Tai Chi in Heart Failure

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Tai Chi in Heart Failure

• Sarah Terry
• BHF Community Heart Failure Sister

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Heart Failure

• Mortality in 5 years is 50
• Incidence increasing with age
• Physically-
• Dyspnoea
• Limited Exercise tolerance
• Activity limitation
• Muscle deconditioning
• Psychosocial-
• Depression
• Anxiety
• Stress
• Isolation

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Exercise in patients with Heart Failure.

• A vicious circle
• Reduced activity ? Muscle cardiac
• de-conditioning ? Reduced exercise tolerance ?
  Reduced activity
• Exercise poses a special challenge for people
  with heart failure (Morantz 2003)
• Patients with heart failure may have lt50 of the
  maximal cardiac output of a healthy person at
  peak exercise (Morantz 2003)

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The Guidelines

• NICE (2003) states
• Patients with CHF should be encouraged to adopt
  
• regular aerobic and/or resistive exercise
• AHA (2003) states
• Exercise training is safe and can benefit
  patients with
• heart failure
• Cardiac Rehab programmes have already shown the
  benefit of exercise for patients following an MI
  or ACS

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Trials Studies

• A study in South Korea of 68 older adults made
  comparisons between those who practised Tai Chi
  and those who did not (Choi 2005)
• Yeh et al (2004) randomised controlled trial
  with Tai Chi vs. Control group. 30 patients
  included, mean age 64 years with chronic stable
  heart failure

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The Aim of Exercise

• To improve the patients overall functional status
  as a result of decreasing their breathlessness
  and fatigue symptoms on exertion

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The Benefits of Exercise

• Reductions in systolic and diastolic blood
  pressure (Taylor-Pillae 2003)
• Improvement in peak oxygen uptake
  (Wang et al 2004)
• Improved balance, lower limb strength and gait
  (Wolf et al 1997)
• Increased exercise tolerance due to adaptations
  in skeletal muscles (Morantz 2003)
• Reductions in stress, depression and fatigue
  (Dimeo et al 2001)

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What is Tai Chi?

• Developed by Taoist monk in 13th century
• Primarily used as a martial art, now used in
  healing and meditation
• In traditional Chinese medicine it is believed
  that illness is a result of imbalance between
  opposing life forces
• Moving meditation that generates the bodys
  natural energy
• Gentle and controlled movements increasing
  flexibility, co-ordination balance

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Why Tai Chi?

• Aging population in local area
• High multiple admissions with heart failure
• Benefits of exercise in patients with heart
  failure
• Evidence of Tai Chi used as an effective form of
  exercise in other medical conditions
• Tai Chi provided a programme that did not
  restrict by age, mobility, ability or
  co-morbidities

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How does it work?

• Cardiovascular system is gently exercised
• The parasympathetic nervous system is stimulated
  causing a decrease in heart rate and dilation of
  the blood vessels
• A basic element of Tai Chi is relearning to walk
• Weight is transferred from one flexed leg to the
  other, improving venous blood return
• Emphasis is placed upon breathing in a positive
  way
• Exercises can be adapted to mirror activities of
  daily living

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Psychological aspects

• Concentration on the movements results in day to
  day worries being left aside
• Encouragement is given to empty the mind of
  stresses prior to starting the session
• Depression anxiety are reduced when practised
  regularly
• Improved mood through changes in concentrations
  of neurohormones and cytokines
• Increased social contact offers a support network

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Tai Chi at Hastings Getting started

• A need was identified for an exercise programme
• An Instructor was found with an interest in the
  health benefits of the art
• Central community venue
• Private transport firm approached for sponsorship
• GP consent obtained
• Patients identified invited
• Audit evaluation tools produced
• Guidelines approved by Lead Consultant for Heart
  Failure

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Hastings The Guidelines

• Patients must be diagnosed with heart failure by
  echocardiogram
• Patients must be aware of their diagnosis
• NYHA I III
• Stable heart failure symptoms
• Exclusions
• NYHA IV
• Patient has had chest pain/discomfort in the past
  24 hours
• Patient is unduly breathless, more than normal
  for them
• Recent surgical intervention
• Unstable on medication
• Current symptomatic arrhythmia
• History of exercise induced arrhythmia

