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The Effects of Reinforced Walking Exercise on Dyspnea-fatigue Symptoms, Daily Activities, Walking Ability, and Health related Quality of Life in Heart Failure Patients
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Original Article

The Effects of Reinforced Walking Exercise on Dyspnea-fatigue Symptoms, Daily Activities, Walking Ability, and Health related Quality of Life in Heart Failure Patients

Korean Journal of Adult Nursing 2016;28(3):266-278.
Published online: June 30, 2016

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Corresponding author: Lee, Haejung College of Nursing, Pusan National University, 49 Busandaehak-ro, Mulgeum-eup, Yangsan 50612, Korea. Tel: +82-51-510-8344, Fax: +82-51-510-8308, E-mail: haejung@pusan.ac.kr
• Received: March 1, 2016   • Accepted: June 22, 2016

Copyright © 2016 Korean Society of Adult Nursing

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • Purpose
    The purpose of this study was to identify the effects of reinforced walking exercise on dyspnea-fatigue symptoms, daily activities, walking ability and health related quality of life (HRQoL) in heart failure patients.
  • Methods
    This study used a randomized controlled trial design. The participants (experimental group=16, control group=25) were recruited from a university hospital in Kyeong-nam area. Data were collected from March to September, 2015. The reinforced walking exercise included goal setting and feedback (telephone and text message) provided for 12 weeks. Dyspnea-Fatigue Index, Korean Activity Scale/Index (KASI), six-minute walking distance (6MWD) and HRQoL were measured. Data were analyzed using descriptive statistics, t-test, Fisher's exact test, χ² test, and Kolmogrove-Smirnov test.
  • Results
    Prior to the intervention there were no differences in the research variables between two groups. The exercise compliance in the experimental group was 100% (walking for 50 minutes per day, 5 times per week). The experimental group had improved dyspnea-fatigue symptoms (t=8.63, p<.001), daily activities (t=-4.92, p<.001), longer 6MWD (t=-5.66, p<.001), and increased HRQoL (t=-9.05, p<.001) compared to the control group.
  • Conclusion
    The reinforced walking exercise could be a cost-effective intervention in heart failure patient, which could enhance patients’ outcomes, such as improving dyspnea-fatigue symptoms, daily activities, walking ability, and quality of life.
Figure 1.
Flow chart of data collection.
kjan-28-266f1.jpg
Table 1.
Reinforced Walking Exercise Program
Categories Contents Time
1) Preparation (1) Perform physical assessment (Vital sign & SpO2) 10 min
(2) Instruct how to use pedometer: Mode & Reset
(3) Offer exercise diary & teach how to use the diary: Recording number of steps, duration of exercise, weekly frequency, heart rate, and dyspnea/fatigue borg scale
2) Goal setting (1) Perform walking exercise using the pedometer 5 min
(2) Start from 5,000 steps & 10% increase/week
 Start from 1 day/week → 5 days/week
 1st week: 5,000 steps & 1 day/week
 2nd week: 6,000 steps & 2 days/week
 3rd week: 7,000 steps & 3 days/week
 4th week: 8,000 steps & 4 days/week
 5th week: 9,000 steps & 5 days/week
 6th week: 10,000 steps & 5 days/week
 7~12th week: maintain 10,000↑steps & 5 days/week
(3) Maintain symptom of dyspnea/fatigue based on borg scale 12~13 point, maximum heart rate 60~70%
3) Feedback (1) Check pedometer data and incomplete data 5 min
(2) Mutually set a weekly goal of walking.
(3) Reinforce maintenance of walking exercise
 → through telephone call:
  1st~6th week=once a week
  7~12th week=every other week
 → by text message: 2 days/week
Table 2.
Characteristics and Homogeneity Test between Control and Experimental Groups (N=41)
Characteristics Categories Total Control (n=25) Exp. (n=16) x2 or t (p)
n (%) or M±SD D n (%) or M±SD n (%) or M±SD
Age (year) (range 40~77) <65 30 (73.2) 17 (68.0) 13 (81.3) 0.87 (.287)§
≥65 11 (26.8) 8 (32.0) 3 (18.8) -0.86 (.393)
58.02±12.04 56.72±14.38 60.06±6.97  
Gender Male 30 (73.2) 17 (68.0) 13 (81.3) 0.87 (.478)§
Female 11 (26.8) 8 (32.0) 3 (18.8)  
Spouse No 2 (4.9) 0 (0.0) 2 (12.5) 3.29 (.146)§
Yes 39 (95.1) 25 (100.0) 14 (87.5)  
Level of education ≤Junior high school 9 (22.0) 7 (28.0) 2 (12.5) 6.61 (.085)
High school 13 (31.7) 5 (20.0) 8 (50.0)  
≥College 19 (46.3) 13 (52.0) 6 (37.5)  
Regular exercise No 41 (100.0) 25 (100.0) 16 (100.0)  
Monthly household income (10,000 won) <100 4 (9.8) 2 (8.0) 2 (12.5) 0.32 (.854)
100~199 7 (17.1) 4 (16.0) 3 (18.8)  
≥200 30 (73.2) 19 (76.0) 11 (68.8)  
Left ventricular ejection fraction (%) 31.15±6.92 31.88±6.98 30.00±6.88 0.85 (.403)
NYHA class II 36 (87.8) 22 (88.8) 14 (87.5) 0.01 (>.999)§
III 5 (12.2) 3 (12.0) 2 (12.5)  
Comorbidity No 16 (39.0) 11 (44.0) 5 (31.3) 0.67 (.519)§
Yes 25 (61.0) 14 (56.0) 11 (68.8)  
 Hypertension 25 (100.0) 14 (56.0) 11 (44.0)  
 Diabetes mellitus 6 (24.0) 2 (8.0) 4 (16.0)  
 Etc. 7 (28.0) 3 (12.0) 4 (16.0)  
Medication Beta-blocker Yes 35 (85.4) 21 (84.0) 14 (87.5) 0.10 (>.999)§
No 6 (14.6) 4 (16.0) 2 (12.5)  
ACE inhibitor Yes 29 (70.7) 17 (68.0) 12 (75.0) 0.23 (.734)§
No 12 (29.3) 8 (32.0) 4 (25.0)  
Diuretics Yes 31 (75.6) 19 (76.0) 12 (75.0) 0.01 (>.999)§
No 10 (24.4) 6 (24.0) 4 (25.0)  
Physical activity (MET-minutes/week) Inactive 26 (63.4) 18 (72.0) 8 (50.0) 3.11 (.211)
Minimally active 11 (26.8) 6 (24.0) 3 (31.3)  
HEPA 4 (9.8) 1 (2.4) 3 (18.8)  

