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Exercise training improves aerobic endurance and musculoskeletal fitness in female cardiac transplant… Haykowsky, Mark; Riess, Kenneth; Figgures, Linda; Kim, Daniel; Warburton, Darren; Jones, Lee; Tymchak, Wayne May 26, 2005

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ralCurrent Controlled Trials in ssBioMed CentCardiovascular MedicineOpen AcceResearchExercise training improves aerobic endurance and musculoskeletal fitness in female cardiac transplant recipientsMark Haykowsky*1, Kenneth Riess1, Linda Figgures1, Daniel Kim2, Darren Warburton3, Lee Jones4 and Wayne Tymchak2Address: 1Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada, 2Division of Cardiology, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada, 3School of Human Kinetics, University of British Columbia, Vancouver, British Columbia, Canada and 4Program of Cancer Prevention Detection and Control, Duke University Medical Center, Durham, North Carolina, USAEmail: Mark Haykowsky* -; Kenneth Riess -; Linda Figgures -; Daniel Kim -; Darren Warburton -; Lee Jones -; Wayne Tymchak -* Corresponding author    AbstractAim: Female cardiac transplant recipients' aerobic capacity is 60% lower than sex and age-predicted values. The effect of exercise training on restoring the impaired aerobic endurance andmuscle strength in female cardiac transplant recipients is not known. This study examined the effectthat aerobic and strength training have on improving aerobic endurance and muscle strength infemale cardiac transplant recipients.Methods: 20 female cardiac transplant recipients (51 ± 11 years) participated in this investigation.The subjects performed a baseline six-minute walk test and a leg-press strength test when theywere discharged following cardiac transplantation. The subjects then participated in a 12-weekexercise program consisting of aerobic and lower extremity strength training. Baseline assessmentswere repeated following completion of the exercise intervention.Results: At baseline, the cardiac transplant recipients' aerobic endurance was 50% lower than age-matched predicted values. The training program resulted in a significant increase in aerobicendurance (pre-training: 322 ± 104 m vs. post-training: 501 ± 99 m, p < 0.05) and leg-press strength(pre-training: 48 ± 16 kg. vs. post-training: 78 ± 27 kg, p < 0.05).Conclusion: Aerobic and strength training are effective interventions that can partially restore theimpaired aerobic endurance and strength found in female cardiac transplant recipients.Exercise training is an effective intervention that can par-tially restore the impaired aerobic capacity and muscu-loskeletal fitness (i.e. muscle strength) found in cardiactransplant recipients [1,2]. However, previous reportsoutcomes in female cardiac transplant recipients is notknown [2-7]. Importantly, a majority of female cardiactransplant recipients do not engage in regular physicalactivity leading to increased levels of fatigue, poor func-Published: 26 May 2005Current Controlled Trials in Cardiovascular Medicine 2005, 6:10 doi:10.1186/1468-6708-6-10Received: 10 May 2005Accepted: 26 May 2005This article is available from:© 2005 Haykowsky et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 4(page number not for citation purposes)have focused exclusively on the effects of exercise trainingin men. Therefore, the effect of exercise training on thesetional status and reduced exercise capacity [8-10]. Basedon this rationale, the aim of this study is to examine theCurrent Controlled Trials in Cardiovascular Medicine 2005, 6:10 that exercise training has on improving aerobicendurance (i.e. distance walked in six-minutes) and lowerextremity muscle strength in female cardiac transplantrecipients. We hypothesized that exercise training wouldbe a feasible and effective intervention to improve aerobicendurance and lower extremity strength in female cardiactransplant recipients.MethodsSubjects and proceduresThe participants for this study consisted of 20 (51 ± 11years) clinically stable female cardiac transplant recipientswho participated in the University of Alberta Post-Trans-plant Exercise Rehabilitation program between 1997 and2003. All assessments and exercise training were per-formed in the Physical Therapy Department at the Univer-sity of Alberta Hospital. Ethics approval for this study wasobtained from the Biomedical Ethics Board at ourUniversity.Outcome AssessmentsThe six-minute walk test was performed in accordancewith the American Thoracic Society guidelines [11]. Inaddition, the six-minute walk scores were compared withage-matched norms for healthy females published by Gib-bons and associates [12]. Leg-press maximal strength test-ing was performed on a commercially available leg-pressmachine with the greatest weight lifted while adhering tostrict technique being used as the maximal score. Allassessments were repeated following the 12-week trainingprogram.Exercise Training InterventionExercise training consisted of supervised aerobic (cyclingand/or treadmill exercise at an intensity between 