Evangelia Kouidi

EXERCISE TRAINING IN PATIENTS WITH END-STAGE RENAL DISEASE ON HEMODIALYSIS: COMPARISON OF THREE REHABILITATION PROGRAMS

Functional capacity of end-stage renal disease patients is dramatically impaired. Although exercise training programs appear to have beneficial morphological, functional and psychosocial effects in end-stage renal disease patients on hemodialysis (HD), the adherence rate is high. The purpose of this study was to compare the effects of three modes of exercise training on aerobic capacity and to identify the most favourable, efficient and preferable to patients on HD with regard to functional improvements and participation rate in the programs. Fifty-eight volunteer patients were screened for low-risk status and selected from the dialysis population. The 48 patients who completed the study protocol were randomly assigned either to one of the three training groups or to a control group. Sixteen of them (Group A - mean age 46.4+/-13.9 years) completed a 6-month supervised outpatient exercise renal rehabilitation program consisting of three weekly sessions of aerobic and strengthening training on the non-dialysis days; 10 (Group B - mean age 48.3+/-12.1 years) completed a 6-month exercise program during HD; 10 (Group C - mean age 51.4+/-12.5 years) followed an unsupervised moderate exercise program at home, and 12 patients (Group D-mean age 50.2+/-7.9 years) were used as patient controls. The level of anemia, the medications and the HD prescription remained stable during the study. Fifteen sex- and age-matched sedentary individuals (Group E - mean age 46.9+/-6.4 years) comprised a healthy control group for baseline data. All subjects at the beginning and end of the study underwent clinical examination, laboratory tests and a treadmill exercise test to fatigue endpoints with direct measurement of aerobic capacity. Group A had a higher dropout rate (24%) compared to groups B (17%) and C (17%). Peak oxygen consumption (VO2 peak) increased by 43% (p < 0.05), anaerobic threshold (VO2AT) by 37% (p < 0.05) and exercise time by 33% (p < 0.05) after training in Group A; by 24% (p < 0.05), 18% (p < 0.05) and 22% (p < 0.05), respectively, in B; and by 17% (p < 0.05), 8% (p < 0.05) and 14% (p < 0.05), respectively, in C; while both remained almost unchanged in Group D. These results demonstrate that intense exercise training on non-dialysis days is the most effective way of training, whereas exercise during HD is also effective and preferable.

Cardiovascular evaluation of middle-aged/senior individuals engaged in leisure-time sport activities: position stand from the sections of exercise physiology and sports cardiology of the European Association of Cardiovascular Prevention and Rehabilitation

Regular aerobic exercise at moderate intensities and an increased physical fitness are associated with a reduced risk of fatal and nonfatal coronary events in middle-aged individuals. In contrast, moderate and vigorous physical exertion is associated with an increased risk for cardiac events, including sudden cardiac death in individuals harbouring cardiovascular disease. The risk-benefit ratio may differ in relation to the individuals age, fitness level, and presence of cardiovascular disease; sedentary individuals with underlying coronary artery disease are at greatest risk. The intention of the present position stand of the European Association of Cardiovascular Prevention and Rehabilitation is to encourage individuals to participate in regular physical activity and derive the benefits of physical exercise while minimizing the risk of cardiovascular adverse events. Therefore, the aim is to establish the most practical method of cardiovascular evaluation in middle-age/senior individuals, who are contemplating exercise or who are already engaged in nonprofessional competitive or recreational leisure sporting activity. These recommendations rely on existing scientific evidence, and in the absence of such, on expert consensus. The methodology of how middle-aged and older individuals should be evaluated appropriately before engaging in regular physical activity is both complex and controversial. On practical grounds the consensus panel recommend that such evaluation should vary according to the individuals cardiac risk profile and the intended level of physical activity. Self assessment of the habitual physical activity level and of the risk factors, are recommended for screening of large populations. Individuals deemed to be at risk require further evaluation by a qualified physician. In senior/adult individuals with an increased risk for coronary events, maximal exercise testing (and possibly further evaluations) is advocated. Hopefully, the recommendations in this paper provide a practical solution for facilitating safe exercise prescription in senior/adults.

