| Object iveThis study is to summarize and review systematically the existing evidence of the use of TCM exercise regimen in patients with congestive heart failure (CHF) by the method of content analysis in the aim to find out their inadequacy and to design a survey questinairre afterward. An epidemiological survey will then be conducted in order to study the current status of TCM exercise regimen in CHF patients. The results of such will become useful information for reference when developing management programs for CHF patients in the future.Methods:The methods has been used in this study including literature review, systematic review and Epidemiological survey which was conducted in three sections. The content of such would be as follows:Part1:Both domestic and foreign articles published in-various medical publications as from2004to2013in relating to the influences of Chinese exercises regimen in patients with chronic heart failure will be searched for literature review.Part2:All domestic and foreign clinical research articles relating to exercise regimen, rehabilitation and treatment for CHF patients as from January,2004to June,2013would be searched from the websites such as the Chinese full-text database of publications (CNKI), VIP database of publications (VIP), Yahoo, Google scholar and Pubmed. The key words and titles being used for searching including "heart failure","chronic heart failure","exercise","health regimen","exercise rehabilitation","rehabilitation","Tai Chi" etc. All clinical trials will be selected and analyzed inductively by the method of content analysis for literature information extraction purpose. Relevant data would be summarized and organized by the establishment of a database. By means of the use of mathematical statistics, comparison and classification as well as Meta-analysis, it may be able to visualize the efficacy and deficiency of various types of clinical exercise rehabilitation and treatment being used in CHF patients in domestic and foreign clinical studies. Also the existing status of TCM exercise regimen being neglected by current literatures would be reviewed and a survey questionnaire would be constructed afterward. All studies with their quality would be evaluated by the Jadad scoring scale quality evaluation method which is recommended by the Cochrane Collaboration. For those studies with higher quality would then be included for further Meta-analysis. The content analysis of all studies would be completed by the aid of the software namely Revman v5.0provided by the Cochrane Collaboration. Part3:According to the results and content of part1and part2of this study, an Epidemiological survey questionnaire would be constructed. CHF patients were recruited from the cardiac department of the Guangdong Provincial Hospital of Traditional Chinese Medicine or the Hong Kong TCM clinic as from November,2013to February,2014and surveyed by well-trained interviewer. All survey information would be entered into a database which was established by the aid of Excel spreadsheets program and further converted into data. The software package Statall.0would be used for data cleaning up and analyzing. For description of numeric variable, the way x±s would be used. While t test and Wilcoxon test would be used for group analysis and for data which is non-normal distribution or heterogeneity of variance respectively. For categorical variables, proportions and rates would be calculated and x2test (or exact test)will be used for group analysis instead. Test level would be set at α=0.05. Data obtained from the analysis would reflect the current status such as their tendentious, compliance, adaptability and effectiveness of TCM exercise regimen in CHF patients. Also any changes of the cardiac function, Chinese syndromes, quality of life and exercise tolerance of the CHF patients after exercise can be detected. The results would provide useful reference for development of chronic heart failure management system in the future. ResultsPart1: The first part of this study indicated that chronic heart failure is the critical state of various heart diseases. It has complicated symptoms with high incidence rate(1.5%-2.0%)particularly in aged patients. Leinal raie has increased by six-fold in the past forty years and is continuing to rise up annually which brings enormous economic burden on national health systems globally.Modern medicine considers the pathogenesis of heart failure is mainly due to ventricular remodeling (remodeling). It also closely related to the activation of sympathetic nervous system (SNS) and the renin-angiotensin-aldosterone system (RAAS), the release of inflammatory cytokines and the changes of humoral factors. While traditional Chinese medical studies always has controversial point of view in the etiology and pathogenesis of heart failure. Most of them thought that the disease is due to the onset of the heart disease itself or due to the influence of other sick organs inside the body. As a consequence it may lead to the deficiency in Yin of the heart or depressive in the Yang and stasis blood cohesion. Together with the damages caused by pathological products such as sputum, water ana stasis etc., which further harm the Yin and Yang of the heart resulting in a vicious cycle. The location of the CHF disease happens at the