Effect of aerobic exercise training on cardio ...

International Journal of Advanced Life Sciences (IJALS)

ISSN 2277 – 758X

Vaiyapuri Anandh et al, IJALS, Volume (6) Issue (5) November - 2013. RESEARCH ARTICLE

Effect of aerobic exercise training on cardio vascular fitness, quality of life and CD4 count in people with HIV/AIDS Vaiyapuri Anandh*, Ivor Peter D’SA**, Jagatheesan Alagesan***, Durai Prabhavathi*** and K Rajendran*** * KSHEMA, Nitte University, Mangalore, India. **Department of Medicine, KSHEMA, Nitte University, Mangalore, India. ***Saveetha College of Physiotherapy, Saveetha University, Chennai, India. Email : [email protected]

Corresponding Author Jagatheesan Alagesan Saveetha College of Physiotherapy, Saveetha University, Chennai, India. Email : [email protected] Article History Received on 03 September, 2013; Received in revised form 02 October, 2013; Accepted 24 October, 2013

Abstract The present study aims to find the effect of Aerobic exercise training on cardio vascular fitness, quality of life and CD4 count in people with HIV/AIDS. The 24 participants were randomly allocated to aerobic exercise group and control group with 12 subjects in each group. Aerobic exercise 3 days/week for 3 months with intensity of 50 to 70 % of target heart rate by Karvonen’s Formula. The control group was advised not to do any exercises. Cardio vascular fitness was assessed by six minute walk test, quality of life was assessed by MOS-HIV health survey and immune system was assessed by CD4 count. Aerobic group showed significant improvement in all three outcome measures with p < 0.05 whereas control group showed no change in CD4 count and quality of life and detrimental change in 6 minute walk test. Aerobic exercises can be better adjunct to pharmacological therapy for people with HIV/AIDSfor improving cardiovascular fitness, quality of life and immune system. Keywords : HIV/AIDS, aerobic exercise, cardio vascular fitness, quality of Life and CD4 count.

[[

Introduction Now-a-days patient with HIV/AIDS are increasing in number, partly due to improved screening, earlier diagnosis, better treatment methods like antiretroviral therapy, specifically highly active antiretroviral therapy (HAART), has enhanced HIV infected patient to live longer and healthier lives (Kalra et al., 2011). Individuals numerous

infected

comorbidities

with caused

HIV by

experience the

disease

progression and medications, lack of physical activity, malnutrition. Common symptoms include loss of muscle mass, fatigue, lypodystrophy, lypoatrophy and decrease in strength, functional capacity and overall quality of life (Hand et al., 2009).

Numerous studies had reported the benefits of exercise for the physiological and psychological wellbeing of HIV seropositive patients. Many studies had reported that exercise lead to increase in functional aerobic capacity,cardio-vascular profile,body cell mass and strength, QOL indices (Andrea Petroczi et al., 2010). Several studies on aerobic exercise training in HIV positive individuals have demonstrated that it is safe, effective and has a number of beneficial outcomes (Stringer et al., 1998 and Paton et al., 2002). Aerobicexercises is the exercise of any activity that uses large muscle group which can be maintained continuously and is rhythmic in nature. In 1948, the WHO defined “Health is not only absence of disease and infirmity but also the presence of physical, psychological and social

Int. j. Adv. Lif. Sci., Available online on at www. Int. J. Adv. Lif. Sci., Available online on at www. ijals.com

