention Aquatic therapy/ Aquatic exercise Comparison Pre/post aquatic exercise Land-based exercise Outcomes Heart function, exercise tolerance, quality of life, adverse events

16 Hypotheses Primary H o : No change in outcomes from baseline to culmination of an aquatic exercise program. H a : Significant change in outcomes between baseline and post-aquatic exercise. Secondary H o : No difference in outcomes between land exercise and aquatic therapy. H a : Outcomes for aquatic therapy are significantly better than outcomes for land exercise.

17 Expected Findings Search: 4-8 high quality articles (level of evidence 1a-2b) that address both questions. Studies: No adverse outcomes for aquatic therapy. Aquatic exercise results in significant positive changes in outcomes Aquatic exercise is better land exercise.

18 Methods: Search Databases: PubMed, CINHAL, PEDro, Cochrane Library Recursive Search Search Terms: aquatic exercise, aquatic therapy, aqua therapy, water-based exercise, water exercise, hydrotherapy AND cardiac, heart failure, CHF Last search conducted on February 10 th 2013

19 Eligibility Criteria Inclusion Criteria Articles in English Subjects with heart failure (classified as LVEF <50%) Water-based exercise program (more than 1 day) Exclusion Criteria Published earlier than 1990 Quality of 3 or lower

20 Statistical Analysis Single Group (Within-group) Individual and grand effect sizes calculated from given means and SD before and after intervention Two Group (Between-group) Individual and grand effect sizes calculated from given postintervention means and SD Calculate Q statistic to address heterogeneity if Q was significant (p<0.05), the random effects model was used 95% confidence interval (CI) Forest plots Conversion of grand effect size to clinical units

21 Results: PRISMA Diagram Records identified through database search: N=953 Abstracts screened: N=98 Full text articles examined: N=25 Duplicates removed and screened by title for relevance Excluded for irrelevance -no aquatic therapy component -participants w/out heart failure (n = 73) Did not meet inclusion criteria -no aquatic therapy component -no quantifiable data (n = 19) Articles included in review*: N=6 *Second reviewer confirmed article eligibility

22 Summary of Studies Author, Year Level of Evidence Caminiti et al, 2011 N 1B, RCT E: 11 C: 10 Mean Age (SD), Gender 68 (7), all male NYHA class (II/III/IV) 13/8/0 Cider et al, B, RCT E: 15 C: (6.1), 8 females 4/21/0 Cider et al, B, RCT E: 10 (8 post) C: 10 (9 post) 67.4 (7.1), 4 females 8/12/0 Municino et al, B, Cohort E: 18 C: none 63 (10), 1 female 9/7/2 Svealv et al, 2009 Teffaha et al, B, Cohort E: 18 (12 post) C: none 1B, RCT E: 12 C: (8), 5 females 53.3 (4.2), all male 7/5/0 3/21/0

23 Summary of Studies Author, Year Caminiti et al, 2011 Cider et al, 2003 & 2012 Municino et al, 2006 Svealv et al, 2009 Teffaha et al, 2011 Intervention protocol Combined aquatic & land exercises vs. land exercise only. 30 min at 60-70% VO2max. + calisthenics Aquatic exercise vs. no exercise 45 min at 40-75% HRR min at HR 60-70% VO2 peak > 20 min + calisthenics at 50% VO2 peak. Education, psychobehavioral support, supervised low-salt diet. 45 min at 40-70% max HRR 8 weeks control period prior to aquatic exercise. Combined aquatic & land exercises vs. land exercise only. 30 min at individual target HR + 50 min of calisthenics. Education, psychosocial, vocational sessions. Duration Total # Frequency sessions weeks 3x/week 824 weeks 3x/week 330 weeks 5x/week 2x/day 816 weeks 2x/week 315 weeks 5x/week

24 Summary of Studies Author, Year Caminiti et al, 2011 Cider et al, 2003 Cider et al, 2012 Municino et al, 2006 Svealv et al, 2009 Teffaha et al, 2011 Outcome Measures of Interest 6MWT, muscle function LVEF, VO2 VO2 peak, 6MWT, MLHF, muscle function VO2 peak, 6MWT, MLHF, muscle function 6MWT, MLHF, VO2 SV, LVEF LVEF, SV, VO2 peak, peak power Significant Outcomes W: muscle function, 6MWT B: 6MWT W: muscle function, 6MWT, work rate, MLHF total and physical dimension score B: work rate, VO2 peak, muscle function W: work rate, VO2 peak, muscle function B: work rate, VO2 peak, muscle function, 6MWT W: 6MWT, MLHF total score, VO2 peak None W: LVEF, SV, peak power, VO2 peak, B: peak power

25 Within-Group 6MWT -Effect size (95% CI) -Statistical significance if CI does not cross zero -Effect Sizes: Small: < 0.2 Moderate: =0.5 Large: > 0.8 Q=24.03 p<0.01 Random Effects Model Used Statistically significant 1.33 (0.07, 2.60)