Exp.=experimental group; NYHA=New York Heart Association; HEPA=Health enhancing physical activity;

Multiple responses;

Liver disease, osteoporosis, angina pectoris, pulmonary disease;

§Fisher's exact test.

Table 3.
Levels of Dyspnea-fatigue Symptoms, Daily Activities, Walking Ability and Health related QoL and Homogeneity Test (N=41)
Characteristics Total Cont. (n=25) Exp. (n=16) t (p)
M±SD M±SD Z (p) M±SD Z (p)
Dyspnea-fatigue symptoms 5.90±1.88 6.20±1.78 0.967 (.307) 5.44±2.00 .943 (.336) 1.28 (.210)
Daily activities (KASI) 34.76±11.75 35.02±11.57 0.646 (.798) 34.35±12.40 .817 (.517) 0.18 (.861)
Walking ability (6MWD; m) 337.32±71.03 339.20±79.11 1.019 (.251) 334.38±58.53 .388 (.998) 0.21 (.835)
HRQoL 69.80±11.69 72.54±11.77 1.052 (.219) 65.53±10.53 .823 (.508) 1.94 (.060)

Exp.=experimental group; Cont.=control group; KASI=Korean Activity Scale/Index; 6MWD=Six-minute walk distance; HRQoL=Health related quality of life.

Kolmogorov-Smirnove test.