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The First group

• 8 patients, plus 1 relative
• Long standing heart failure patients
• Already known to the Community Heart Failure
  Service
• Weekly sessions over 8 weeks
• 6 required transport
• Minnesota QOL assessment completed pre post
  programme
• 1 hour Tai Chi completed
• 45 minutes education session after the Tai Chi
• Supervised by Heart Failure Sister

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What did we learn? The Good

• The transport scheme allowed those usually unable
  to access such programmes to join in
• The subjective major benefit appeared to be
  social interaction between the patients and their
  carers/relatives
• Evaluation showed a need to increase the duration
  of the programme and also the need to continue
  the project

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.and the Bad!

• Venue not ideal for colder weather
• QOL Scores did not improve
• Transport issues

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Hastings - Overall Outcomes

• 31 patients have attended the programme
• 16 Males vs. 15 Females
• Average Age 75 years (Range 48-91 years)
• All NYHA class II III
• 26 brought a partner
• 61 used the transport scheme
• Only 15 QOL assessments fully completed
• Small reduction in QOL scores (3)

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Anecdotal Outcomes

• Patients enjoyed the opportunity to meet their
  nurse regularly to ask questions express
  concerns
• Patients stated that they could do more activity
  before getting their usual symptoms
• Patients showed high interest in written
  materials

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Education Discussion topics
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Tai Chi at Hastings The Future

• The programme has spread to the Bexhill Rother
  area, since appointment of Community HF Sister in
  the area
• Referrals accepted from other health care
  professionals
• Review QOL measurement tools
• Cost implications of the programme continue to
  determine venue and accessibility

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What do the Patients think?

• I used to fall over several times a week, Ive
  havent fallen over in 5 days, since the last
  session
• Improvement to my posture, breathing and
  circulation
• Happy to be here, I feel like I have made new
  friends
• This has benefited my balance, tension and
  self-esteem
• I found the sessions useful informative and
  the social aspect helpful
• The sessions were very relaxing
• I have realised that I am not alone
• Many HF patients are fearful of their future
  regarding their ability to cope with everyday
  life as a result of their altered physical
  condition. The Tai Chi course and discussion
  sessions would most likely dispel that fear

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References

• Morantz C. 2003. Practice GuidelinesAHA releases
  statement on Exercise and Heart Failure. American
  Family Physician. Sept 1.
• Pina IL et al. 2003. Exercise and Heart Failurea
  statement from the American Heart Association
  Committee on Exercise, Rehabilitation and
  Prevention. Circulation. 107. 1210-1225.
• Song et al.2003.Effects of Tai Chi exercise on
  pain, balance, muscle strength and perceived
  difficulties in physical functioning in older
  women with osteoarthritisa randomised clinical
  trial. Journal of Rheumatology.30(9).2039-44.
• Taylor-Pillae RE. 2003. Tai Chi as an adjunct to
  Cardiac rehabilitation exercise training. Journal
  of Cardiopulmonary Rehabilitation. 23. 90-96.
• Wang C et al. 2004. The effect of Tai Chi on
  health outcomes in patients with chronic
  conditions. Archives on Internal Medicine. 164.
  493-501.
• Wenger NK et al. 1995. Cardiac RehabilitationClin
  ical Practice guideline No.17. US Dept of Health
  and Human Services.
• Wolf SL et al. 1996. Reducing frailty and falls
  in older persons. Journal of the American
  Geriatric Society. 44. 489-497.
• Wolf SL et al. 1997. Exploring basics for Tai Chi
  Chaun as a therapeutic exercise approach.
  Archives of Physical Medicine and Rehabilitation.
  78. 886-892.
• Yeh GY et al. Effects of Tai Chi Mind Body
  Movement Therapy on Functional Status and
  Exercise capacity in patients with chronic heart
  failure. American Journal of Medicine. 117.
  541-548.

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Any Questions?