Importance of characteristics and modalities of physical activity and exercise in the management of cardiovascular health in individuals with cardiovascular risk factors: recommendations from the EACPR (Part II)

In a previous paper, as the first of a series of three on the importance of characteristics and modalities of physical activity (PA) and exercise in the management of cardiovascular health within the general population, we concluded that, in the population at large, PA and aerobic exercise capacity clearly are inversely associated with increased cardiovascular disease risk and all-cause and cardiovascular mortality and that a dose–response curve on cardiovascular outcome has been demonstrated in most studies. More and more evidence is accumulated that engaging in regular PA and exercise interventions are essential components for reducing the severity of cardiovascular risk factors, such as obesity and abdominal fat, high BP, metabolic risk factors, and systemic inflammation. However, it is less clear whether and which type of PA and exercise intervention (aerobic exercise, dynamic resistive exercise, or both) or characteristic of exercise (frequency, intensity, time or duration, and volume) would yield more benefit for each separate risk factor. The present paper, therefore, will review and make recommendations for PA and exercise training in the management of cardiovascular health in individuals with cardiovascular risk factors. The guidance offered in this series of papers is aimed at medical doctors, health practitioners, kinesiologists, physiotherapists and exercise physiologists, politicians, public health policy makers, and individual members of the public. Based on previous and the current literature overviews, recommendations from the European Association on Cardiovascular Prevention and Rehabilitation are formulated regarding type, volume, and intensity of PA and regarding appropriate risk evaluation during exercise in individuals with cardiovascular risk factors.

Exercise Renal Rehabilitation Program: Psychosocial Effects

The aim of this study was to assess the psychosocial effects of exercise training on hemodialysis (HD) patients. Thirty-one uremic patients, aged 50.6+/-11.6 years, on maintenance HD were studied. Twenty patients were selected at random for a 6-month exercise renal rehabilitation program (ERRP) consisting of 3 weekly sessions of exercise training. The other 11 patients were assigned to sedentary control status. A formal psychosocial assessment, which included affective (Beck Depression Inventory, BDI), quality of life (Quality of Life Index, QLI) and personality (Eysenck Personality Questionnaire, EPQ) parameters, was performed with validated questionnaires at the beginning and the end of the ERRP. After training significant improvement occurred in physical capacity (VO2max increased from 16.8+/-6.2 to 23.2+/-7.6 ml/kg/min, p < 0.05). Although the level of depression did not differ betwen the 2 groups at pretesting, the ERRP group showed a decrease in their self-report of depression (decrease in BDI score value, from 21.0+/-10.4 to 13.7+/-9.5, p < 0.05) after the training program. From the relationship between the baseline levels of BDI depression and changes in VO2max in the ERRP group it was suggested that the most severely depressed patients got the greatest beneficial effects from exercise training. Moreover, trained patients demonstrated an improvement in QLI (from 6.3+/-1.5 to 9.0+/-0.9, p < 0.05). This improvement was found to be dependent on the participation in ERRP, the effects of the training and the improvement in the depression. All the above functional and psychosocial parameters remained unchanged in the controls. The results demonstrate that ERRP is an effective emotional therapeutic method for HD patients and improves their quality of life.

Cardiac effects of exercise rehabilitation in hemodialysis patients.