Table 4.
Walking Compliance and Levels of Physical Activity in Experimental Group (N=16)
Characteristics Pretest Posttest t (p)
n (%) or M±SD n (%) or M±SD
Walking compliance (MET-minute/week)
 <825 15 (93.8) 0 (0.0)
 ≥825 1 (6.3) 16 (100.0)
Physical activity 2110.50±1693.79 3611.25±2513.51 3.45 (.041)
 Inactive 8 (50.0) 0 (0.0)
 Minimally active 5 (31.3) 12 (75.0)
 HEPA 3 (18.8) 4 (25.0)

MET=metabolic equivalent task; HEPA=health enhancing physical activity;

Walking 3.3 MET × 50 min/day × 5 times/week=825 MET-min/week;

International Physical Activity Questionnaire scoring protocol (MET-min/week).

Table 5.
Effects of Reinforced Walking Exercise Program on Patients Outcomes (N=41)
Variables Groups Pretest Posttest t (p) Mean differences t (p)
M±SD M±SD
Global perceived improvement in dyspnea-fatigue Cont. (n=25) - 4.08±0.57     8.63
Exp. (n=16) - 2.56±0.51     (<.001)
Daily activities (KASI) Cont. (n=25) 35.02±11.57 35.38±12.00 0.60 (.553) 0.36±3.02 -4.92 (<.001)
Exp. (n=16) 34.35±12.40 39.80±13.03 6.16 (<.001) 5.45±3.53  
Walking ability (6MWD, m) Cont. (n=25) 339.20±79.11 349.60±78.87 -1.64 (.114) 10.40±31.69 -5.66 (<.001)
Exp. (n=16) 334.38±58.53 403.13±52.50 -8.23 (<.001) 68.75±33.04  
Health related quality of life Cont. (n=25) 72.54±11.77 72.77±12.48 -0.37 (.709) 0.23±3.04 -9.05 (<.001)
Exp. (n=16) 65.53±10.53 79.79±7.340 -9.99 (<.001) 14.26±5.71  

Exp.=experimental group; Cont.=control group; KASI=Korean Activity Scale/Index; 6MWD=6 minute walk distance;

t-tests for mean differences between pretest and posttests within groups,

t-test for mean differences between experimental and control groups.

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Figure & Data

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    The Effects of Reinforced Walking Exercise on Dyspnea-fatigue Symptoms, Daily Activities, Walking Ability, and Health related Quality of Life in Heart Failure Patients
    Korean J Adult Nurs. 2016;28(3):266-278.   Published online June 30, 2016
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    The Effects of Reinforced Walking Exercise on Dyspnea-fatigue Symptoms, Daily Activities, Walking Ability, and Health related Quality of Life in Heart Failure Patients
    Korean J Adult Nurs. 2016;28(3):266-278.   Published online June 30, 2016
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    The Effects of Reinforced Walking Exercise on Dyspnea-fatigue Symptoms, Daily Activities, Walking Ability, and Health related Quality of Life in Heart Failure Patients
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    Figure 1. Flow chart of data collection.
    The Effects of Reinforced Walking Exercise on Dyspnea-fatigue Symptoms, Daily Activities, Walking Ability, and Health related Quality of Life in Heart Failure Patients

    Reinforced Walking Exercise Program

    Categories Contents Time
    1) Preparation (1) Perform physical assessment (Vital sign & SpO2) 10 min
    (2) Instruct how to use pedometer: Mode & Reset
    (3) Offer exercise diary & teach how to use the diary: Recording number of steps, duration of exercise, weekly frequency, heart rate, and dyspnea/fatigue borg scale
    2) Goal setting (1) Perform walking exercise using the pedometer 5 min
    (2) Start from 5,000 steps & 10% increase/week
     Start from 1 day/week → 5 days/week
     1st week: 5,000 steps & 1 day/week
     2nd week: 6,000 steps & 2 days/week
     3rd week: 7,000 steps & 3 days/week
     4th week: 8,000 steps & 4 days/week
     5th week: 9,000 steps & 5 days/week
     6th week: 10,000 steps & 5 days/week
     7~12th week: maintain 10,000↑steps & 5 days/week
    (3) Maintain symptom of dyspnea/fatigue based on borg scale 12~13 point, maximum heart rate 60~70%
    3) Feedback (1) Check pedometer data and incomplete data 5 min
    (2) Mutually set a weekly goal of walking.
    (3) Reinforce maintenance of walking exercise
     → through telephone call:
      1st~6th week=once a week
      7~12th week=every other week
     → by text message: 2 days/week

