Review: Exercise rehabilitation improves outcomes by a small amount in chronic heart failure

Abstract

Question In community-dwelling patients with chronic heart failure (CHF), does exercise improve quality of life (QoL) and physical function? Review scope Included studies assessed structured exercise training programs with standard, quantifiable exercises (e.g., aerobic or resistance training) in outpatient or community settings in patients with stable CHF and reported QoL and/or functional ability. Studies of exercise types that could not be quantified, such as dance, yoga, and tai chi, were excluded. PROSPERO CRD42016046546. Review methods MEDLINE, Scopus, Cochrane Library, ProQuest, CINAHL, AMED (to Jul 2017); and reference lists were searched for English-language studies published after 1994. Case studies and reviews were excluded. 40 studies (n =5411, mean age 50 to 76 y, 21% to 100% men), including 27 randomized controlled trials (RCTs), met the inclusion criteria. Study duration ranged from 8 to 52 weeks. 9 measures were used to assess QoL, and 3 were used to assess physical function. Study quality, as measured by the Physiotherapy Evidence Database scale, ranged from 2 to 7 (mean 4.9) out of 11; 10 trials adequately described allocation concealment. Main results The main results are in the Table; meta-analysis of only RCTs found similar results. No particular exercise variables, including program length, intervention frequency, training length, or exercise intensity were found to be related to QoL or physical function. Conclusion In community-dwelling patients with chronic heart failure, exercise rehabilitation slightly improves quality of life and physical function. Exercise rehabilitation vs control in community-dwelling patients with chronic heart failure* Outcomes Number of trials (n) Standardized mean difference at 8 to 52 wk (95% CI) Quality of life 32 (3753) 1.16 (0.76 to 1.56) Physical function 18 (3437) 0.89 (0.40 to 1.38) *CI defined in Glossary. Positive mean difference favors the exercise group. Assessed with 9 measures. Assessed with 3 measures. Commentary Treatment during acute or subacute hospitalization typically focuses on medical management of the reason for admission rather than the potential harms of hospitalization-related immobility. However, clinicians are becoming more aware of the adverse effects that can occur within a few days of immobility, including reduction in muscle mass, weakness, frailty, increased risk for falls, hip fractures, and reduced functional status (1, 2). The review by Peiris and colleagues showed that physical therapy can improve function and reduce length of stay in hospitalized patients, but there are several issues to consider. Physical therapy can be provided by physiotherapists, physiotherapy assistants, and nurses, but delivery of physical therapy is complicated when patients are medically unstable and/or on acute medical or surgical wards without rehabilitation facilities. Moreover, it can be difficult to determine which components of physical therapy are critical for improvements in outcomes, especially when physical therapy is delivered to patients who receive other care, including assistance with personal hygiene, transferring, and transport for medically necessary investigations. The trial by Martnez-Velilla and colleagues found that an exercise program during acute hospitalization improved functional capacity at discharge. The intervention did not require treatment by a trained physiotherapist, and the trial did not assess such physiotherapy-relevant outcomes as range of motion, weakness, or stiffness of muscles. Thus, results of this RCT can be generalized to acute medical or surgical wards without dedicated physiotherapy staff. Mounting evidence shows that physical therapy improves such other clinically important outcomes as activities of daily living, bone health, mood, and cognition, all of which can be negatively affected by immobility (3). The RCT by Martnez-Velilla and colleagues showed that a multicomponent exercise intervention improved Barthel Index scores for independence and cognitive levels in hospitalized elderly patients. The systematic review by Palmer and colleagues provides evidence for the beneficial effects of exercise on QoL and physical function in community-dwelling patients with CHF. No adverse events (e.g., falls) related to physical therapy were reported in the reviews by Peiris and colleagues and Palmer and colleagues or in the RCT by Martnez-Velilla and colleagues. A trial included in the review by Peiris and colleagues suggests that exercise rehabilitation for subacute patients may be cost-effective (4). The 2 systematic reviews and RCT reported here show that physical or exercise therapy can improve clinically important physiologic and functional outcomes in adults and can reduce length of stay in older patients who have been admitted for a short hospital stay.