Exercise training has well documented beneficial effects in a variety of cardiac disorders. End stage renal disease patients present many cardiovascular complications and suffer from impaired exercise capacity. No study to date has adequately examined the cardiac responses to exercise training in renal patients on hemodialysis (HD). To determine the effects of an exercise rehabilitation program on the left ventricular function at rest and during submaximal effort, 38 end-stage renal disease patients on maintenance HD were randomised into three groups. Sixteen of them (group A--mean age 46.4+/-13.9 years), without clinical features of heart failure, participated in a 6-month supervised exercise renal rehabilitation program consisting of three weekly sessions of aerobic training, 10 (group B--mean age 51.4+/-12.5 years) followed a moderate exercise program at home, and the other 12 (group C--mean age 50.2+/-7.9 years) were not trained and remained as controls. The level of anemia and the HD prescription remained constant during the study. Fifteen sex- and age-matched sedentary individuals (group D--mean age 46.9+/-6.4 years) were the healthy controls. All subjects at the start and end of the program underwent physical examination, laboratory tests, treadmill exercise testing, M-mode and 2-D echocardiograms performed at rest and at peak of supine bicycle exercise. Left ventricular volumes (EDV, ESV) and mass (LVM) were measured and ejection fraction (EF), stroke volume index (SVI) and cardiac output index (COI) were calculated by standard formulae. The maximal oxygen consumption increased by 43% (P<0.001) and the exercise time by 33% (P<0.001) after training in group A, by 17% (P<0.001) and 14% (P<0.01), respectively, in B, and both remained unchanged in group C. Training in group A was also associated with an increase in LVIDd (from 52.1+/-6.4 to 54.0+/-6.1 mm, P<0.001) and LVM (226+/-67 to 240+/-84 g, P<0.05) at rest with no change noted in groups B and C. Following a 6-month exercise training in group A an increase was also found in the resting EF by 5% (P<0.01) and SVI by 14% (P<0.001). There was no change found in groups B and C. Supine bicycle exercise after training in group A was associated with an improvement in EF by 14% compared to the pre-training change (P<0.001), SVI by 14% (P<0.001) and COI by 73% (P<0.001). These changes from rest to submaximal exercise were less pronounced in group B following training at home. The untrained patients demonstrated no changes in LV systolic function over the 6-month period. These results demonstrate that intense exercise training improves LV systolic function at rest in HD patients; both intense and moderate physical training leads to enhanced cardiac performance during supine submaximal exercise.

Quality of life, psychological and physiological changes following exercise training in patients with chronic heart failure.

OBJECTIVE To assess the physiological and psychosocial effects of exercise training in chronic heart failure. SUBJECTS/PATIENTS Twenty-six men with heart failure (New York Heart Association functional classes II and III) aged 52.5 (SD 9.8) years, were studied. METHODS The subjects were randomized either to rehabilitation group (Group A: 16 patients), participating in a 6-month exercise training program, or to control group (Group B: 10 patients). A psychosocial assessment, which included affective (Beck Depression Inventory and Hospital Anxiety and Depression Scale), quality of life (Quality of Life Index, Minnesota Living with Heart Failure Questionnaire and the Scale of Life Satisfaction) and personality (Eysenck Personality Questionnaire) parameters, was performed at the beginning and the end of the study. RESULTS After training VO2 peak increased by 36% and exercise time by 35%, p < 0.05. A significant decrease in anxiety and depression was also observed. Moreover, trained patients demonstrated a significant improvement in quality of life. No significant correlations were found between deltaVO2 peak and all psychosocial parameter gains. However, the more depressed patients showed the largest physiological responses. CONCLUSION An exercise rehabilitation program in patients with chronic heart failure is useful for improving their work capacity and psychosocial status. Improvements in psychological status seem to be independent of the aerobic gains.

ESC study group of sports cardiology position paper on adverse cardiovascular effects of doping in athletes.

The use of doping substances and methods is extensive not only among elite athletes, but also among amateur and recreational athletes. Many types of drugs are used by athletes to enhance performance, to reduce anxiety, to increase muscle mass, to reduce weight or to mask the use of other drugs during testing. However, the abuse of doping substances and methods has been associated with the occurrence of numerous health side-effects. The adverse effects depend on the type of the consumed drug, as well as the amount and duration of intake and the sensitivity of the body, since there is a large inter-individual variability in responses to a drug. Usually the doses used in sports are much higher than those used for therapeutic purposes and the use of several drugs in combination is frequent, leading to higher risk of side-effects. Among biomedical side-effects of doping, the cardiovascular ones are the most deleterious. Myocardial infarction, hyperlipidemia, hypertension, thrombosis, arrythmogenesis, heart failure and sudden cardiac death have been noted following drug abuse. This paper reviews the literature on the adverse cardiovascular effects after abuse of prohibited substances and methods in athletes, aiming to inform physicians, trainers and athletes and to discourage individuals from using drugs during sports.

