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Effect of a Physical Exercise Program on the Functional Capacity of Liver Transplant Patients
Effect of a Physical Exercise Program on the Functional Capacity of Liver Transplant Patients A.M.C. Garciaa,d, C.E. Venerosoa,c,d, D.D. Soaresb,c,d, A.S. Limae, and M.I.T.D. Correiae,* a Post-Graduate Program in Sports Sciences, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil; bDepartment of Physical Education, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil; cLaboratory of Physiology of Exercise, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil; dEscola de Educação Física, Fisioterapia e Terapia Ocupacional, Universidade Federal de Minas Gerais, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil; and eDepartment of Surgery, Alfa Institute of Gastroenterology, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
ABSTRACT Background. Recently there has been great concern about the quality of life and health of liver transplant patients (LTP). These patients often present with metabolic disorders, which can improve with regular physical exercise. The aim of this study was to investigate the effect of a physical exercise program on the functional capacity of LTP. Method. The distance walked in the 6-minute walk test and the resting energy expenditure (REE) were evaluated in 15 subjects who regularly attend the outpatient Bias Fortes Clinic at Universidade Federal de Minas Gerais. The patients were divided into 2 groups, the Exercise Group (EG) (6 men and 3 women; 52 15 years old, BMI 22.4 4.0 kg/m2) performed 24 sessions of continuous 30 min treadmill exercise. Intensity of exercise was increased from 50%e70% of the maximum heart rate over the training period. A group of 3 men and 3 women (39 15 years, BMI 24.5 4.4 kg/m2) served as controls (CG). Results. After undergoing exercise training, patients in the EG showed a 19.4% increase in the distance walked (pre ¼ 453.6 128.0 m and post ¼ 582.5 90.1 m). Also, there was an increase in their REE (pre ¼ 1,060.0 194.2 kcal and post ¼ 1,375.0 258.6 kcal) (P < .05) indicating an increase in their exercise capacity and metabolic improvements. There were no differences in the distance walked (pre ¼ 516.5 62.0 m and post ¼ 517.7 71.9 m) and REE (pre ¼ 1,393.0 213.3 kcal to post ¼ 1,465.0 170.3 kcal) (P > .05) for CG. Our results are in agreement with previous studies. Conclusions. We conclude that the exercise program promoted significant improvements in functional capacity. These findings have positive implications for the control of metabolic diseases, which are common in patients after liver transplantation.
P
HYSICAL inactivity is the fourth leading cause of death worldwide. It is therefore recommended that people of all ages should engage in regular physical activity, because of its significant health benefits [1]. The effects of physical activity on the cardiovascular and musculoskeletal systems are more widely known but its benefits on the metabolic, endocrine, and immune systems also are considerable [1,2]. In recent years, there has been growing concern about the quality of life and the health of liver transplant patients (LTP) [3e8]. After the liver transplantation, the onset of metabolic disorders is a landmark feature that reflects several metabolic changes [8e11]. These metabolic disorders
can be countered by regular practice of physical exercise [3e8,11]. However, exercise limitations and loss of functional capacity are common in LTP [3e8,11,12]. The 6-minute walk test (6MWT) has been traditionally used for patients with respiratory diseases, but it is now used to evaluate aerobic capacity and survival in patients suffering from other *Address correspondence to Maria Isabel T.D. Correia, Alfa Institute of Gastroenterology, School of Medicine, Universidade Federal de Minas Gerais, Av. Alfredo Balena 110, sala 208, Zip code: 31270-901, Belo Horizonte, MG e Brazil. E-mail: isabel_correia@uol. com.br
ª 2014 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/14/$esee front matter http://dx.doi.org/10.1016/j.transproceed.2014.05.023
Transplantation Proceedings, 46, 1807e1808 (2014)
1807
1808
GARCIA, VENEROSO, SOARES ET AL
Table 1. Average Distance, Resting Energy Expenditure Before and After Training for Control Group (CG; n [ 6) and Liver Transplant Patient Exercise Group (EG, n [ 9) Group
Average distance (m) REE (kcal)
CG EG CG EG
Preexercise
516.5 453.6 1,393.0 1,060.0
62.0 128.0* 213.3 194.2†
Postexercise
517.7 582.5 1,465.0 1,375.0
71.9 90.1* 170.3 258.6†
*†Significantly different compared with the postexercise program with preexercise, for the same group. P .05. All results are presented as mean standard error.
