239. High Intensity Intermittent Exercise Training

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239. High Intensity Intermittent Exercise Training

CATEGORY: Fitness, Workout & Exercise 500 Courses

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Syllabus

CHAPTER 1: INTRODUCTION………………………………………………………………………………………………….1
CHAPTER 2: LITERATURE REVIEW………………………………………………………………………………………..6
2.1 Chronic heart failure ………………………………………………………………………………………………………..7
2.1.1 Definition of chronic heart failure ………………………………………………………………………………..7
2.1.2 Diagnosis and classification of chronic heart failure……………………………………………………….7
2.2 Pathophysiology of chronic heart failure……………………………………………………………………………9
2.2.1 Cardiovascular function………………………………………………………………………………………………9
2.2.2 Neurohormonal hypothesis………………………………………………………………………………………….9
2.2.3 Muscle hypothesis……………………………………………………………………………………………………10
2.2.4 Ergoreflex activation ………………………………………………………………………………………………..11
2.2.5 Inflammatory cytokine hypothesis ……………………………………………………………………………..12
2.2.6 Excessive ventilatory response…………………………………………………………………………………..12
2.3 Determinants of exercise capacity in CHF………………………………………………………………………..12
2.4 Current medical therapy for CHF……………………………………………………………………………………14
2.5 Exercise training as therapy for CHF………………………………………………………………………………17
2.5.1 Exercise training review papers and meta-analyses ………………………………………………………18
2.5.2 Proposed mechanisms for benefits following exercise training ………………………………………19
2.5.3 Reduction in all cause mortality and hospitalisation: HF-ACTION trial ………………………….20
2.5.4 Effect on exercise capacity………………………………………………………………………………………..22
2.5.4.1 Peak oxygen uptake (VO2peak) …………………………………………………………………………..22
2.5.4.2 Sub-maximal exercise capacity………………………………………………………………………….23
2.5.5 Improvements in cardiovascular function ……………………………………………………………………23
2.5.5.1 Left ventricular function …………………………………………………………………………………..23
2.5.6 Peripheral blood flow and endothelial function…………………………………………………………….24
2.5.7 Anti-inflammatory effect…………………………………………………………………………………………..24
2.5.8 Skeletal muscle function……………………………………………………………………………………………25
2.5.9 Ventilatory function …………………………………………………………………………………………………26
2.5.10 Neuroendocrine and autonomic nervous system activity …………………………………………..27
2.5.11 Cardiac energy metabolism …………………………………………………………………………………..27
2.5.12 Improvements in health-related quality of life………………………………………………………….28
2.5.13 Cost-effectiveness………………………………………………………………………………………………..28
2.6 Current guidelines for exercise training …………………………………………………………………………..29
2.6.1 Safety of exercise training …………………………………………………………………………………………29
2.6.2 The exercise dose …………………………………………………………………………………………………….30
2.6.2.1 Exercise intensity…………………………………………………………………………………………….31
2.6.2.2 Exercise intensity domains ……………………………………………………………………………….31
2.6.3 Exercise guidelines for chronic heart failure ………………………………………………………………..34
2.6.4 Intermittent exercise training……………………………………………………………………………………..37
2.6.4.1 Physiology of intermittent training …………………………………………………………………….39
2.6.4.2 Rationale for high intensity intermittent exercise for CHF…………………………………….40
2.6.4.3 Methods for intermittent exercise prescription …………………………………………………….40
2.6.4.4 A novel application of intermittent exercise prescription ………………………………………41
2.6.5 Circuit training ………………………………………………………………………………………………………..42