12 to 14on the BORG perceived exertion scale for 30 to 40 min-utes/day including warm-up and cool-down, 5 days/week) and lower extremity strength training.Data analysisStatistical analysis was performed with a one-way analysisof variance. The alpha level was set "a priori" at p < 0.05.Data are presented as mean ± SD.ResultsBaseline testing was performed 37 ± 27 days after cardiactransplantation.Aerobic EnduranceAt baseline, our participants' aerobic endurance was 50%lower than age-matched predicted values (Figure 1).Twelve weeks of training resulted in a significant increasein aerobic endurance, however, it remained 22% lowerLeg PressLeg-press maximal strength increased by 64% after threemonths of training (pre: 48 ± 16 kg vs. post: 78 ± 27 kg, p< 0.05).DiscussionThis is the first study to examine the effect that combinedaerobic and strength training have on improving aerobicendurance and musculoskeletal fitness in female cardiactransplant recipients. The main finding of this study isthat combined aerobic and strength training is a feasibleand effective intervention to partially restore female car-diac transplant recipients' aerobic endurance and leg-press strength.Cole et al. [9] recently found that female cardiac trans-plant recipients' aerobic capacity was 60% lower than age-predicted values. Consistent with this finding, our trans-plant recipients' baseline aerobic endurance was 50%lower than age predicted values. Moreover, our partici-pants pre-training leg-press strength was 36% lower thanthat found in age-matched male cardiac transplant recipi-ents tested in our laboratory [13]. The mechanismsresponsible for the impaired cardiovascular and muscu-loskeletal fitness are likely secondary to abnormalities incardiac and skeletal muscle function associated with pre-transplant heart failure, post-transplant deconditioning,cardiac denervation or immunosuppressuion therapy[14].Several research groups [2,3,13] have demonstrated thatexercise training initiated in the early post-operativeperiod is associated with an increase aerobic endurance[13], muscle mass [2], muscle strength [2,13] and bonedensity [3] in male cardiac transplant recipients. Thisstudy extends previous investigations by demonstratingthat 12 weeks of combined aerobic and strength trainingare associated with a significant and marked improve-ment in aerobic endurance and muscle strength in femalecardiac transplant recipients. The mechanisms responsi-ble for the improvement in aerobic endurance was notexamined in this study, however, they may be due to favo-rable improvements in mitochondrial oxidative proper-ties [15,16] that increase arteriovenous oxygen differenceduring exertion as aerobic training does not alter exercisecardiac output in this population [4,17]. The trainingmediated increase in leg-press strength that we found islikely secondary to the increase in muscle mass that occurswith aerobic [4] or combined aerobic and strength train-ing [2]. The consequence of our training mediatedimprovement in cardiorespiratory and musculoskeletalfitness is that it may result in a favorable improvement inmortality. Specifically, Kavanagh et al. [18] reported thatPage 2 of 4(page number not for citation purposes)than age-predicted values (Figure 1). cardiac transplant recipients with the greatest training-Current Controlled Trials in Cardiovascular Medicine 2005, 6:10 improvement in aerobic capacity and lean bodymass had a lower mortality rate 12 years after cessation ofthe training program.A limitation of our investigation is that we did not have anon-exercise control group. However, our cardiac trans-plant recipients are required to participate in a supervised12-week exercise program beginning as an inpatient andcompleted as an outpatient. Despite this limitation, theimprovement in aerobic endurance and leg-press strengthassociated with our training program is similar to thatfound in male cardiac transplant recipients who partici-pated in our outpatient exercise rehabilitation program[13].SummaryA majority of female cardiac transplant recipients adhereto a sedentary lifestyle and as result their aerobic capacityplant recipients' aerobic endurance and lower extremitystrength is not known. The primary finding of this inves-tigation is that 12 weeks of aerobic and strength trainingis an effective intervention that can improve aerobicendurance and musculoskeletal fitness in recent femalecardiac transplant recipients. Moreover, the improvementin aerobic endurance and leg-press strength is similar tothat found in male cardiac transplant recipients after com-bined aerobic and strength training. In summary, femalecardiac transplant recipients should be encouraged to per-form aerobic and strength training to increase their aero-bic endurance and musculoskeletal fitness.Competing interestsThe author(s) declare that they have no competinginterests.Authors' contributionsEffect of exercise training on the distance walked in six-minutesFigure 1Effect of exercise training on the distance walked in six-minutes. *, p < 0.05 vs. pre-training; †, p < 0.05 vs. post-training.Page 3 