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

Hyekyung Jin; Haejung Lee

doi:10.7469/kjan.2016.28.3.266

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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

Hyekyung Jin, Haejung Lee

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

DOI: https://doi.org/10.7469/kjan.2016.28.3.266

College of Nursing, Pusan National University, Yangsan, Korea

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

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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Abstract
REFERENCES

Abstract

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.
Key Words: Heart failure; Walking; Quality of life

Figure 1.

Flow chart of data collection.

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)
Characteristics		Categories	n (%) or M±SD	D n (%) or M±SD	n (%) or M±SD	x² or t (p)
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)^§
Gender		Female	11 (26.8)	8 (32.0)	3 (18.8)
Spouse		No	2 (4.9)	0 (0.0)	2 (12.5)	3.29 (.146)^§
Spouse		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)^§
NYHA class		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)^§
	Beta-blocker	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)^§
	ACE inhibitor	No	12 (29.3)	8 (32.0)	4 (25.0)
	Diuretics	Yes	31 (75.6)	19 (76.0)	12 (75.0)	0.01 (＞.999)^§
	Diuretics	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)
Characteristics	M±SD	M±SD	Z^† (p)	M±SD	Z^† (p)	t (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)
Characteristics	n (%) or M±SD	n (%) or M±SD	t (p)
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)
Variables	Groups	M±SD	M±SD	t (p)^†	Mean differences	t (p)
Global perceived improvement in dyspnea-fatigue	Cont. (n=25)	-	4.08±0.57			8.63
Global perceived improvement in dyspnea-fatigue	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)
Daily activities (KASI)	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)
Walking ability (6MWD, m)	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)
Health related quality of life	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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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

DOI: https://doi.org/10.7475/kjan.2016.28.3.266

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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

DOI: https://doi.org/10.7475/kjan.2016.28.3.266

Figure

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

Figure 1. Flow chart of data collection.

Figure 1.

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

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)
Characteristics		Categories	n (%) or M±SD	D n (%) or M±SD	n (%) or M±SD	x² or t (p)
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)^§
Gender		Female	11 (26.8)	8 (32.0)	3 (18.8)
Spouse		No	2 (4.9)	0 (0.0)	2 (12.5)	3.29 (.146)^§
Spouse		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)^§
NYHA class		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)^§
	Beta-blocker	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)^§
	ACE inhibitor	No	12 (29.3)	8 (32.0)	4 (25.0)
	Diuretics	Yes	31 (75.6)	19 (76.0)	12 (75.0)	0.01 (＞.999)^§
	Diuretics	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)
Characteristics	M±SD	M±SD	Z^† (p)	M±SD	Z^† (p)	t (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)
Characteristics	n (%) or M±SD	n (%) or M±SD	t (p)
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)
Variables	Groups	M±SD	M±SD	t (p)^†	Mean differences	t (p)
Global perceived improvement in dyspnea-fatigue	Cont. (n=25)	-	4.08±0.57			8.63
Global perceived improvement in dyspnea-fatigue	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)
Daily activities (KASI)	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)
Walking ability (6MWD, m)	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)
Health related quality of life	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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