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Table of Contents
Year : 2020  |  Volume : 11  |  Issue : 1  |  Page : 15-20

Effect of exercise training on dimensions of quality of life and fatigue in people with congestive heart failure class II and III: A randomized controlled trial

1 Social Determinants of Health Research Center, School of Allied Medical Sciences, Shahrekord University of Medical Sciences, Sanandaj, Iran
2 Department of Operative Dentistry, School of Dentistry, Shahrekord University of Medical Sciences, Sanandaj, Iran
3 Department of Medical-Surgical, Nursing and Midwifery, Shahrekord University of Medical Sciences, Sanandaj, Iran
4 Department of Nursing, Faculty of Nursing and Midwifery, Kurdistan University of Medical Sciences, Sanandaj, Iran

Date of Submission17-Apr-2019
Date of Decision06-Dec-2019
Date of Acceptance13-Dec-2019
Date of Web Publication29-Jan-2020

Correspondence Address:
Dr. Ali Hasanpour-Dehkordi
Social Determinants of Health Research Center, School of Allied Medical Sciences, Shahrekord University of Medical sciences, Shahrekord
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/INJMS.INJMS_43_19

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Background: Improved living conditions and increased life expectancy have led to aging in societies. Increased incidence of chronic heart disease is one of the most important economic, social, and health challenges of the 21st century. Aim: This study aimed to examine the effect of exercise training on dimensions of quality of life and mental status in people with congestive heart failure Class II and III. Materials and Methods: This study was carried out on patients with chronic heart failure. For this purpose, 52 eligible patients were chosen and randomly divided into case and control groups. The participants in the case group were asked to follow an exercise program three sessions per week in the morning for 24 weeks. This exercise program comprised 5–10 min of warming, 20–30 min of exercise, and 5 min of cool-down. Data were collected by the SF-36 questionnaire and analyzed by the SPSS version 18. Results: The results revealed that there was a significant difference in the mean score of various dimensions of quality of life including NYHA functional Classes II (P = 0.032) and III (P = 0.027), fatigue, BP, and general health in Classes II (P < 0.001) and III (P = 0.021) between the two groups before and after the intervention. Conclusion: Given that exercise leads to improvement of physical functioning, role-physical, role-emotional, social functioning, mental status, general health, and lower levels of fatigue and body pain in patients with congestive heart failure, it is recommended that patients incorporate regular exercise into their daily routines.

Keywords: Congestive heart failure, exercise training, fatigue, quality of life

How to cite this article:
Hasanpour-Dehkordi A, Yadollahi M, Tali SS, Gheshlagh RG. Effect of exercise training on dimensions of quality of life and fatigue in people with congestive heart failure class II and III: A randomized controlled trial. Indian J Med Spec 2020;11:15-20

How to cite this URL:
Hasanpour-Dehkordi A, Yadollahi M, Tali SS, Gheshlagh RG. Effect of exercise training on dimensions of quality of life and fatigue in people with congestive heart failure class II and III: A randomized controlled trial. Indian J Med Spec [serial online] 2020 [cited 2023 Mar 31];11:15-20. Available from: http://www.ijms.in/text.asp?2020/11/1/15/277240

