The Effects of Combined Aerobic and Resistance Training on Quality of Life in

Heart Failure: A Systematic Literature Review

Jordyn Echlin - 1060037

KIN 4400

April 10th, 2020

 Table of Contents

Introduction ​ [4]

Rationale [4]
​

Objectives [5]

Methods

Eligibility Criteria [5]

Information Sources [6]

Search [6]

Risk of Bias [6]

Results

Study Selection [6]

Prisma Flow [7]

Study Characteristics [8]

​

Data Extraction Table [8-13]

Synthesis of Individual Studies [13]

​

Health Complaints Score [14]

Minnesota Living with Heart Failure Questionnaire [14]

Short-Form 36 [15]

Risk of Bias Across Studies [15]

Discussion ​[16]

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Summary of Evidence [16]
​

Limitations [16]
​

Conclusions ​[17]

References ​[18]

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Introduction

Rationale

Heart failure [HF] is one of the leading causes of death worldwide, with 23 million people

reported suffering last year (10&12). Even with technological advances, HF is becoming

more prevalent in society (5-8), based on the increased aging population and ability to

identify disease (7,8&11.). HF occurs when the heart does not pump blood adequately,

therefore limiting oxygen delivery to necessary tissues and organs, including the heart itself

(12). Symptoms of HF include dyspnea (shortness of breath), increased fatigability and

decreased exercise tolerance (6&13). Exercise capacity amongst people diagnosed with HF is

said to be approximately 50-70% of “healthy normal” predicted values (7). Lowered ability to

exercise influences physical fitness and quality of life [QoL] (7).

Previous studies describe positive effects associated with aerobic training [A.T.] for

maintaining symptoms of HF (3,4&8). In the found studies, A.T. is performed in forms of

walking or cycling with the goal to increase work intensity, duration or distance (1-12). A.T.

is mainly prescribed based on measured oxygen utilization (VO2peak) or walking capacity

(6MWT) and at low-moderate intensities for longer durations (1-12). Individually, A.T. may

not be the most optimal treatment for HF because of its lack to impact muscle growth and

mimic functional tasks (7). More recent studies are proving that combining A.T. with

moderate intensity resistance training [R.T.] is safe and beneficial for people diagnosed with

HF (3&7). R.T. is considered to be repetitive functional movements that incorporate weight

with the goal to increase muscular capacity (1). Due to loss of muscle mass as a result of

aging, R.T. could be beneficial for an elderly population (7).

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Physical function has been shown to increase with exercise training, ultimately increasing

exercise capacity and QoL (). QoL is commonly defined throughout studies as being

self-determined based on one’s perceived ability to perform everyday tasks (8). QoL is based

on many factors; psychological, socioeconomic and physical (6&8). Through this systematic

review, QoL was assessed subjectively through questionnaires in relation to treatment of

combined aerobic and resistance training [C.T.].

Objective

The purpose of this systematic literature review was to examine current research comparing

the effects of A.T. vs. C.T. on QoL in people over 45 suffering from HF; with the hypothesis

that combined training will have an increased benefit on QoL.

Methods

Eligibility Criteria
​

To be eligible for consideration in the following literature review, studies needed to be

legible, full-text primary articles. Articles needed to consider solely aerobic and resistance

training combined [C.T.] as exercise interventions for HF. Participants needed to be humans

aged 45 or older, considering the aging population. This study was not gender specific due to

the lack of information pertaining to women and HF. The studies used included participants

of New York Heart Association (NYHA) class II and III, defined as having a left-ventricular

ejection fraction (LVEF) ≥ 40%, meaning patients were safe and eligible to exercise. Any

studies with major comorbidities defined amongst participant groups were excluded to avoid

specific populations.

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Information Sources

Primary research articles were identified using two scientific databases; Medline via Ovid

and Cochrane Library. Multiple searches were conducted in order to condense the number of

articles being examined between January - March, 2020.

Search

Using Medline via ovid, final key search terms included resistance training and heart failure.

The two terms were then combined with the AND function. Humans over 45 were then added

as additional limits.