heart but closely related to the other four organs including kidney, spleen, lung and liver. The foundation for diagnosis and treatment of CHF is theretore tne deficiency in organ and enhancement in pathological products or the mixing of both.Traditional Chinese medicine thinks that the body movement manipulated according to traditional Chinese exercise regimen may regulate the upwara auu downward movement of Yang Qi resulting in Yang enrichment. Sufficient Yang Qi ensures the smooth flowing of the blood circulation, balances the Qi of Yin and Yang, regulates the harmony between internal organs and meridians, and strengthens the function of heart and lung which finally reduces the incidence of heart failure.Modern medicine considers aerobic exercise combined with drugs treatment can relieve the pathogenesis of heart failure including the abnormal diood flow dynamics, peripheral vascular resistance, cardiac energy metabolism anc the renin-angiotensin-aldosterone system. It also help to palliate the influences caused by oxidative stress and inflammation as well as enhance the skeletal muscle energy metabolism which together control the ventricular remodeling process resulting in the relief of heart failure symptoms. The TCM and modern medical system seemed theoretically difference but consistent in concept. Besides, TCM always thinks that exercise regimen should be handy and easy but not bounded by any style. That means any kind of movement including aerobic exercise should be included in the scope of traditional Chinese medicine. In order to avoid confusion,this article will classify those historic exercises with strong underlying traditional Chinese medicine theory such as Tai Chi, Wu Qin Xi, Ba Duan Jin and Qigong etc. as "TCM exercise" and those without such as walking, swimming as "modern medicine popular exercise" or simply "popular exercise"At present, it is unanimously agreed by both domestic and foreign studies that exercise regimen is benefit to CHF patients. However, the exercise methods being used were lack of uniformityand certainty. It cannot be ruled out two assumptions that:(1) there may exist some other exercise regimen which being neglected clinically but can be as/more effective in improving the symptoms of CHF patients;(2) in reality there may be some CHF patients either following or not following the exercise regimen instructed by the hospital medical officers but using jointly or solely "TCM exercise" as their own exercise program which they may find it beneficial and so they insist.It is therefore necessary to conduct a systematic review and epidemiological survey in order to not only confirmed the above two hypotheses but further visualize the current status of the use of Traditional Chinese medicine (TCM)exercise regimen in patients with chronic heart failure. Part2:The second part of this study recruited105domestic and foreign articles published in between2004to2013relating to Chinese exercises rehabilitation and treatment regimen in CHF patients by means of computer and hand search. Preliminary findings shown that there was a significant upward trend in the publishing of clinical studies relating to the TCM exercise regimen, rehabilitation and therapy in patients with CHF in recent years. Also all related studies were using a combination of exercises and medication as a protocol for their treatment groups during experiment. According to the modified Jadad scale score, only1article has the highest score of3-point Jadad rating among57domestic articles while only2-point or less, which represents lower quality rating, for the rest. For the48foreign articles, only5of them score higher than4-point Jadad rating which showing that the existing articles were of relatively low quality in general.At present, the mostly accepted efficacy indices used by domestic and foreign researchers for the study of exercise regimen in CHF patients were successively known as the six minutes walk test (6MWT) distance, Minnesota Life Scale(MSL)score, left ventricular ejection fraction(LVEF%), heart rate(HR) and maximal oxygen uptake(Vo2max). For the most popular exercise regimen practicing by CHF patients, it will be walking followed by cycling and jogging. TCM exercises are obviously being overlooked. Meta-analysis in this paper showed that aerobic exercise is effective in improving the above efficacy indices (P<0.05). But similar results in improving the6MWT distance and the MLS score can also be found when patients using Tai Chi as their exercise program (P<0.05) which confirms our first assumptions that:"there may exist some other...". Unfortunately the results were lack of convincing due to that the related articles were of very low quality.Part3:120questionnaires were distributed to the CHF patients with same number being returned. The return rate was100%. The mean age of patients recruited was63.81±13.60years old who mainly got married (96cases,80.00%). Most of them have their education up to academic secondary school (52cases,43.00%) and half of the patients were labor and other half were white collar. More than half of the patients were retired (65cases,54.00%). Patients with cardiac function classified as NYHA class II and III were in majority in a total percentage of79.20%which means that a large proportion of patients with heart failure have their