  Introduction Top

Congestive heart failure (CHF) patients are at increased risk of hospital admissions and death, which can lead to numerous social and economic problems for patients, health-care systems, and society.[1] The prevalence of heart failure in Iran is 8%, which is higher than that reported from Asia and across the world, and the cost of the disease is estimated to be 400 billion rials per year which is alarming, so preventive measures should be taken to lower the costs.[2],[3] CHF leads to reduced muscle mass and strength as well as intolerance to exercise. CHF patients cannot fulfill their daily routines appropriately and depend on others. Furthermore, CHF adversely influences different aspects of quality of life (physical, psychological, social, well-being perception, and public health).[4] Dyspnea and fatigue can restrict their daily lives and result in exercise intolerance.[5] The general health conditions and quality of life in these patients could be changed by physical signs of psychological problems, food, drugs' side effects, and social constraints.[6] Hence, disease-associated challenges lead to seclusion and social loneliness in patients.[7] Moreover, the individuals undergo mental and psychological pressures and will face physical obstacles and finally repeated hospitalizations.[8],[9] Dyspnea and fatigue results in stress, anxiety, decrease of consciousness, poor general health, and quality of life.[10] Patients with heart failure can experience restrictions in doing daily activities such as walking and going shopping. Various measures have been taken in most experimental studies so far to control heart failure (reducing the frequency of hospitalization and addressing the physical, psychological, economic, and social problems of patients). There are many choices for controlling heart failure, one of which is exercise.[11] Prevalence of heart failure is increasing, and it adversely impacts on the public health. Nowadays, attention to physical activity in these patients is very important therefore, the present study was conducted to investigate the Impact of exercise training on dimensions of quality of life and the level of fatigue in patients with CHF Class II and III coming to hospital affiliated to Shahrekord University of Medical Sciences at the southwest of Iran.

  Materials and Methods Top

Design and sample

Ethical approval (Code No. 85-9-1) was obtained from the Ethics Committee of the University and the study protocol was registered as IRCT201306251376831 in the Iranian Registry of Clinical Trials by Clinical Research Center of Iran's Ministry of Health and Medical Education. This clinical trial was performed after the necessary approval was obtained from the Deputy of Research and Technology of Shahrekord University of Medical Sciences, Iran. In view of the previous studies and by the formula of sample size calculation, the needed sample size for this study was calculated at 52 individuals who were selected by the convenience sampling method. Of these, 12 were in CHF Class II and 40 were in CHF Class III. Then, based on random allocation rule, the participants were randomly divided into case (Class II and III) and control (Class II and III) groups. Written consent form was obtained from all patients for participation in the study.

Inclusion criteria

The inclusion criteria included patients suffering from chronic heart disease, age of 60 ± 5 years, volunteering to participate in the study, as well as the diagnosis of congestive heart failure by a cardiologist, clinical symptoms, echocardiography, left ventricular ejection fraction ≤40%, the ability to do the exercise in question after pharmacotherapy, the physician's approval, lack of other chronic diseases (rheumatoid arthritis, fractures, etc.), as well as lack of traveling and heart transplantation until 3 months after the exercise program.

Class II

Heart rate abnormality (tachycardia), jugular venous elevation, lung crackles, wheezing, and third heart sound.

Class III

Alveolar pulmonary edema, interstitial pulmonary edema, bilateral pleural effusion, and cardiothoracic ratio higher than 0.50.

Exclusion criteria

The exclusion criteria included coronary artery bypass surgery during the study, withdrawing from the study at any stage of this study, and percutaneous transluminal coronary angioplasty/coronary artery bypass grafting surgery in the previous year.

Exercise was performed three sessions per week for 24 weeks, for 40 min in the morning consisting of 5–10 min of warm-up, 25–30 min of exercise (walking), and 5 min of cool-down for the experimental group. Aerobic exercise was done by trained personnel in the sports facilities or gyms in the hospitals affiliated with Shahrekord University of Medical Sciences under the supervision of nursing and medical teams. Exercise continued until the heart rate reached 60% of heart rate reserve. At the completion of the sixth session, exercise (walking) duration increased to 30–35 min and heart rate to 70% of heart rate reserve. Each patient exercised based on his/her resistance and ability. Exercising was stopped when patients felt physically tired or had severe dyspnea, fatigue, dizziness, or other issues that might endanger their health with reference to Rhoten Fatigue Scale. To assess the reproducibility of gas exchange parameters, the cardiopulmonary test was carried out 3–5 days before starting the protocol for all patients again to serve as baseline. The evaluation was also repeated at the completion of the research. Furthermore, the patients' blood pressure and heart rates were frequently measured before and after the study. Patients in the control group were given educational support, but no exercise protocol was administered. Nevertheless, patients in both the groups received their medications as prescribed by the cardiologist.