Risk of Bias

To avoid risk of bias, only primary articles were considered, however bias is presumed to be

moderate. All articles used were randomized control trials (RCT) except for one

non-randomized longitudinal control clinical study (7). All studies contained both men and

women. Population sizes varied with one study having 285 participants (9), however the

majority of studies had between 20-60 participants (2-4,6-8,10&11). Since QoL is

subjectively measured through questionnaires, bias may be considered higher.

Results

Study Selection

The search within medline via ovid generated 34 articles. The same search terms generated

37 articles in Cochrane Library. Seven other articles had been previously hand-selected prior

to finalizing the search. A total of 78 articles were to be considered. Using Zotero research

assistant, duplicates were removed and 65 articles remained. Based on titles and abstracts, 33

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articles were eliminated due to; having a study population less than 45 years old [1],

population specific, meaning additional comorbidities were identified [4], incomplete articles

[12], reviews [5] written in a different language with no translation options [1], research older

than 15 years [6], and irrelevance to topic [4]. Twenty-three full- text articles were removed

because quality of life was not an outcome measure [17] or they had additional intervention

methods [6]. A total of 9 primary articles were reviewed. Refer to Figure 1.

Fig.1. PRISMA Flow Diagram of study selection.

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Study Characteristics

As previously mentioned in methods, all studies considered A.T. vs. C.T. in humans over 45

diagnosed with HF and the impact on QoL. The studies were either conducted in a treatment

centre or at home; five studies were based out of hospitals or rehabilitation clinics

(2-4,9&10), three studies were home-based (6,8&11), and one study incorporated both

settings(7). The majority of studies ranged from 20-60 participants (2-4,6-8,10&11), except

for the study done by Huerst et al (9) which had a population sample of 285. The duration of

studies varied anywhere from 4 weeks (9) to 12 months (7). Intensities and modes of exercise

were individualized and varied across studies.​ ​Studies either had a control that was instructed

to maintain regular daily activities (3&8) or the control was considered solely A.T.

(2,4,6,7,9-11). All studies considered C.T. as treatment. C.T. was kept the same aerobically

throughout studies, with the addition of R.T.

Figure 2: Data Extraction Table - Summary of Primary Sources.

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Synthesis of Results of Individual Studies

The outcome measure being considered for this review was QoL. All other outcomes

measured across the nine studies were not considered. QoL was measured subjectively

through questionnaires at baseline and on completion across all studies. Primary QoL

questionnaires included the Health Complaints Scale [HSC] (4), Minnesota Living with HF

Questionnaire [MLHFQ] (3,6-8,10&11), and Short-Form 36 [SF36] Questionnaire (2,7&9).

Health Complaints Scale [HCS]

Beckers et al (4) used the HCS to measure QoL. The HCS is a self-reported questionnaire

with 12 questions, rated from 0-5 (from nothing-extreme), relating to common cardiac

symptoms . This scale has been previously used to measure health-related QoL in patients

diagnosed with HF and different cardiac problems. The study found that 42% of total

participants recorded a sig. decrease on the HCS, with 60% of the decrease reported from the

combined training group. (4)

Minnesota Living with HF Questionnaire [MLHFQ]

The MLHFQ was used across 6 studies (3,6-8,10&11). The MLHFQ includes 21

disease-specific questions related to mental, physical and socioeconomic factors (6&7). The

questionnaire is self-reported and scored on a scale of 0-105 (3,6,7,10&11). A change in

score of 5 points is considered clinically significant (3,6,7,10&11). MLHFQ results varied

across control and treatment groups in all studies. Iepsen et al (10) found an increase in QoL

in both training groups, with no difference between them. Chien et al, (6) and Cress et al (8)

found a sig. change in their treatment group compared to control. Ignaszewski et al (11)

found a sig. increase in QoL for the exercise group, and a decrease in Qol for the control

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group. Al-Kurtass et al (3) unexpectedly found that the A.T. group had an improvement in

QoL compared to C.T. Cider et al (7) found minor effects between both groups. Overall

results are inconclusive.