physical activity being slightly/obviously restricted by the disease. The fundamental underlying diseases of these patients were hypertensive heart disease (61cases,50.83%) and the main comorbidity were also hypertension disease(79cases,65.83%)followed by hyperlipidemia(56cases,46.67%), coronary disease (43cases,35.83%) and diabetes (41cases,35.00%) indicating that the three hyper-diseases namely hypertension, hyperlipidemia and hyperglycemia are the main risk factors in inducing heart failure. Whereas traditional Chinese medicine differentiates the etiology of CHF is mainly due to heart Yang deficit (39cases) as well as the combination of Qi deficit and blood stasis (38cases). Therefore the rule in dealing with CHF in TCM is by warmly enhancing the Yang of the heart and kidney.The number of CHF patients who have exercise daily in the past three months were less than those who have not (46:74patients). However most of the CHF patients have obvious tendentious towards TCM exercise regimen no matter they have exercise habit or not. Besides, the tendentious may not necessarily be affected by the strength of the heart function. Rather, it may possibly due to psychological factors or excuses such as no time or tired as the reasons for resisting to do exercise.Nearly half of the patients(25patients,54.35%)comply with the popular exercise program as suggested by the medical officers. However, there were7patients took TCM exercises include Tai Chi(4patients), Ba Duan Jin(2patients)and Qigong(1patient) jointly with the popular exercise program. For those patients (21patients)who did not comply with the instructions,13of them thought that the exercises of their own choice were more suitable. Of which8patients chose solely TCM exercises including Tai Chi and Ba Duan Jin (4patients each) as their exercise program which confirms our second assumption in the above that:"in reality there may be..."During exercise, very few patients felt slightly/some tiredness (26cases,56.52%) and slightly/some wheezing (28cases,60.87%) but relieved soon after they took some rest. Most of the patients felt no nausea and vomiting (39cases,84.78%) or other discomfort (44cases,95.65%) at all signifying that CHF patients have good adaptability in exercises regimen.Most CHF patients after exercise felt improvement or not getting worse in their emotion, spirit, energy, sleep, appetite, and other daily living. Their blood pressure, blood glucose and blood lipid indices were either decreased or not worsen. Twenty patients(43.48%)reduced their hypertensive drug content and none of the patients needed heavier dosage. Patients with their NYHA classification decreased or no major change were in majority(29cases,63.00%).Forty-six CHF patients who have exercise got higher score in Minnesota Life Scale score when compare to those74patients who have not. The difference observed was statistically significant with P<0.05by t test. It can be considered that CHF patients with TCM exercise regimen have better quality of life than those patients who without.The46patients who have exercise habit were further divided into three sub-groups namely Group A:CHF patients who choose popular exercise only; Group B:patients who choose TCM exercise only; and Group C:patients who choose both popular and TCM exercise at the same time with their Minnesota Life Scale (MLS) scores to be calculated statistically and accordingly. As a result Group A, B and C has a score of28.65±15.70,27.00±9.58and26.86±8.93points respectively of which Group C has the lowest average score which meant that patients in that group have the best quality of life comparatively. Patients in Group B also have lower score than Group A. Therefore no matter the CHF patients using jointly or solely TCM exercise as their exercise program, their quality of life were no worse than simply using the popular exercise. The result seemed to be consistent with the systematic review finding in part2of this study.However, one-way classification analysis of variance indicated that there were no statically significant when compare the Minnesota Live Scale scores among the three groups (P>0.05). It is still unable to ascertain that patients with CHF in the three groups taking different exercise programs results in different quality of life. Possibly it may due to the sample size of this survey was too small to reflect effectively the current status of the improvement in quality of life by TCM exercise in CHF patients. ConclusionAlthough there was insufficient sample in this survey to conclude that TCM exercise may effectively improve the quality of life of the CHF patients, there is yet certain evidence showing that TCM exercises may definitely be benefit to these groups of patients. Together with very rare adverse effect being reported, the effect of TCM exercise should not be undermined. In the future, more studies concerning TCM exercise in CHF patients with larger sample size, multi-center and higher quality are expected. The results of such may help the promotion and application of TCM exercise regimen to CHF patients which hopefully may bring new options to them for their rehabilitation. Also it may provide reliable reference for development of exercise program and chronic disease management programs for the CHF patients in the future. |
PDF Full Text Request