26 Within-Group VO2 Fixed Effect Model Within-Group Muscle Power 0.5 (0.15, 0.85) Statistically significant 0.42 (0.07, 0.77)

27 Within-Group QOL Fixed Effect Model Negative Effect Size Indicates Improvement Statistically significant (-0.97, -0.10)

28 Within-Group LVEF Fixed Effect Model NOT Statistically significant 0.08 (-0.30, 0.45)

29 Between-Groups VO2 Positive Effect Size Favors Aquatic Exercise Fixed Effect Model NOT Statistically significant 0.16 (-0.42, 0.75)

30 Between-Groups Muscle Power Fixed Effect Model NOT Statistically significant 0.47 (-0.12, 1.06)

31 Discussion Primary For ejection fraction H o : No change in outcomes from baseline to culmination of an aquatic exercise program. For 6MWT, VO2, muscle power and QOL H a : Significant change in outcomes between baseline and post-aquatic exercise. Secondary H o : No difference in outcomes between land exercise and aquatic therapy. H a : Outcomes for aquatic therapy are significantly better than outcomes for land exercise.

32 Clinical Significance: Within-Groups 6MWT VO2 Muscle Power Ejection Fraction Quality of Life Clinical Units 124 meters 1.5 ml/kg/min 11.6 watts 0.5% 8.6 point reduction on MLHF MCID 25 meters ml/kg/min 10 watts 5% 5-7 points Clinically Significant YES YES YES NO YES MCID = Minimal Clinically Important Difference

33 Clinical Significance: Between-Groups Clinical Units VO2 1 ml/kg/min MCID ml/kg/min Clinically Significant YES Muscle Power 12.6 watts 10 watts YES Clinically but not statistically significant differences Favors aquatic exercise

34 Other Findings High Compliance Cider et al.. reported an adherence of 92% in 2012, and 95% in Participants enjoyed the training sessions and wished to continue once the study was over. Compared to high drop out rate of other programs

35 Harm/Cost HARM No serious adverse events 3 participants with worsening chf 1 medication issue, 1 infection, 1 unknown (Teffaha 2011, Cider 2012) 3 participants reported mild fatigue during 1 st 2 weeks (Cider 2003) 1 with pronounced freezing after warm water immersion (Svealv 2009) COST Cons Renting or managing a therapeutic pool Facility maintenance, staff Pay out of pocket Distance needed to travel Pros Group Classes Community pools Potentially decreased medical costs

36 Clinical Implications Aquatic exercise can be recommended for patients with mild to moderated chf Adjunct or alternative to land-based exercise Improves physical capacity and quality of life Good option for patients with comorbidities or decreased motivation Possible greater improvement with greater number of sessions Supervision and education recommended initially

37 Limitations Review: Only one researcher performed search May not have captured all relevant data Only 2 studies for between-group analyses Other outcomes not assessed Individual Studies: Small sample sizes Mostly male participants Patients with mild to moderate chf only Variability in protocols

38 Further Research High quality RCTs Larger sample size Differences between aquatic exercise and landbased exercise No combined interventions Develop a Protocol Frequency Duration

39 Conclusions Aquatic Exercise is safe and effective for adults with mild to moderate chf Leads to improvements in exercise tolerance (muscle power, VO2, 6MWT) and increased quality of life No significant changes in heart function (LVEF) or differences found between land- and aquaticbased exercise, however more research is needed.

40 Primary References Caminiti G, Volterrani M, Marazzi G, et al. Hydrotherapy added to endurance training versus endurance training alone in elderly patients with chronic heart failure: a randomized pilot study. Int J Cardiol. 2011;148: [available online Nov 2009] Cider A, Schaufelberger M, Sunnerhagen KS, Andersson B. Aquatic Exercise is effective in improving exercise performance in patients with heart failure and type 2 diabetes mellitus. Evid Based Complement Alternat Med. 2012;2012:1-8. [article ID ] Cider A, Schaufelberger M, Sunnerhagen KS, Andersson B. Hydrotherapy a new approach to improve function in the older patient with chronic heart failure. Eur J Heart Fail. 2003;5: Municinó A, Nicolino A, Milanese M, et al; for Cardio-HKT Study Group. Hydrotherapy in advanced heart failure: the cardio-hkt pilot study. Monaldi Arch Chest Dis. 2006;66(4): Sveälv BG, Cider A, Täng MS, Angwald E, Kardassis D, Andersson B. Benefit of warm water immersion on biventricular function in patients with chronic heart failure. Cardiovasc Ultrasound. 2009;7:33. Teffaha D, Mourot L, Vernochet P, et al. Relevance of water gymnastics in rehabilitation programs in patients with chronic heart failure or coronary artery disease with normal left ventricular function. J Card Fail. 2011;17(8):