2.7 Ecological validity: application to current practice …………………………………………………………..43
2.7.1 Cardiac rehabilitation ……………………………………………………………………………………………….44
2.7.2 UK based cardiac rehabilitation programmes……………………………………………………………….45
2.7.3 Current provision of cardiac rehabilitation for CHF patients………………………………………….46
2.8 Methodological considerations in the study of responses to exercise training in CHF…………46
2.8.1 Cardiopulmonary exercise testing (CPET)…………………………………………………………………..47
2.8.1.1 Exercise mode…………………………………………………………………………………………………47
2.8.1.2 Effect of test protocol duration ………………………………………………………………………….48
2.8.2 Reproducibility………………………………………………………………………………………………………..48
2.8.3 Outcome measures in CPET………………………………………………………………………………………49
2.8.3.1 VO2peak …………………………………………………………………………………………………………..49
2.8.3.2 Ventilatory threshold (VT) ……………………………………………………………………………….50
2.8.3.3 Ventilatory efficiency ………………………………………………………………………………………51
2.8.3.4 Oxygen uptake-work rate relationship (ΔVO2/ΔWR) …………………………………………..52
2.8.4 Heart rate response to exercise in CHF ……………………………………………………………………….52
2.8.5 Rating of perceived exertion (RPE)…………………………………………………………………………….53
2.8.6 B-type natriuretic peptide (BNP)………………………………………………………………………………..55
2.8.7 Daily physical activity………………………………………………………………………………………………57
2.8.8 Quality of life ………………………………………………………………………………………………………….57
2.8.8.1 Disease-specific quality of life: Minnesota Living with Heart Failure Questionnaire
(MLHFQ) ……………………………………………………………………………………………………………………..58
2.8.8.2 Generic health status: Medical Outcomes Short Form 36 (SF-36) ………………………….59
2.8.8.3 Clinical significance…………………………………………………………………………………………59
2.9 Proposed aims of the thesis ……………………………………………………………………………………………..61
CHAPTER 3: GENERAL METHODS………………………………………………………………………………………..63
3.0 Introduction……………………………………………………………………………………………………………………64
3.1 Study location…………………………………………………………………………………………………………………64
3.2 Participants and ethics ……………………………………………………………………………………………………65
3.2.1 Research ethics………………………………………………………………………………………………………..66
3.2.2 Informed consent……………………………………………………………………………………………………..67
3.3 Procedures for maximal exercise testing…………………………………………………………………………..67
3.3.1 Maximal cardiopulmonary exercise test (standard test) and maximum short time exercise
capacity test (steep test)…………………………………………………………………………………………………………67
3.3.2 Measurements………………………………………………………………………………………………………….68
3.4 Procedures for continuous and intermittent exercise tests…………………………………………………69
3.4.1 Experimental procedures…………………………………………………………………………………………..71
3.5 Statistical analysis…………………………………………………………………………………………………………..72
EXPERIMENTAL CHAPTERS …………………………………………………………………………………………………73
CHAPTER 4: REPRODUCIBILITY OF VARIABLES DERIVED FROM MAXIMAL
INCREMENTAL CYCLING TESTS IN CHF AND HEALTHY CONTROLS………………………………..74