diseases and who are undergoing a rehabilitation program [13] such as LTP [12]. The 6MWT is easy to perform, inexpensive, reproducible and safe [13]. The aim of this study was to investigate the effect of a physical exercise program on REE and functional capacity of liver transplant patients. PATIENTS AND METHODS This study has been approved by the Human Subjects Ethics Committee of the Universidade Federal de Minas Gerais (UFMG) (EC# 552.0.203.000/11). Fifteen LTP who underwent liver transplant surgery 6e12 months prior to the beginning of the study and were seen at the outpatient Bias Fortes Clinic - UFMG, participated in the study. The subjects were randomly divided into two groups. The Exercise Group (EG) (6 men and 3 women; 52 15 years), performed 24 sessions of continuous 30 min treadmill exercise. Intensity was increased from 50%e70% of the maximum heart rate over the training period. Another group (3 men and 3 women; 39 15 years) served as controls (CG). All subjects were evaluated for body mass index (BMI), distance walked in the 6-minute walk test (6MWT) and resting energy expenditure (REE). Body mass and height were measured using a mechanical scale and a stadiometer (Filizola, Sao Paulo, Brazil). The BMI was directly calculated from weight and height measurements (kg/m2) to characterize the sample. The 6MWT was used as an objective assessment of the subject’s exercise capacity and was expressed in meters. Patients were encouraged to walk as fast as they could on a flat and hard surface. The 6MWT was conducted according to the American Thoracic Society Statements: Guidelines for the Six-Minute Walk Test (2002) [13]. Oxygen saturation (SpO2) and heart rate (HR) were measured before and after the test. The calculation of theoretical expected walking distance and the values of the lower limit of normality were obtained according to the reference equations by Enright and Sherrill (1998) [14]. The REE was estimated from respiratory gas analysis performed using an indirect calorimetry, open circuit method (Quark RMR Gas Analyzer, Cosmed, Rome, Italy). The tests were always performed between 08:00 and 09:30 AM. Patients reported to the lab after a 12-hour fasting period. They remained awake in the recumbent position while the metabolic measurements were obtained. The gas analyzer was calibrated immediately before every test. Data were analyzed using an ANOVA 1-Way and the Tukey test as post-hoc (GraphPad Prism, Version 5.0). All results are presented as mean standard error. The significance level was set at P .05.
RESULTS
All patients from EG completed 24 sessions of aerobic training. The patients in the EG showed a 19.4% increase in the distance walked. There was no difference in the distance walked by the
CG (P > .05) (Table 1). There were significant differences in REE after the training period, during which the EG patients presented with an increase in REE (P .05). There was no difference in the REE of the CG (P > .05) (Table 1). DISCUSSION
The results of our study are in agreement with previous studies that reported beneficial effects of a supervised program of physical exercise for the rehabilitation of liver transplant patients. The current study showed that the intervention group patients significantly improved functional capacity and REE. These findings have positive implications in the control of metabolic diseases common in patients after liver transplant surgery. ACKNOWLEDGMENT We acknowledge the relevant contributions made by Prof. Dr. Emerson Silami Garcia who is supported by CAPES.