    Characteristics and Homogeneity Test between Control and Experimental Groups (N=41)

    Characteristics Categories Total Control (n=25) Exp. (n=16) x2 or t (p)
    n (%) or M±SD D n (%) or M±SD n (%) or M±SD
    Age (year) (range 40~77) <65 30 (73.2) 17 (68.0) 13 (81.3) 0.87 (.287)§
    ≥65 11 (26.8) 8 (32.0) 3 (18.8) -0.86 (.393)
    58.02±12.04 56.72±14.38 60.06±6.97  
    Gender Male 30 (73.2) 17 (68.0) 13 (81.3) 0.87 (.478)§
    Female 11 (26.8) 8 (32.0) 3 (18.8)  
    Spouse No 2 (4.9) 0 (0.0) 2 (12.5) 3.29 (.146)§
    Yes 39 (95.1) 25 (100.0) 14 (87.5)  
    Level of education ≤Junior high school 9 (22.0) 7 (28.0) 2 (12.5) 6.61 (.085)
    High school 13 (31.7) 5 (20.0) 8 (50.0)  
    ≥College 19 (46.3) 13 (52.0) 6 (37.5)  
    Regular exercise No 41 (100.0) 25 (100.0) 16 (100.0)  
    Monthly household income (10,000 won) <100 4 (9.8) 2 (8.0) 2 (12.5) 0.32 (.854)
    100~199 7 (17.1) 4 (16.0) 3 (18.8)  
    ≥200 30 (73.2) 19 (76.0) 11 (68.8)  
    Left ventricular ejection fraction (%) 31.15±6.92 31.88±6.98 30.00±6.88 0.85 (.403)
    NYHA class II 36 (87.8) 22 (88.8) 14 (87.5) 0.01 (>.999)§
    III 5 (12.2) 3 (12.0) 2 (12.5)  
    Comorbidity No 16 (39.0) 11 (44.0) 5 (31.3) 0.67 (.519)§
    Yes 25 (61.0) 14 (56.0) 11 (68.8)  
     Hypertension 25 (100.0) 14 (56.0) 11 (44.0)  
     Diabetes mellitus 6 (24.0) 2 (8.0) 4 (16.0)  
     Etc. 7 (28.0) 3 (12.0) 4 (16.0)  
    Medication Beta-blocker Yes 35 (85.4) 21 (84.0) 14 (87.5) 0.10 (>.999)§
    No 6 (14.6) 4 (16.0) 2 (12.5)  
    ACE inhibitor Yes 29 (70.7) 17 (68.0) 12 (75.0) 0.23 (.734)§
    No 12 (29.3) 8 (32.0) 4 (25.0)  
    Diuretics Yes 31 (75.6) 19 (76.0) 12 (75.0) 0.01 (>.999)§
    No 10 (24.4) 6 (24.0) 4 (25.0)  
    Physical activity (MET-minutes/week) Inactive 26 (63.4) 18 (72.0) 8 (50.0) 3.11 (.211)
    Minimally active 11 (26.8) 6 (24.0) 3 (31.3)  
    HEPA 4 (9.8) 1 (2.4) 3 (18.8)  

    Exp.=experimental group; NYHA=New York Heart Association; HEPA=Health enhancing physical activity;

    Multiple responses;

    Liver disease, osteoporosis, angina pectoris, pulmonary disease;

    §Fisher's exact test.

    Levels of Dyspnea-fatigue Symptoms, Daily Activities, Walking Ability and Health related QoL and Homogeneity Test (N=41)

    Characteristics Total Cont. (n=25) Exp. (n=16) t (p)
    M±SD M±SD Z (p) M±SD Z (p)
    Dyspnea-fatigue symptoms 5.90±1.88 6.20±1.78 0.967 (.307) 5.44±2.00 .943 (.336) 1.28 (.210)
    Daily activities (KASI) 34.76±11.75 35.02±11.57 0.646 (.798) 34.35±12.40 .817 (.517) 0.18 (.861)
    Walking ability (6MWD; m) 337.32±71.03 339.20±79.11 1.019 (.251) 334.38±58.53 .388 (.998) 0.21 (.835)
    HRQoL 69.80±11.69 72.54±11.77 1.052 (.219) 65.53±10.53 .823 (.508) 1.94 (.060)

    Exp.=experimental group; Cont.=control group; KASI=Korean Activity Scale/Index; 6MWD=Six-minute walk distance; HRQoL=Health related quality of life.