The quality of life questionnaire (SF-36), the demographic questionnaire, and echocardiography were used to collect the data. To determine the patients' quality of life, Persian version of the SF-36 was used to assess physical functioning, role limitations because of physical problems, role limitations because of emotional problems, social condition, physical pain, energy, vitality, mental health, and general health in the elderly with cardiac diseases. Validity and reliability of the Persian version of this questionnaire had already been confirmed.[12] Questionnaires were completed by all patients, and vital signs and echocardiography parameters were recorded by a nurse at baseline and 24 weeks after the completion of the study. The patients' fatigue was measured by visual analog scale, which is a 10-point Likert scale in which 1 represents energetic (no fatigue), 5 does moderate fatigue, and 10 does severe fatigue.

Data analysis

Statistical analysis was performed using independent t test, student t test and ANOVA. Significance level was considered at <0.05. data are presented as mean± standard deviation.

  Results Top

Demographic data and functional variables in the two groups are summarized in [Table 1]. Most of the patients were male, retired, or unemployed. At baseline, no significant difference was observed in blood pressure, pulse, physical functioning, role-physical, role-emotional, social functional, mental status, general health, fatigue level, and body pain between the two groups.
Table 1: Characteristics of patients with congestive heart failure in different functional classes of congestive heart failure

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Although the findings indicated that in different functional classes (II and III), there was no change in physical functioning in the control group, bodily pain and fatigue increased significantly, and all other parameters worsened significantly. However, in cases (intervention group), bodily pain and fatigue decreased significantly, and all other parameters improved significantly [Table 2].
Table 2: Comparison of dimension quality of life in congestive heart failure patients in different functional classes in case and control

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Besides, the results indicated that blood pressure and pulse increased significantly and general health declined significantly in the control group, but in the case group, blood pressure and pulse decreased significantly and general health increased significantly.

  Discussion Top

The present study results indicated that in the case group, the fatigue level in different functional classes of CHF (II and III) decreased after the intervention compared to that in the control group. Our results also determined that exercise could reduce the severity of fatigue and increase the tolerance of physical activity in patients with pulmonary arterial hypertension. This indicates the potential importance of physical exercises as a complementary therapy. The aerobic exercises used in this study are often recommended or prescribed to the general population.[13] In addition, our findings showed that the patients' physical functioning enhanced after exercise, so that they were able to do their daily activities comparably more easily. The results of other studies indicate that regular and continuous physical activities increase social communication, self-satisfaction and satisfaction with others, sexual relations, and relationships with friends.[14] The findings in this study indicated that exercise training led to an improvement of role-physical and role-emotional status among patients, so that they expressed their feelings more easily, communicated with others, experienced less loneliness and isolation, and generally developed a good rapport with others.[15] In this study, the patients in the experimental group had better social functioning and energy as compared with the control group. In other words, the exercise enhanced self-esteem, freshness, and vitality and improved mental conditions in the patients. In agreement with the findings of the present study, the results of some studies indicate that regular and continuous physical activities increase social communication, self-satisfaction and satisfaction with others, sexual relations, and relationships with friends.[16],[17],[18],[19] After the study, the mean score of physical pain in different functional classes of CHF was significantly different between the case and control groups. Consistent with the present study, the findings of other studies have revealed that pain intensity decreases after exercise.[20] Furthermore, the results have shown that there is no statistically significant difference in depression between the two groups.[21],[22] Symptoms of CHF overlap with depression and often make it possible to detect the latter. Both CHF and depression are characterized by fatigue, loss of energy, low appetite, sleep disturbance, mental retardation, and lack of concentration. Symptoms of depression may be present in 85% of patients with CHF. In addition, major clinical depression was found in 26% of cases that is significantly higher than the general population's depression levels (2.1%).[23] In this study, the findings indicated that exercise training led to a significant increase in the scores of all aspects of quality of life in different functional classes of CHF in the case group compared with the control groups, so that it was higher in Class I than Class II, whereas in the control group, quality of life decreased in most dimensions, especially in Class II.