4.0 Introduction……………………………………………………………………………………………………………………75
4.1 Methods………………………………………………………………………………………………………………………….79
4.1.1 Participants……………………………………………………………………………………………………………..79
4.1.2 Experimental design …………………………………………………………………………………………………79
4.1.3 Data analysis …………………………………………………………………………………………………………..79
4.1.3.1 Calculation of continuous and intermittent exercise workloads………………………………82
4.1.4 Statistical analysis ……………………………………………………………………………………………………82
4.2 Results…………………………………………………………………………………………………………………………..83
4.2.1 Reproducibility of standard test………………………………………………………………………………….86
4.2.1.1 Reproducibility of standard test for CHF patients ………………………………………………..92
4.2.2 Reproducibility of steep test………………………………………………………………………………………94
4.2.3 Comparison of intermittent exercise intensity derived from standard and steep tests…………97
4.2.4 Comparison of VO2peak in standard and steep tests……………………………………………………….98
4.3 Discussion …………………………………………………………………………………………………………………….100
4.3.1 Reproducibility of standard test………………………………………………………………………………..100
4.3.2 Reproducibility of steep test…………………………………………………………………………………….105
4.3.3 Comparison of intermittent exercise intensity derived from standard and steep tests……….106
4.4 Conclusion ……………………………………………………………………………………………………………………109
CHAPTER 5: ACUTE RESPONSES TO CONTINUOUS AND INTERMITTENT EXERCISE IN CHF
AND HEALTHY CONTROLS…………………………………………………………………………………………………111
5.0 Introduction………………………………………………………………………………………………………………….112
5.1 Methods…………………………………………………………………………………………………………………….115
5.1.1 Participants……………………………………………………………………………………………………………115
5.1.2 Experimental design ……………………………………………………………………………………………….115
5.1.3 Data analysis …………………………………………………………………………………………………………115
5.1.4 Statistical analysis ………………………………………………………………………………………………….116
5.2 Results………………………………………………………………………………………………………………………….116
5.3 Discussion …………………………………………………………………………………………………………………123
5.4 Conclusion ……………………………………………………………………………………………………………………127
CHAPTER 6: THE EFFECT OF VOLATILITY ON ACUTE RESPONSES TO INTERMITTENT
EXERCISE IN CHF AND HEALTHY CONTROLS…………………………………………………………………..128
6.0 Introduction…………………………………………………………………………………………………………………129
6.1 Methods………………………………………………………………………………………………………………………..130
6.1.1 Participants……………………………………………………………………………………………………………130
6.1.2 Experimental design ……………………………………………………………………………………………….130
6.2 Results………………………………………………………………………………………………………………………….131
6.3 Discussion …………………………………………………………………………………………………………………….137
6.4 Conclusion ……………………………………………………………………………………………………………………140

CHAPTER 7: COMPARISON OF HIGH INTENSITY INTERMITTENT TRAINING TO CIRCUIT-
BASED AEROBIC TRAINING AT IMROVING FUNCTIONALCAPACITY, VENTILATORY

EFFICIENCY, BNP AND QUALITY OF LIFE IN CHF……………………………………………………………..142
7.0 Introduction………………………………………………………………………………………………………………….143
7.1 Methods………………………………………………………………………………………………………………………..148
7.1.1 Participants……………………………………………………………………………………………………………148
7.1.2 Experimental design ……………………………………………………………………………………………….149
7.1.3 Cardiopulmonary exercise test …………………………………………………………………………………150
7.1.4 Cardiac rehabilitation ……………………………………………………………………………………………..151
7.1.5 Exercise training…………………………………………………………………………………………………….151
7.1.6 Blood sampling and analysis……………………………………………………………………………………153
7.1.7 Quality of life measures…………………………………………………………………………………………..153
7.1.7.1 Minnesota Living with Heart Failure Questionnaire……………………………………………153
7.1.7.2 Medical Outcomes Study Short Form Health Survey (SF-36)………………………………154
7.1.8 Physical activity record …………………………………………………………………………………………..154
7.1.9 Statistical analysis ………………………………………………………………………………………………….154
7.2 Results………………………………………………………………………………………………………………………….156
7.2.1 Participants……………………………………………………………………………………………………………156
7.2.2 Medication…………………………………………………………………………………………………………….160
7.2.3 Safety……………………………………………………………………………………………………………………160
7.2.4 Compliance……………………………………………………………………………………………………………160
7.2.5 Effect of exercise training on CPET variables ……………………………………………………………161
7.2.5.1 Inter-individual variation ………………………………………………………………………………..163
7.2.6 BNP……………………………………………………………………………………………………………………..167
7.2.7 Heart rate ………………………………………………………………………………………………………………167
7.2.8 Quality of life ………………………………………………………………………………………………………..167
7.2.8.1 Minnesota Living with Heart Failure Questionnaire (MLHFQ)……………………………167
7.2.8.2 Short-Form 36 (SF-36) …………………………………………………………………………………..170
7.2.9 Relationship between change in functional capacity and quality of life in the circuit and
intermittent groups………………………………………………………………………………………………………………173
7.2.10 Training data……………………………………………………………………………………………………..173
7.2.11 Physical activity record………………………………………………………………………………………176
7.3 Discussion …………………………………………………………………………………………………………………….178
7.3.1 Recruitment and compliance ……………………………………………………………………………………178
7.3.2 Exercise performance ……………………………………………………………………………………………..179
7.3.3 Changes in ventilatory response to exercise……………………………………………………………….181
7.3.4 Inter-individual response to training………………………………………………………………………….183
7.3.5 Potential mechanisms for response to exercise training ……………………………………………….185
7.3.6 Methodological issues…………………………………………………………………………………………….187
7.3.7 BNP……………………………………………………………………………………………………………………..189
7.3.8 Daily physical activity…………………………………………………………………………………………….190
7.3.9 Quality of life measures…………………………………………………………………………………………..191
7.3.9.1 Minnesota Living with Heart Failure Questionnaire……………………………………………191
7.3.9.2 SF-36……………………………………………………………………………………………………………192
7.3.10 Practical implications………………………………………………………………………………………….194
7.3.11 Study limitations………………………………………………………………………………………………..194
7.4 Conclusions…………………………………………………………………………………………………………………..195