Page 569


ISSN 2277 – 758X

Vaiyapuri Anandh et al, IJALS, Volume (6) Issue (5) November - 2013. RESEARCH ARTICLE well being”. Quality of life is an issue becoming very steadily more important in health care practice and health care research (Wu et al., 1997). Materials and Methods The study was conducted at Physiotherapy out Patient Department of Saveetha Medical College and Hospital, Chennai. Study was cleared by institutional ethical committee. 24 subjects of both sexes in age range of 30 to 50 years with HIV infections were included for the study irrespective of their anti-retro viral therapy status. Subjects with active inflammatory disease such asactive hepatitis, active gout, other active inflammatory diseases, active malignancy, history of a serious medical condition, including heart problems, tuberculosis, cancer, hypertension, uncontrolled diabetes, or osteoporosis, steroid therapy and already on a consistent and rigorous exercise regimen were excluded. All subjects fulfilling selection criteria were provided informed consent for participating in the research. All subjects were allotted with an identification code before starting baseline assessments andwere used in all records to assure maximum confidentiality and blinding and to avoid social stigma. All 24 subjects after baseline assessment were randomly allotted into two groups by using sealed envelopes (Fig.-1). The experimental group was receiving Aerobic exercises and Control group receiving no exercises. Typical duration of intervention was 3 days per week for 3 months of 1 hour per session. Aerobic exercise session involved a warming up period for 10 minutes, followed by 30 minutes of Aerobic exercise and a cooling down period at the end for 10 minutes. Breathing exercises, Stretching activities for major muscle groups and free exercises for major joints were included in the warming up and cooling down session. Treadmill walking, Arm ergometer, Elliptical trainer each for 10 minute with intensity of 50 to 70% of target heart rate by Karvonen’s Formula.

Cardio Vascular Fitness was assessed by Six Minute Walk Test (6MWD), QOL was assessed by MOS-HIV Health Surveyby apost graduate physiotherapist who is blinded to group allotment. Immune System was tested by CD4 count by sending the blood sample to an ISO certified lab outside the study center. All three outcome measures were tested at baseline and end of three months of intervention. Results There were ten males and two females in experimental group and seven males and five females in control group. The Mean ± SD age of experimental Group is 42.25 ± 6.24 and Control Group is 42.42 ± 5.23 years. The homogeneity of variances of the data at baseline and significant differences of post intervention data were analysed by Independent t test for continuous variables and Mann Whitney U test for ordinal variables. Significant changes within group was analysed with paired ‘t’ test for continuous variables and Wilcoxon signed rank test for ordinal variables. An overall significance level was maintained at p-value less than 0.05.12 subjects were recruited in each group, there were two dropouts in experimental group; one found difficulty in transport and one moved out of city two dropouts in control group moved out of city. Intention to treat analysis for all outcome measures was carried out with individual’s latest available data or baseline data as applicable. The independent ‘t’ test for between group analyses at baseline for CD4 count shows p value equal to 0.984 and for 6 MWD equal to 0.260. The Mann Whitney U test for QOL score shows p value equal to 0.840. All these variables were proved homogeneous at baseline. Table - 1 shows the details of within group analysis of aerobic exercises group for CD4 count and 6 MWD analyzed by paired t-test and QOL scores analyzed by Wilcoxon signed rank test for all completed


Page 570

ISSN 2277 – 758X


Vaiyapuri Anandh et al, IJALS, Volume (6) Issue (5) November - 2013. RESEARCH ARTICLE Table - 1. Within group analysis for experimental group Experimental Group Before CD4 Count After

Mean ± SD 533.20 ± 102.49 590.50 ± 107.92

Min 362 407

Max 694 768

Before After Before

747.60 ± 115.07 841.80 ± 85.56 39.40 ± 14.40

601 701 18

903 953 61

After

60.20 ± 3.99

53

67

Before After

Mean ± SD 521.80±115.70 486.30±147.09

Min 331 331

Max 723 723

Before After Before After

669.30±107.67 609.80±106.62 35.80±15.32 30.00±12.82

476 441 21 18

803 774 64 57

6 MWD QOL

p .009 .004 .007

Table – 2. Within group analysis for control group Control Group CD4 Count 6 MWD QOL

p .073 .010 .123

subjects. Intention to treat analysis shows p value equal to 0.013 for CD4 count, 0.008 for 6 MWD and 0.004 for QOL scores. The p value for all variables is less than 0.05 proves aerobic exercises are effective in increasing CD4 count, 6 MWD and QOL in subjects with HIV/AIDS. Table - 2 shows the details of within group analysis of control group for CD4 count and 6 min walk test analyzed by paired t-test and QOL scores analyzed by Wilcoxon signed rank test for all completed subjects. Intention to treat analysis shows p value equal to 0.072 for CD4 count, 0.006 for 6 MWD and 0.138 for QOL scores. The p value for 6 MWD is less than 0.05, but the mean changes are detrimental, other two variables show p value more than 0.05 and proves that control group is not effective in increasing CD4 count, 6 MWD and QOL in subjects with HIV/AIDS. Fig. -1: CONSORT Diagram of randomized clinical trial: number of participants screened, randomized, and retained and analyses.