REFERENCES [1] Kolh HW, Craig CL, Lambert EV, et al. The pandemic of physical inactivity: global action for public health. Lancet 2012;380(9838):294e305. [2] US Department of Health and Human Services. Objectives 22-2 and 22-3. In: Healthy people 2010 (conference ed, in 2 vols). Washington, DC: US Department of Health and Human Services; 2000. Available at http://www.healthypeople.gov. [3] Painter P, Krasnoff J, Paul SM, et al. Physical activity and health-related quality of life in liver transplant recipients. Liver Transpl 2001;7:213e9. [4] Stephenson AL, Yoshida EM, Abboud RT, et al. Impaired exercise performance after successful liver transplantation. Transplantation 2001;72:1161e4. [5] Van Ginneken BT, Van Den Berg-Emons HJ, Metselaar HJ, et al. Effects of a rehabilitation programme on daily functioning, participation, health-related quality of life, anxiety and depression in liver transplant recipients. Disabil Rehabil 2010;32(25):2107e12. [6] Rongies W, Stepniewska S, Lewandowska M, et al. Physical activity long-term after liver transplantation yields better quality of life. Ann Transplant 2011;16(3):126e31. [7] Massala D, Mannocci A, Unim B, et al. Quality of life and physical activity in liver transplantation patients: Results of a casecontrol study in Italy. Transplant Proc 2012;44:1346e50. [8] Tomás MT, Santa-Clara H, Bruno PM, et al. The impact of exercise training on liver transplanted familial amyloidotic polyneuropathy (FAP) patients. Transplantation 2013;95:372e7. [9] Anastácio L, Ferreira LG, Lima AS, et al. Metabolic syndrome and its components after liver transplantation: incidence, prevalence, risk factors and implications. Clin Nutr (Edinb) 2010;29(2):175e9. [10] Ladevaia M, Giusto M, Giannelli V, et al. Metabolic syndrome and cardiovascular risk after liver transplantation: A singlecenter experience. Transplant Proc 2012;44:2005e6. [11] Iscar M, Montoliu MA, Ortega T, et al. Functional capacity before and after liver transplantation. Transplant Proc 2009;41:1014e5. [12] Foroncewicz B, Mucha K, Szparaga B, et al. Rehabilitation and 6-minute walk test after liver transplantation. Transplant Proc 2011;43:3021e4. [13] American Thoracic Society. ATS Statement. Guidelines for the six-minute walk test. Am J Respir Crit Care Med 2002;166:111e7. [14] Enrigh PL, Sherril DL. Reference equations for the sixminute walk in healthy adults. Am J Respir Crit Care Med 1998;158:1384e7.
ABSTRACT Background. Recently there has been great concern about the quality of life and health of liver transplant patients (LTP). These patients often present with metabolic disorders, which can improve with regular physical exercise. The aim of this study was to investigate the effect of a physical exercise program on the functional capacity of LTP. Method. The distance walked in the 6-minute walk test and the resting energy expenditure (REE) were evaluated in 15 subjects who regularly attend the outpatient Bias Fortes Clinic at Universidade Federal de Minas Gerais. The patients were divided into 2 groups, the Exercise Group (EG) (6 men and 3 women; 52 15 years old, BMI 22.4 4.0 kg/m2) performed 24 sessions of continuous 30 min treadmill exercise. Intensity of exercise was increased from 50%e70% of the maximum heart rate over the training period. A group of 3 men and 3 women (39 15 years, BMI 24.5 4.4 kg/m2) served as controls (CG). Results. After undergoing exercise training, patients in the EG showed a 19.4% increase in the distance walked (pre ¼ 453.6 128.0 m and post ¼ 582.5 90.1 m). Also, there was an increase in their REE (pre ¼ 1,060.0 194.2 kcal and post ¼ 1,375.0 258.6 kcal) (P < .05) indicating an increase in their exercise capacity and metabolic improvements. There were no differences in the distance walked (pre ¼ 516.5 62.0 m and post ¼ 517.7 71.9 m) and REE (pre ¼ 1,393.0 213.3 kcal to post ¼ 1,465.0 170.3 kcal) (P > .05) for CG. Our results are in agreement with previous studies. Conclusions. We conclude that the exercise program promoted significant improvements in functional capacity. These findings have positive implications for the control of metabolic diseases, which are common in patients after liver transplantation.