CHAPTER 8: EXAMPLES OF FURTHER CHALLENGES IN THE EXERCISE TESTING OF CHF
PATIENTS…………………………………………………………………………………………………………………………….197
8.0 Introduction………………………………………………………………………………………………………………….198
8.1 Exercise testing in CHF with implantable devices…………………………………………………………..198
8.1.1 Case study 1: non-activation of heart rate response during cycle ergometer testing …………199
8.1.2 Case study 2: Cycle ergometer testing in 2 different pacemaker modes…………………………201
8.2 Case study 3: Abnormal VO2 response at peak exercise………………………………………………….203
8.3 Heart rate response to exercise in patients with atrial fibrillation ……………………………………205
8.4 Heart rate guidelines for exercise intensity prescription………………………………………………….206
8.5 Heart rate recovery……………………………………………………………………………………………………….207
8.6 Lung function ……………………………………………………………………………………………………………….207
CHAPTER 9: GENERAL DISCUSSION & CONCLUSIONS……………………………………………………..208
9.0 Introduction………………………………………………………………………………………………………………….209
9.1 Limitations of maximal CPET for exercise intensity prescription ……………………………………210
9.2 Limitations of the steep test (Meyer et al, 1997) for intermittent exercise prescription ……..211
9.3 Continuous and intermittent exercise of equal total workload elicit similar cardiorespiratory
responses in CHF and healthy older individuals ……………………………………………………………………..212
9.4 Changing the volatility of intermittent exercise intensity does not alter cardiorespiratory
responses ………………………………………………………………………………………………………………………………213
9.5 High intensity intermittent exercise training is an alternative training mode for cardiac
rehabilitation programmes…………………………………………………………………………………………………….213
9.6 The effect of the total exercise dose on the training response …………………………………………..214
9.6.1 Frequency and duration …………………………………………………………………………………………..214
9.6.2 Intensity………………………………………………………………………………………………………………..215
9.6.3 Mode…………………………………………………………………………………………………………………….215
9.7 Inter-individual difference in training response ……………………………………………………………..216
9.8 Effect of exercise training on quality of life …………………………………………………………………….216
9.9 The time-course of benefits from exercise training in CHF ……………………………………………..217
9.10 Conclusion………………………………………………………………………………………………………………..219
9.11 Future directions………………………………………………………………………………………………………222

REFERENCES……………………………………………………………………………………………………………………….225
APPENDICES ………………………………………………………………………………………………………………………..244

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