Discussion An ever-growing number of published studies suggest and acknowledge that exercise is the best and


Page 571


ISSN 2277 – 758X

Vaiyapuri Anandh et al, IJALS, Volume (6) Issue (5) November - 2013. RESEARCH ARTICLE effective therapeutic interventions for HIV/AIDS infected people to make their living qualitatively. Notwithstanding, to the best of our knowledge, this is the first study done for Indian peoples with HIV/AIDS. Aerobic exercise session involved a warming up period for 10 minutes, followed by 30 minutes of aerobic period with intensity of 50 to 70 % of target heart rate by Karvonen’s Formula, and a cooling down period at the end for 10 minutes. Control group was advised not to do any exercises, but to carry on their Activities of daily living and his /her occupation. Initially making the participants to understand the exercises and setting the intensity was faced difficult in initial week. Slowly the participants adhered to the study protocol and followed all instructions. All exercises were performed under supervision. The results of Aerobic exercises group had shown that there was statistically significant difference in CD4 counts, improvement in the performance of 6 MWT, and improvement in quality of life that was assessed by MOS-HIV scales. These results had been supported by many studies (Obrien et al., 2006; Anandh et al., 2012; Dolan et al., 2006; Galantino et al., 2005). O’Brein et al. (2006) stated that, performing constant or interval aerobic exercises for at least three times per week for four weeks may lead to increased CD4 count, improved cardiopulmonary fitness and improved psychological status. Beneficial effects of aerobic exercises are decreased body mass index, subcutaneous fat, abdominal girth and reports of improved quality of life. Physiological adaptations to aerobic exercise training may improve fatigue, decrease functional limitations and reduce physical disability resulting from HIV infection. Review done on effects of exercise on Immune functions by (Laperriere et al., 1997) found that, a trend

towards an increase in the number of CD4 cells in all study. Mustafa and colleagues (Stringer, 1999) found that HIV infected individuals self-reporting exercise participation had 107.5% higher CD4 counts when compared to HIV-infected individuals who denied exercise participation. Optimizing health-related quality of life (HQRL) has become important treatment focus for patients HIV infection. Consideration of HQRL is especially relevant with the development of new antiretroviral agents that have significant side effects. A review of existing studies revealed that certain therapies for HIVand opportunistic infections exact a significant cost in terms of HQRL. In this study, it was totally 2 groups, 1 experimental group namely aerobic exercise group and second was a control group. Typical duration of intervention was 3 days per week for 3 months of 1 hour per session. Three outcome measures were Six Minute Walk Test for assessing Cardio Vascular Fitness, Quality of Life by MOS-HIV Health Survey, and CD4 count by lab investigation for assessing Immune System. The results revealed that there was improvement in performance of 6 Minute walk Test, improvement in quality of life, CD4 counts increased in experimental group, when compared to control group. In this study, individually the effects of excises like aerobic are assessed and proved there was marked improvement in cardio-vascular fitness, increase in CD4 counts, and positive changes in quality of life. The study would be better if HIV infected participants are differentiated either receiving HAART or not. The limitations in this study may be inclusion of other bio chemical analysis as outcome measures like lymphocyte count, platelet count, WBC count CD3, and CD8 count. Long time follow up of the subjects like 2 to 5 years after intervention were not analyzed in this study due to lack of time. The sample size in


Page 572


ISSN 2277 – 758X

Vaiyapuri Anandh et al, IJALS, Volume (6) Issue (5) November - 2013. RESEARCH ARTICLE this research is calculated to 7 for the significance level of 0.05 based on prevalence of HIV/AIDS subjects in Tamilnadu, but we have recruited 12 subjects for the study and in all groups more than 9 subjects were completed the intervention duration study. Aerobic exercise training in an HIV positive patient group is safe and effective in improving exercise tolerance. In addition, it proves most marked improvements in aerobic function and quality of life occur with high intensity exercise training. Aerobic exercise training should be promoted as a nonpharmacological therapy for the treatment of HIV positive patients in the intermediate stages of their disease.(Paton et al., 2002 and Terry et al., 1999). Anandh et al. (2012) concluded in three different pilot studies on the effect of aerobic exercise in the subjects with HIV/AIDS for improving cardiovascular fitness assessed by 3 minute step test and quality of life by MOS-HIV Scale. In summary, our results indicate that a three month supervised aerobic exercise program improves the performance of 6 MWT, increase in CD4 counts, improvement in Quality of life. When implementing therapeutic exercise programs for HIV infected patients, it is recommended that programs be individualized on the basis of the functional capacity and individual symptomology of each client. Conclusion Aerobic exercise training (3 days per week for 3 months of 1 hour per session) improves Cardio Vascular Fitness, Immune System and Quality of Life of people with HIV/AIDS. References Anandh, V., Dsa, I.P., Rathod, V. and Alagesan, J. 2012. Effect of aerobic exercises on cardio vascular fitness and quality of life in people with