    Kolmogorov-Smirnove test.

    Walking Compliance and Levels of Physical Activity in Experimental Group (N=16)

    Characteristics Pretest Posttest t (p)
    n (%) or M±SD n (%) or M±SD
    Walking compliance (MET-minute/week)
     <825 15 (93.8) 0 (0.0)
     ≥825 1 (6.3) 16 (100.0)
    Physical activity 2110.50±1693.79 3611.25±2513.51 3.45 (.041)
     Inactive 8 (50.0) 0 (0.0)
     Minimally active 5 (31.3) 12 (75.0)
     HEPA 3 (18.8) 4 (25.0)

    MET=metabolic equivalent task; HEPA=health enhancing physical activity;

    Walking 3.3 MET × 50 min/day × 5 times/week=825 MET-min/week;

    International Physical Activity Questionnaire scoring protocol (MET-min/week).

    Effects of Reinforced Walking Exercise Program on Patients Outcomes (N=41)

    Variables Groups Pretest Posttest t (p) Mean differences t (p)
    M±SD M±SD
    Global perceived improvement in dyspnea-fatigue Cont. (n=25) - 4.08±0.57     8.63
    Exp. (n=16) - 2.56±0.51     (<.001)
    Daily activities (KASI) Cont. (n=25) 35.02±11.57 35.38±12.00 0.60 (.553) 0.36±3.02 -4.92 (<.001)
    Exp. (n=16) 34.35±12.40 39.80±13.03 6.16 (<.001) 5.45±3.53  
    Walking ability (6MWD, m) Cont. (n=25) 339.20±79.11 349.60±78.87 -1.64 (.114) 10.40±31.69 -5.66 (<.001)
    Exp. (n=16) 334.38±58.53 403.13±52.50 -8.23 (<.001) 68.75±33.04  
    Health related quality of life Cont. (n=25) 72.54±11.77 72.77±12.48 -0.37 (.709) 0.23±3.04 -9.05 (<.001)
    Exp. (n=16) 65.53±10.53 79.79±7.340 -9.99 (<.001) 14.26±5.71  

    Exp.=experimental group; Cont.=control group; KASI=Korean Activity Scale/Index; 6MWD=6 minute walk distance;

    t-tests for mean differences between pretest and posttests within groups,

    t-test for mean differences between experimental and control groups.

    Table 1. Reinforced Walking Exercise Program

    Table 2. Characteristics and Homogeneity Test between Control and Experimental Groups (N=41)

    Exp.=experimental group; NYHA=New York Heart Association; HEPA=Health enhancing physical activity;

    Multiple responses;

    Liver disease, osteoporosis, angina pectoris, pulmonary disease;

    Fisher's exact test.

    Table 3. Levels of Dyspnea-fatigue Symptoms, Daily Activities, Walking Ability and Health related QoL and Homogeneity Test (N=41)

    Exp.=experimental group; Cont.=control group; KASI=Korean Activity Scale/Index; 6MWD=Six-minute walk distance; HRQoL=Health related quality of life.

    Kolmogorov-Smirnove test.

    Table 4. Walking Compliance and Levels of Physical Activity in Experimental Group (N=16)

    MET=metabolic equivalent task; HEPA=health enhancing physical activity;

    Walking 3.3 MET × 50 min/day × 5 times/week=825 MET-min/week;

    International Physical Activity Questionnaire scoring protocol (MET-min/week).

    Table 5. Effects of Reinforced Walking Exercise Program on Patients Outcomes (N=41)

    Exp.=experimental group; Cont.=control group; KASI=Korean Activity Scale/Index; 6MWD=6 minute walk distance;

    t-tests for mean differences between pretest and posttests within groups,

    t-test for mean differences between experimental and control groups.

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