Furthermore, previous studies revealed that exercise training improved health and different dimensions of quality of life.[24],[25] Georgiou et al. showed that exercise training had a significant impact on the decrease of length of hospital stay and consequently hospital costs and physician referral. In addition, exercise training causes improvement of health and increase in longevity.[26] Another study revealed that exercise training lowered mortality, the length of hospital stay, and readmission in patients with fibrillation and cardiac arrhythmias in health-care centers.[27] Moreover, research findings show that exercise training causes enhancement of cardiac output without additional charge to the pulmonary arteries. The results of one study showed that exercise training significantly increased physical functioning, reduced feeling of inability, increased left ventricular ejection fraction, enhanced exercise training tolerance, and promoted quality of life and health.[11] The current study revealed that exercise training reduced systolic and diastolic pressure and pulse rate in patients with CHF Class II and III. The results of another study indicated that the heart receive more oxygen following exercising and therefore cardiac output increased in the case group. However, in the control group, no significant change was observed in the results.[28] The results of some studies have shown that there is a direct correlation between the quality of life dimensions and pain and fatigue, so that pain, emotional distress, and fatigue deteriorate all dimensions of quality of life.[29],[30]

Chronic diseases seriously affect individuals' overall health and quality of life.[31] Exercise is not suitable for all cases of heart failure, and before the start of the exercise, patients must be examined by a physician to be allowed to do exercise.[17],[22] Any variations in the lifestyles of patients with heart failure or changes in their physical activities should be made under the direct guidance of a nurse or a cardiologist; otherwise, it results in physical damage or deterioration of the patients' health.

Peak training capacity, measured by VO2 peak, is the best predictor of survival in patients with CHF. Increased performance in these patients is associated with improved quality of life and may also improve with the prognosis. Therefore, exercise programs designed to improve capacity in patients with CHF should specifically target functional capacity limitations in these patients.[32] The optimal exercise dose is needed to decrease disease-related symptoms. Effective strategies for self-efficacy of chronic diseases include developing relationships with a provider, maintaining positive attitudes, and having a supporting person. Problem-solving and critical thinking with health-care providers help patients manage a chronic illness that requires various day-to-day decisions for optimal disease control.[33],[34]

  Conclusion Top

Our results revealed that quality of life was adversely affected by congestive heart failure. Given that exercise training leads to improvement of physical functioning, role-physical, role-emotional, social functioning, mental status, general health, and lower levels of fatigue and body pain, it is recommended that regular exercise be incorporated into the daily routines of elderly patients.

Limitation of the study

Our results were obtained in controlled conditions, and therefore, unsupervised exercise program should not be advised according to these results.

Financial support and sponsorship

This research was funded by the Deputy of Research and Technology of Shahrekord University of Medical Sciences.

Conflicts of interest

There are no conflicts of interest.