Short-Form 36 [SF36]

The SF-36 was used to measure QoL in three studies. The SF-36 has been previously used in

HF, with high validity and reliability results (7). Ades et al (2) and Huerst at al(9) revealed an

increase in QoL amongst C.T. Cider et al (7) found minor effects between both groups.

Overall, the majority of studies recorded an increase in QoL associated with C.T. compared

to A.T. (2,4,6,8,9&11), with one study recording an increase in both groups (10) and two

studies recording negative results (3&7).

Risk of Bias Across Studies

Many studies had high drop-out rates prior to commencing, therefore eligible participants

may have high perceived QoL already due to willingness to participate, access to facilities,

social support etc.(). Three RCTs were clearly identified as open-label, meaning participants

and researchers were aware of treatment protocol (4,6&11). It would be hard to double-blind

the clinical population associated with HF for safety purposes, however not being blinded

allows for an increase in possibility of bias. Participants could increase adherence rates from

knowing their training routine and the purpose of study. Researchers might act differently if

they know what group they are assigned to monitor. Some studies used education to inform

patients of the benefits of treatment which could influence motivation to participate (6&9).

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Discussion

Summary of Evidence

The majority of studies showed an increase in QoL associated with C.T. compared to A.T.

however, results were inconclusive and the following should be considered. Smaller sample

sizes can lead to higher percentages than appeared. For example, Ades et al (2) reported an

increase in QoL with training, however they only considered 13 people diagnosed with HF

and compared it to a considered healthy control. Their results may have been different if they

included more people.

Many studies were based at home and had self-reported training logs which could have

skewed results. Cress et al (8) was the only at-home study that documented how at-home

exercise was objectively measured, using an Omron step counter, increasing reliability of

their results.

Although QoL is a subjective outcome to measure, it is validated and important because

one’s actual physical ability may not reflect their perceived ability (7&8). One’s perceived

ability may change over-time, therefore QoL results should be considered individually,

comparing baseline results to post-treatment results. Other factors may need to be considered

alongside QoL to prove significant benefits.

Limitations

Individual study limitations were commonly identified as having small sample sizes and low

adherence rates (2,8&10). Study durations vary from 4 weeks (9) to 12 months (7), therefore

results may be inconclusive.

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The author of this review is an undergraduate student exploring scientific database searches.

Review-level limitations include using a limited number of databases to complete the search

leaving a gap in the retrieval of identified research. The author applied additional limits from

the begining with research being conducted in humans ages 45 and older, and within the

previous 15 years. An example of a follow-up literature review could include quality of life

as a key search term and use additional databases; such as Pubmed.

Conclusions

In conclusion, it has been seen that patients diagnosed with HF can benefit from C.T. with a

potential to improve QoL. QoL is subjective and results should be considered with caution,

however when comparing individual data from baseline to finish, results are considered

reliable. QoL is an important measurement to consider but looking at other correlated

outcomes may yield more valid results. Science and health are continually evolving and

future studies will forever be required in research.

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 References 
 
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Resistance training alters skeletal muscle structure and function in human heart 
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Vanburen, P. ​Effect of Resistance Training on Physical Disability in Chronic Heart 
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3. Al-Kurtass, S. Daub, B. Haykowsky, M.J. Kim, D. Mandic, S. Taylor, D. 
Tymchak, W. Quinney, H.A. ​Effects of Aerobic or Aerobic and Resistance Training 
on Cardiorespiratory and Skeletal Muscle Function in Heart Failure: a Randomized 
Controlled Pilot Trial. ​Clinical Rehabilitation. ​23-3: 207-216, 2009. 
4. Beckers, P. Conraads, V. Denollet, J. Possemiers, N. Vrints, C. Wuyts, F. 
Combined Endurance-Resistance Training vs. Endurance Training in Patients with 
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Resistance Exercise Bands in Patients with Chronic Heart Failure. Long-term Effects
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 11. Ignaszewski, A. Safiyari-Hafizi, H. Taunton, J. Warburton, D.E.R.​ The Health 
Benefits of a 12-Week Home-Based Interval Training Cardiac Rehabilitation Program 
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