of 4(page number not for citation purposes)is 60% lower than age-predicted values [9]. The effect thatexercise training has on improving female cardiac trans-MH. Conceived the study, performed data analysis andmanuscript preparation.Publish with BioMed Central   and  every scientist can read your work free of charge"BioMed Central will be the most significant development for disseminating the results of biomedical research in our lifetime."Sir Paul Nurse, Cancer Research UKYour research papers will be:available free of charge to the entire biomedical communitypeer reviewed and published immediately upon acceptancecited in PubMed and archived on PubMed Central Current Controlled Trials in Cardiovascular Medicine 2005, 6:10 Assisted with data collection and manuscriptpreparation.LF. Performed the exercise rehabilitation training andassisted with manuscript preparation.DK. Assisted with manuscript preparation.DW. Assisted with manuscript preparation.LJ. Assisted with manuscript preparation.WT. Assisted with manuscript preparation.All authors read and approved the final manuscript.References1. Kobashigawa JA, Leaf DA, Lee N, Gleeson MP, Liu H, Hamilton MA,Moriguchi JD, Kawata N, Einhorn K, Herlihy E, Laks H: A controlledtrial of exercise rehabilitation after heart transplantation. NEngl J Med 1999, 340:272-277.2. Braith RW, Welsch MA, Mills RMJ, Keller JW, Pollock ML: Resist-ance exercise prevents glucocorticoid-induced myopathy inheart transplant recipients. Med Sci Sports Exerc 1998,30:483-489.3. Braith RW, Mills RM, Welsch MA, Keller JW, Pollock ML: Resist-ance exercise training restores bone mineral density in hearttransplant recipients. J Am Coll Cardiol 1996, 28:1471-1477.4. Kavanagh T, Yacoub MH, Mertens DJ, Kennedy J, Campbell RB, Saw-yer P: Cardiorespiratory responses to exercise training afterorthotopic cardiac transplantation. Circulation 1988,77:162-171.5. Lampert E, Oyono-Enguelle S, Mettauer B, Freund H, Lonsdorfer J:Short endurance training improves lactate removal ability inpatients with heart transplants. Med Sci Sports Exerc 1996,28:801-807.6. Ehrman J, Keteyian S, Fedel F, Rhoads K, Levine TB, Shepard R: Car-diovascular responses of heart transplant recipients tograded exercise testing. J Appl Physiol 1992, 73:260-264.7. Keteyian S, Shepard R, Ehrman J, Fedel F, Glick C, Rhoads K, LevineTB: Cardiovascular responses of heart transplant patients toexercise training. J Appl Physiol 1991, 70:2627-2631.8. Evangelista LS, Doering LV, Dracup K, Kobashigawa JA: Measuringphysical activity among female heart transplant recipients.The Journal of Heart and Lung Transplantation 2003, 22.:S220..9. Cole BT, Kobashigawa JA, Patel JK, Moriguchi J, Espejo Vassilakis M,Go SE, Chait J, Lak H: Perception is deceiving: The real genderspecific exercise capacity of heart transplant recipients. TheJournal of Heart and Lung Transplantation 2003, 22.:S220..10. Reyes CJ, Evangelista LS, Doering L, Dracup K, Cesario DA, Kobash-igawa J: Physical and psychological attributes of fatigue infemale heart transplant recipients. J Heart Lung Transplant 2004,23:614-619.11. ATS statement: guidelines for the six-minute walk test. Am JRespir Crit Care Med 2002, 166:111-117.12. Gibbons WJ, Fruchter N, Sloan S, Levy RD: Reference values for amultiple repetition 6-minute walk test in healthy adultsolder than 20 years. J Cardiopulm Rehabil 2001, 21:87-93.13. Haykowsky M, Eves N, Figgures L, Koller M, Burton J, Tymchak W:Early initiation of aerobic and resistance training improvespeak aerobic power, leg-press maximal strength and dis-tance walked in six minutes in recent cardiac transplantrecipients. The Journal of Heart and Lung Transplantation 2003,22:S179.14. Warburton DE, Sheel AW, Hodges AN, Stewart IB, Yoshida EM, LevyRD, McKenzie DC: Effects of upper extremity exercise trainingon peak aerobic and anaerobic fitness in patients afterresponse of mitochondrial function to short-term endurancetraining in skeletal muscle of heart transplant recipients. J AmColl Cardiol 2003, 42:126-132.16. Lampert E, Mettauer B, Hoppeler H, Charloux A, Charpentier A,Lonsdorfer J: Skeletal muscle response to short endurancetraining in heart transplant recipients. J Am Coll Cardiol 1998,32:420-426.17. Geny B, Saini J, Mettauer B, Lampert E, Piquard F, Follenius M, EpaillyE, Schnedecker B, Eisenmann B, Haberey P, Lonsdorfer J: Effect ofshort-term endurance training on exercise capacity, haemo-dynamics and atrial natriuretic peptide secretion in hearttransplant recipients. Eur J Appl Physiol Occup Physiol 1996,73:259-266.18. Kavanagh T, Mertens DJ, Shephard RJ, Beyene J, Kennedy J, CampbellR, Sawyer P, Yacoub M: Long-term cardiorespiratory results ofexercise training following cardiac transplantation. Am JCardiol 2003, 91:190-194.yours — you keep the copyrightSubmit your manuscript here: 4 of 4(page number not for citation purposes)transplantation. Am J Cardiol 2004, 93:939-943.15. Zoll J, N'Guessan B, Ribera F, Lampert E, Fortin D, Veksler V, BigardX, Geny B, Lonsdorfer J, Ventura-Clapier R, Mettauer B: Preserved


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