  References Top

Chun S, Tu JV, Wijeysundera HC, Austin PC, Wang X, Levy D, et al. Lifetime analysis of hospitalizations and survival of patients newly admitted with heart failure. Circ Heart Fail 2012;5:414-21.  Back to cited text no. 1
Mansoreye N, Poursharifi H. The correlation between social support and self-care in patients with heart failure: The mediating role of illness perception. J Health Promot Manag 2017;6:43-50.  Back to cited text no. 2
Zeighami Mohammadi S, Farmani P, Shakoor M, Fahidy F, Fallah Taherpazir E, Mohseni B. Correlation between type D personality and quality of life in heart failure patients. Int J BioMed Public Health 2018;1:76-81  Back to cited text no. 3
Go A, Mozaffarian D, Roger V, Benjamin E, Berry J, Borden W, et al. On behalf of the American Heart Association statistics committee and stroke statistics subcommittee. Circulation 2013;127:e1-240.  Back to cited text no. 4
Smith OR, Michielsen HJ, Pelle AJ, Schiffer AA, Winter JB, Denollet J. Symptoms of fatigue in chronic heart failure patients: Clinical and psychological predictors. Eur J Heart Fail 2007;9:922-7.  Back to cited text no. 5
Ponikowski P, Anker SD, AlHabib KF, Cowie MR, Force TL, Hu S, et al. Heart failure: Preventing disease and death worldwide. ESC Heart Fail 2014;1:4-25.  Back to cited text no. 6
Albus C. Psychological and social factors in coronary heart disease. Ann Med 2010;42:487-94.  Back to cited text no. 7
Asadi-samani M, Bahmani M. Trends on the treatment of atherosclerosis; new improvements. Angiol Persica Acta 2016;1:2-3.  Back to cited text no. 8
Gabet A, Juillière Y, Lamarche-Vadel A, Vernay M, Olié V. National trends in rate of patients hospitalized for heart failure and heart failure mortality in France, 2000-2012. Eur J Heart Fail 2015;17:583-90.  Back to cited text no. 9
Wiklund M, Malmgren-Olsson EB, Ohman A, Bergström E, Fjellman-Wiklund A. Subjective health complaints in older adolescents are related to perceived stress, anxiety and gender – A cross-sectional school study in Northern Sweden. BMC Public Health 2012;12:993.  Back to cited text no. 10
Kitzman DW, Brubaker PH, Morgan TM, Stewart KP, Little WC. Exercise training in older patients with heart failure and preserved ejection fraction: A randomized, controlled, single-blind trial. Circ Heart Fail 2010;3:659-67.  Back to cited text no. 11
Motamed N, Ayatollahi AR, Zare N, Sadeghi-Hassanabadi A. Validity and reliability of the Persian translation of the SF-36 version 2 questionnaire. East Mediterr Health J 2005;11:349-57.  Back to cited text no. 12
Weinstein AA, Chin LM, Keyser RE, Kennedy M, Nathan SD, Woolstenhulme JG, et al. Effect of aerobic exercise training on fatigue and physical activity in patients with pulmonary arterial hypertension. Respir Med 2013;107:778-84.  Back to cited text no. 13
Conraads VM, Deaton C, Piotrowicz E, Santaularia N, Tierney S, Piepoli MF, et al. Adherence of heart failure patients to exercise: Barriers and possible solutions: A position statement of the Study Group on Exercise Training in Heart Failure of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2012;14:451-8.  Back to cited text no. 14
Brovold T, Skelton DA, Bergland A. Older adults recently discharged from the hospital: Effect of aerobic interval exercise on health-related quality of life, physical fitness, and physical activity. J Am Geriatr Soc 2013;61:1580-5.  Back to cited text no. 15
Bocalini DS, dos Santos L, Serra AJ. Physical exercise improves the functional capacity and quality of life in patients with heart failure. Clinics (Sao Paulo) 2008;63:437-42.  Back to cited text no. 16
Edelmann F, Gelbrich G, Düngen HD, Fröhling S, Wachter R, Stahrenberg R, et al. Exercise training improves exercise capacity and diastolic function in patients with heart failure with preserved ejection fraction: Results of the Ex-DHF (Exercise training in Diastolic Heart Failure) pilot study. J Am Coll Cardiol 2011;58:1780-91.  Back to cited text no. 17
Nolte K, Herrmann-Lingen C, Wachter R, Gelbrich G, Düngen HD, Duvinage A, et al. Effects of exercise training on different quality of life dimensions in heart failure with preserved ejection fraction: The Ex-DHF-P trial. Eur J Prev Cardiol 2015;22:582-93.  Back to cited text no. 18