P
HYSICAL inactivity is the fourth leading cause of death worldwide. It is therefore recommended that people of all ages should engage in regular physical activity, because of its significant health benefits [1]. The effects of physical activity on the cardiovascular and musculoskeletal systems are more widely known but its benefits on the metabolic, endocrine, and immune systems also are considerable [1,2]. In recent years, there has been growing concern about the quality of life and the health of liver transplant patients (LTP) [3e8]. After the liver transplantation, the onset of metabolic disorders is a landmark feature that reflects several metabolic changes [8e11]. These metabolic disorders
can be countered by regular practice of physical exercise [3e8,11]. However, exercise limitations and loss of functional capacity are common in LTP [3e8,11,12]. The 6-minute walk test (6MWT) has been traditionally used for patients with respiratory diseases, but it is now used to evaluate aerobic capacity and survival in patients suffering from other *Address correspondence to Maria Isabel T.D. Correia, Alfa Institute of Gastroenterology, School of Medicine, Universidade Federal de Minas Gerais, Av. Alfredo Balena 110, sala 208, Zip code: 31270-901, Belo Horizonte, MG e Brazil. E-mail: isabel_correia@uol. com.br
ª 2014 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/14/$esee front matter http://dx.doi.org/10.1016/j.transproceed.2014.05.023
Transplantation Proceedings, 46, 1807e1808 (2014)
1807
1808
GARCIA, VENEROSO, SOARES ET AL
Table 1. Average Distance, Resting Energy Expenditure Before and After Training for Control Group (CG; n [ 6) and Liver Transplant Patient Exercise Group (EG, n [ 9) Group
Average distance (m) REE (kcal)
CG EG CG EG
Preexercise
516.5 453.6 1,393.0 1,060.0
62.0 128.0* 213.3 194.2†
Postexercise
517.7 582.5 1,465.0 1,375.0
71.9 90.1* 170.3 258.6†
*†Significantly different compared with the postexercise program with preexercise, for the same group. P .05. All results are presented as mean standard error.
diseases and who are undergoing a rehabilitation program [13] such as LTP [12]. The 6MWT is easy to perform, inexpensive, reproducible and safe [13]. The aim of this study was to investigate the effect of a physical exercise program on REE and functional capacity of liver transplant patients. PATIENTS AND METHODS This study has been approved by the Human Subjects Ethics Committee of the Universidade Federal de Minas Gerais (UFMG) (EC# 552.0.203.000/11). Fifteen LTP who underwent liver transplant surgery 6e12 months prior to the beginning of the study and were seen at the outpatient Bias Fortes Clinic - UFMG, participated in the study. The subjects were randomly divided into two groups. The Exercise Group (EG) (6 men and 3 women; 52 15 years), performed 24 sessions of continuous 30 min treadmill exercise. Intensity was increased from 50%e70% of the maximum heart rate over the training period. Another group (3 men and 3 women; 39 15 years) served as controls (CG). All subjects were evaluated for body mass index (BMI), distance walked in the 6-minute walk test (6MWT) and resting energy expenditure (REE). Body mass and height were measured using a mechanical scale and a stadiometer (Filizola, Sao Paulo, Brazil). The BMI was directly calculated from weight and height measurements (kg/m2) to characterize the sample. The 6MWT was used as an objective assessment of the subject’s exercise capacity and was expressed in meters. Patients were encouraged to walk as fast as they could on a flat and hard surface. The 6MWT was conducted according to the American Thoracic Society Statements: Guidelines for the Six-Minute Walk Test (2002) [13]. Oxygen saturation (SpO2) and heart rate (HR) were measured before and after the test. The calculation of theoretical expected walking distance and the values of the lower limit of normality were obtained according to the reference equations by Enright and Sherrill (1998) [14]. The REE was estimated from respiratory gas analysis performed using an indirect calorimetry, open circuit method (Quark RMR Gas Analyzer, Cosmed, Rome, Italy). The tests were always performed between 08:00 and 09:30 AM. Patients reported to the lab after a 12-hour fasting period. They remained awake in the recumbent position while the metabolic measurements were obtained. The gas analyzer was calibrated immediately before every test. Data were analyzed using an ANOVA 1-Way and the Tukey test as post-hoc (GraphPad Prism, Version 5.0). All results are presented as mean standard error. The significance level was set at P .05.