HIV/AIDS. International Journal of Current Research and Review., 3(8) : 65-70. Andrea Petroczi., Kim., Hawkins., Gareth, Jones. and Naughton, D.P. 2010. HIV patient characteristics that affect adherence to exercise programmes: An Observational Study. AIDS J., 25(4): 148-155. Ciccolo, J.T., Jowers, E.M. and Bartholomew, J.B. 2004. The benefits of exercise training for quality of life in HIV/AIDS in the post-HAART Era. Sports Med., 34(8) : 487- 499. Dolan, S.E., Frontera, W., Librizzi, J., Ljungquist, K., Juan, S. and Dorman, R. 2006. Effects of a supervised home-based aerobic and progressive resistance training regimen in women infected with human immunodeficiency virus: A randomized trial. Arch Intern Med., 166(12) : 1225 – 1231. Galantino, M.L., Shepard, K., Krafft, L., Laperriere, A., Ducette, J. and Sorbello, A. 2005. The effect of group aerobic exercise and tai chi on functional outcomes and quality of life for persons living with acquired immunodeficiency syndrome. J. Altern. Complement Med., 11(6) : 1085-1092. LaPerriere, A., Klimas, N., Fletcher, M.A., Perry, A., Ironson, G. and Perna, F. 1997. Change in CD4+ cell enumeration following aerobic exercise training in HIV-1 disease: possible mechanisms and practical applications. Int. J. Sports Med., 18(1) : 56-61. O’brien, K., Nixon, S., Tynan, A.M. and Glazier, R.H. 2006. Aerobic exercise interventions for people living with HIV/AIDS: Implications for Practice, Education, and Research. Physiotherapy Can., 58(2) : 114-129. Paton, N.I., Chapman, C.A., Chan, S.P., Tan, K.M., Leo, Y.S. and Aboulhab J. 2002. Validation of the medical outcomes study HIV health survey as a measure of quality of life in HIV-infected patients in Singapore. Int. J. STD. AIDS., 13(7), 456-461.


Page 573


ISSN 2277 – 758X

Vaiyapuri Anandh et al, IJALS, Volume (6) Issue (5) November - 2013. RESEARCH ARTICLE Paton, N.I., Chapman, C.A., Chan, S.P., Tan, K.M., Leo, Y.S. and Aboulhab, J. 2002. Validation of the medical outcomes study HIV health survey as a measure of quality of life in HIV-infected patients in Singapore. Int. J. STD. AIDS., 13(7) : 456-461.

Terry, L., Sprinz, E. and Ribeiro, J.P. 1999. Moderate and high intensity exercise training in HIV-1 seropositive individuals: A Randomized trial, International Journal Sports Medicine., 20(2): 142-146.

Stringer, W.W. 1999. HIV and Aerobic exercise current recommendations. Sports Med., 28(6) : 389 - 395.

Wu, AW., Revicki, D.A., Jacobson, D. and Malitz, F.E. 1997. Evidence for reliability, validity and usefulness of the medical outcomes study HIV health survey (MOS-HIV). Quality of life research., 6(6): 481-493.

Stringer, W.W., Berezovskaja, M., O’Brien, W.A., Beck, C.K. and Casaburi, R. 1998. The effect of exercise training on aerobic fitness, immune indices, and quality of life in HIV positive patients. Medicine and science in sports and exercise., 30(1): 11-16.

Corresponding Author : Jagatheesan Alagesan, Saveetha College of Physiotherapy, Saveetha University, Chennai, India. Email: [email protected], © 2013, IJALS. All Rights Reserved.


Page 574