Importance of characteristics and modalities of physical activity and exercise in defining the benefits to cardiovascular health within the general population: recommendations from the EACPR (Part I):

Over the last decades, more and more evidence is accumulated that physical activity (PA) and exercise interventions are essential components in primary and secondary prevention for cardiovascular disease. However, it is less clear whether and which type of PA and exercise intervention (aerobic exercise, dynamic resistive exercise, or both) or characteristic of exercise (frequency, intensity, time or duration, and volume) would yield more benefit in achieving cardiovascular health. The present paper, as the first of a series of three, will make specific recommendations on the importance of these characteristics for cardiovascular health in the population at large. The guidance offered in this series of papers is aimed at medical doctors, health practitioners, kinesiologists, physiotherapists and exercise physiologists, politicians, public health policy makers, and the individual member of the public. Based on previous and the current literature, recommendations from the European Association on Cardiovascular Prevention and Rehabilitation are formulated regarding type, volume, and intensity of PA and exercise.

Central and peripheral adaptations to physical training in patients with end-stage renal disease

AbstractRenal replacement treatment options are life-saving treatments for patients with end-stage renal disease (ESRD). However, prolonged survival in patients with ESRD is associated with various functional and morphological disorders from almost all systems. Anaemia, deconditioning, cardiac dysfunction, impairment of cardiac autonomic control and skeletal muscle weakness and fatigue, primarily because of ‘uraemic’ myopathy and neuropathy, are the main predisposing factors for their poor functional ability.Physical training is being recommended as a complementary therapeutic modality. There are generally 3 methods of exercise training applied in patients with ESRD: (i) the supervised outpatient programme that is held in a rehabilitation centre; (ii) a home exercise rehabilitation programme; and (iii) exercise rehabilitation programme during the first hours of the haemodialysis treatment in the renal unit. All the available training data show that the application of an exercise training programme in patients with ESRD enhances their physical fitness. This improvement is due to central and mainly peripheral adaptations. Exercise training in these patients increases aerobic capacity, causes favourable left ventricular functional adaptations, reduces blood pressure in patients with hypertension, modifies other coronary risk factors, increases the cardiac vagal activity and suppresses the incidence of cardiac arrhythmias. Moreover, exercise training has beneficial effects on muscle structural and functional abnormalities. These central and peripheral adaptations to exercise training cause an increase in their functional capacity and offer them a chance of a better quality of life. Moreover, exercise training improves exercise tolerance of renal post-transplant patients.

Comparative study of field and laboratory tests for the evaluation of aerobic capacity in soccer players.

The purpose of this study was to evaluate the maximal oxygen uptake (VO2max) values in soccer players as assessed by field and laboratory tests. Thirty-five elite young soccer players were studied (mean age 18.1 ± 1.0 years, training duration 8.3 ± 1.5 years) in the middle of the playing season. All subjects performed 2 maximal field tests: the Yo-Yo endurance test (T1) for the estimation of VO2max according to normogram values, and the Yo-Yo intermittent endurance test (T2) using portable telemetric ergospirometry; as well as 2 maximal exercise tests on the treadmill with continuous (T3) and intermittent (T4) protocols. The estimated VO2max values of the T1 test (56.33 ml·kg-1·min-1) were 10.5%, 11.4%, and 13.3% (p ≤ 0.05) lower than those of the T2 (62.96 ml·kg-1·min-1), T3(63.59 ml·kg-1·min-1) and T4 (64.98 ml·kg-1·min-1) tests, respectively. Significant differences were also found between the intermittent exercise protocols T1 and T3 (p ≤ 0.001) and the continuous exercise protocols T2 and T4 (p ≤ 0.001). There was a high degree of cross correlation between the VO2max values of the 3 ergospirometric tests (T2 versus T3, r = 0.47, p ≤ 0.005; T2versus T4, r = 0.59, p ≤ 0.001; T3 versus T4 r = 0.79, p ≤ 0.001). It is necessary to use ergospirometry to accurately estimate aerobic capacity in soccer players. Nevertheless, the Yo-Yo field tests should be used by coaches because they are easy and helpful tools in the training program setting and for player follow-up during the playing season.