Sandri M, Kozarez I, Adams V, Mangner N, Höllriegel R, Erbs S, et al. Age-related effects of exercise training on diastolic function in heart failure with reduced ejection fraction: The Leipzig Exercise Intervention in Chronic Heart Failure and Aging (LEICA) Diastolic Dysfunction Study. Eur Heart J 2012;33:1758-68.  Back to cited text no. 19
van Middelkoop M, Rubinstein SM, Verhagen AP, Ostelo RW, Koes BW, van Tulder MW. Exercise therapy for chronic nonspecific low-back pain. Best Pract Res Clin Rheumatol 2010;24:193-204.  Back to cited text no. 20
Diana K, Mehdi K, Mahyar M. Cardiac effects of exercise rehabilitation on quality of life, depression and anxiety in patients with heart failure patients. J. Fundam. Mental Health 2015;17:8-13.  Back to cited text no. 21
Herring MP, Puetz TW, O'Connor PJ, Dishman RK. Effect of exercise training on depressive symptoms among patients with a chronic illness: A systematic review and meta-analysis of randomized controlled trials. Arch Intern Med 2012;172:101-11.  Back to cited text no. 22
Yohannes AM, Willgoss TG, Baldwin RC, Connolly MJ. Depression and anxiety in chronic heart failure and chronic obstructive pulmonary disease: Prevalence, relevance, clinical implications and management principles. Int J Geriatr Psychiatry 2010;25:1209-21.  Back to cited text no. 23
Carmona-Bernal C, Ruiz-García A, Villa-Gil M, Sánchez-Armengol A, Quintana-Gallego E, Ortega-Ruiz F, et al. Quality of life in patients with congestive heart failure and central sleep apnea. Sleep Med 2008;9:646-51.  Back to cited text no. 24
Hassanpour-Dehkordi A, Jalali A. Effect of progressive muscle relaxation on the fatigue and quality of life among Iranian aging persons. Acta Med Iran 2016;54:430-6.  Back to cited text no. 25
Georgiou D, Chen Y, Appadoo S, Belardinelli R, Greene R, Parides MK, et al. Cost-effectiveness analysis of long-term moderate exercise training in chronic heart failure. Am J Cardiol 2001;87:984-8.  Back to cited text no. 26
Inglis S, McLennan S, Dawson A, Birchmore L, Horowitz JD, Wilkinson D, et al. A new solution for an old problem? Effects of a nurse-led, multidisciplinary, home-based intervention on readmission and mortality in patients with chronic atrial fibrillation. J Cardiovasc Nurs 2004;19:118-27.  Back to cited text no. 27
Tsai JC, Wang WH, Chan P, Lin LJ, Wang CH, Tomlinson B, et al. The beneficial effects of Tai Chi Chuan on blood pressure and lipid profile and anxiety status in a randomized controlled trial. J Altern Complement Med 2003;9:747-54.  Back to cited text no. 28
Gormsen L, Rosenberg R, Bach FW, Jensen TS. Depression, anxiety, health-related quality of life and pain in patients with chronic fibromyalgia and neuropathic pain. Eur J Pain 2010;14:127.e1-8.  Back to cited text no. 29
Mock V, Pickett M, Ropka ME, Muscari Lin E, Stewart KJ, Rhodes VA, et al. Fatigue and quality of life outcomes of exercise during cancer treatment. Cancer Pract 2001;9:119-27.  Back to cited text no. 30
Iqbal J, Francis L, Reid J, Murray S, Denvir M. Quality of life in patients with chronic heart failure and their carers: A 3-year follow-up study assessing hospitalization and mortality. Eur J Heart Fail 2010;12:1002-8.  Back to cited text no. 31
Maiorana A, O'Driscoll G, Cheetham C, Collis J, Goodman C, Rankin S, et al. Combined aerobic and resistance exercise training improves functional capacity and strength in CHF. J Appl Physiol (1985) 2000;88:1565-70.  Back to cited text no. 32
Hasanpour-Dehkordi A, Solati K. The efficacy of three learning methods collaborative, context-based learning and traditional, on learning, attitude and behaviour of undergraduate nursing students: Integrating theory and practice. J Clin Diagn Res 2016;10:VC01-4.  Back to cited text no. 33
Keteyian SJ. Exercise training in congestive heart failure: Risks and benefits. Prog Cardiovasc Dis 2011;53:419-28.  Back to cited text no. 34


  [Table 1], [Table 2]

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