RESULTS
All patients from EG completed 24 sessions of aerobic training. The patients in the EG showed a 19.4% increase in the distance walked. There was no difference in the distance walked by the
CG (P > .05) (Table 1). There were significant differences in REE after the training period, during which the EG patients presented with an increase in REE (P .05). There was no difference in the REE of the CG (P > .05) (Table 1). DISCUSSION
The results of our study are in agreement with previous studies that reported beneficial effects of a supervised program of physical exercise for the rehabilitation of liver transplant patients. The current study showed that the intervention group patients significantly improved functional capacity and REE. These findings have positive implications in the control of metabolic diseases common in patients after liver transplant surgery. ACKNOWLEDGMENT We acknowledge the relevant contributions made by Prof. Dr. Emerson Silami Garcia who is supported by CAPES.
REFERENCES [1] Kolh HW, Craig CL, Lambert EV, et al. The pandemic of physical inactivity: global action for public health. Lancet 2012;380(9838):294e305. [2] US Department of Health and Human Services. Objectives 22-2 and 22-3. In: Healthy people 2010 (conference ed, in 2 vols). Washington, DC: US Department of Health and Human Services; 2000. Available at http://www.healthypeople.gov. [3] Painter P, Krasnoff J, Paul SM, et al. Physical activity and health-related quality of life in liver transplant recipients. Liver Transpl 2001;7:213e9. [4] Stephenson AL, Yoshida EM, Abboud RT, et al. Impaired exercise performance after successful liver transplantation. Transplantation 2001;72:1161e4. [5] Van Ginneken BT, Van Den Berg-Emons HJ, Metselaar HJ, et al. Effects of a rehabilitation programme on daily functioning, participation, health-related quality of life, anxiety and depression in liver transplant recipients. Disabil Rehabil 2010;32(25):2107e12. [6] Rongies W, Stepniewska S, Lewandowska M, et al. Physical activity long-term after liver transplantation yields better quality of life. Ann Transplant 2011;16(3):126e31. [7] Massala D, Mannocci A, Unim B, et al. Quality of life and physical activity in liver transplantation patients: Results of a casecontrol study in Italy. Transplant Proc 2012;44:1346e50. [8] Tomás MT, Santa-Clara H, Bruno PM, et al. The impact of exercise training on liver transplanted familial amyloidotic polyneuropathy (FAP) patients. Transplantation 2013;95:372e7. [9] Anastácio L, Ferreira LG, Lima AS, et al. Metabolic syndrome and its components after liver transplantation: incidence, prevalence, risk factors and implications. Clin Nutr (Edinb) 2010;29(2):175e9. [10] Ladevaia M, Giusto M, Giannelli V, et al. Metabolic syndrome and cardiovascular risk after liver transplantation: A singlecenter experience. Transplant Proc 2012;44:2005e6. [11] Iscar M, Montoliu MA, Ortega T, et al. Functional capacity before and after liver transplantation. Transplant Proc 2009;41:1014e5. [12] Foroncewicz B, Mucha K, Szparaga B, et al. Rehabilitation and 6-minute walk test after liver transplantation. Transplant Proc 2011;43:3021e4. [13] American Thoracic Society. ATS Statement. Guidelines for the six-minute walk test. Am J Respir Crit Care Med 2002;166:111e7. [14] Enrigh PL, Sherril DL. Reference equations for the sixminute walk in healthy adults. Am J Respir Crit Care Med 1998;158:1384e7.