41 Secondary References American Heart Association (AHA). About Heart Failure. Failure_UCM_002044_Article.jsp. Accessed Dec 7th, American Heart Association (AHA). Classes of heart failure. Aug Failure_UCM_306328_Article.jsp. Accessed Jan 4 th, Borenstein M, Hedges L, Higgins J, Rothstein H. Comprehensive Meta-analysis [software]. Version 2, Biostat, Englewood, NJ Carvalho V, Bocchi E, Guimaraes G. The Borg scale as an important tool of self-monitoring and self-regulation of exercise prescription in heart failure patients during hydrotherapy: a randomized blinded controlled trial. Circ J. 2009;73(10): Carvalho V, Guimaraes G. An overall view of physical exercise prescription and training monitoring for heart failure patients. Cardiol J. 2010;17(6): Cider A, Svealv B, Tang M, Schaufelberger M, Andersson B. Immersion in warm water induces improvement in cardiac function in patients with chronic heart failure. Eur J Heart Fail. 2006;8: Coghill N, Cooper A. Motivators and de-motivators for adherence to a program of sustained walking. Prev Med. 2009;49: Conraads V, Deaton C, Piotrowicz E, et al. Adherence of heart failure patients to exercise: barriers and possible solutions. Eur J Heart Fail. 2012;14: Corra U, Giannuzzi P, Adamopoulos S, et al. Executive summary of the position paper of the Working Group on Cardiac Rehabilitation and Exercise Physiology of the European Society of Cardiology (ESC): core components of cardiac rehabilitation in chronic heart failure. Eur J Cardiovasc Prev Rehabil. 2005;12(4): Ezekowitz J. The VO2 increase with testosterone addition - heart failure (VITA-HF) trial. Accessed Mar 21 st, Fernhall B, Manfredi T, Congdon K. Prescribing water-based exercise from treadmill and arm ergometry in cardiac patients. Med Sci Sport Exer. 1992;24(1): Gabbett T. Performance changes following a field conditioning program in junior and senior rugby league players. J Strength Cond Res. 2006;20(1): Gremeaux V, Troisgros O, Benaim S, et al. Determining the minimal clinically important difference for the six-minute walk test and the 200-meter fast-walk test during cardiac rehabilitation program in coronary artery disease patients after acute coronary syndrome. Arch Phys Med Rehabil. 2011;92(4): McMurray J, Pfeffer M. Heart Failure. Lancet. 2005;365(9474):

42 Secondary References, cont. Meyer K. Left ventricular dysfunction and chronic heart failure: should aqua therapy and swimming be allowed? Br J Sports Med. 2006;40: Meyer K, Bucking J. Exercise in heart failure: should aqua therapy and swimming be allowed? Med Sci Sport Exer. 2004;36(17): Meyer K, Leblanc M. Aquatic therapies in patients with compromised left ventricular function and heart failure. Clin Invest Med. 2008;31(2):E90 7. Mourot L, Teffaha D, Bouhaddi M, et al. Exercise rehabilitation restores physiological cardiovascular responses to shortterm head-out water immersion in patients with chronic heart failure. J Cardpulm Rehabil Prev. 2010;30: Papathanasiou G, Tsamis N, Georgiadou P, Adamopoulos S. Beneficial effects of physical training and methodology of exercise prescription in patients with heart failure. Hellenic J Cardiol. 2008;49: Rector T. Overview of the Minnesota living with heart failure questionnaire. Jan 1 st, wmjawza. Accessed Mar 21 st, Rehab measures. 6 minute walk test. Accessed Mar 19 th, Roger V, Go A, Lloyd-Jones D, et al. Heart disease and stroke statistics update: a report from the American Heart Association. Circulation. 2012;125:e2 e220. Rosamond W, Flegal K, Furie K, et al. Heart disease and stroke statistics update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2008;117:e25 e146. Schmid J, Noveanu M, Morger C, et al. Influence of water immersion, water gymnastics and swimming on cardiac output in patients with heart failure. Heart. 2007;93: Silvers W, Rutledge E, Dolny D. Peak cardiorespiratory responses during aquatic and land treadmill exercise. 2007: Sramek P, Simeckova M, Jansky L, Savlikova J, Vybiral S. Human physiological responses to immersion into water of different temperatures. Eur J Appl Physiol. 2000;81(15): Sutherland E, Make B. Maximum exercise as an outcome in COPD: minimally clinically important difference. COPD. 2005;2(1): Working Group on Cardiac Rehabilitation and Exercise Physiology & Working Group on Heart Failure of the European Society of Cardiology. Recommendations for exercise testing in chronic heart failure patients. Eur Heart J. 2001;22(1):37 45.

43 Acknowledgements Betty Smoot, PT, DPTSc Arlene McCarthy, PT, MS, DPT, NCS Diane Allen, PT, PhD George Haras, DPTc Pat Rugo, DPTc UCSF/SFSU class of 2013

44 Questions?