aquatic exercise benefits in heart and kidney health · aquatic exercise benefits in heart and...

Aquatic Exercise Benefits in Heart and Kidney Health Bruce Becker, MD

A graduate of Tulane University School of Medicine, Dr. Becker completed his residency training in Physical Medicine and Rehabilitation at the University of Washington. Prior to moving to Spokane, He is a Clinical Professor in the Department of Rehabilitation Medicine at the University of Washington School of Medicine, and also serves as Research Professor at Washington State University, where he is Director of the National Aquatics and Sports Medicine Institute, pursuing physiologic research during aquatic activity. He has a major interest in aquatic rehabilitation, and is President of the American Society of Medical Hydrology. In 1997, Dr. Becker and Andrew Cole, MD co-authored the textbook Comprehensive Aquatic Therapy, which was also published in Portuguese and German. The second edition of the textbook was published in 2002, and a third edition was published in 2011 by Washington State University Press. He has authored chapters on aquatic therapy in most of the leading textbooks in rehabilitation, published aquatic research articles in numerous journals and lectured nationally and internationally in the area of aquatics. Dr. Becker has been honored by his peers every year from 1998 to the present through his selection to the Best Doctors in America: Physical Medicine & Rehabilitation listings. In 1999, the Aquatic Therapy and Rehabilitation Institute named Dr. Becker as Aquatic Professional of the Year at their annual meeting in San Diego. Aquatics International Magazine named him to the Power 25 in Aquatics in 2006 and again in 2011. He is to be inducted into the International Swimming Hall of Fame in May 2011 for his work in adapted aquatics. He is the recipient of major aquatic research grants from the National Swimming Pool Foundation.

Abstract Cardiovascular disease is one of the most prevalent chronic diseases in America and poses huge economic burdens on our health care system. Aquatic exercise produces physiologic effects that may be quite beneficial in this group of diseases, yet the effects of aquatic exercise are neither widely understood as valuable nor widely utilized. Many of the same physiologic effects that impact the cardiac system are potentially beneficial in the management of chronic kidney disease. There is a wealth of recent research supporting value for aquatic exercise that will be presented, with guidelines for the aquatic practitioner.

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AQUATIC EXERCISE IN HEART & KIDNEY DISEASE

Bruce E. Becker, MDResearch Professor

Director, National Aquatics & Sports Medicine InstituteWashington State University

Clinical ProfessorUniversity of Washington

[email protected]

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Cardiac Physiology Pulmonary Physiology

Renal Physiology Neurophysiology MSK Physiology

The Physics of H2O

Aquatic Forces & Physiology

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Normal Cardiac Function


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5

Cardiac Changes during immersion

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Cardiac outputincreases

Cardiac outputincreases

Water Immersion to chest or higherWater Immersion to chest or higher

Increased hydrostatic pressure

Increased hydrostatic pressure

Venous compressionVenous compression Lymphatic compressionLymphatic compression

Central bloodvolume increases

Central bloodvolume increases

Atrial pressurerises

Atrial pressurerises

Pulmonary Arterial Pressure rises

Pulmonary Arterial Pressure rises

Cardiac volumeincreases

Cardiac volumeincreases

Strokevolume increases

Strokevolume increases


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Vascular Pressures during Immersion

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CORONARY HEART DISEASE RISK FACTORS

• Low Maximal Aerobic Capacity (Cardiorespiratory fitness CRF)

• Increased Arterial Blood Pressure (both systolic & diastolic)

• Abnormal Blood Lipids and Lipoproteins

• Abnormal CHO Metabolism & Insulin Sensitivity

• Excessive Bodyweight and Fatness

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Impact of swimming on mortality risk in men

Cooper Institute Aerobics Center Longitudinal Study 1971-2003

Chase, Sui, Blair: Swimming and All-Cause Mortality Risk Compared With Running, Walking and Sedentary Habits in Men, IJARE, (2) 2008:213-2

Com

para

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Ris

k of

All-

Cau

se D

eath

11/5

62 M

ale

Sw

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ers

3,386 deaths during 543,330 man-years of exposure


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Maximal Aerobic Capacity

• Independent risk factor for cardiovascular and all-cause mortality

• More important than smoking, obesity, diabetes, high lipids & hypertension

• Low values associated with risk of disability, decreased cognitive function & quality of life

Cardiorespiratory Fitness (CRF)

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• Most studies show immersion to produce a transient reduction in BP and peripheral vascular resistance

• Regular aquatic exercise may decrease BP in hypertensive pts.

• Interestingly, a few studies have shown that regular swimmers show a slight elevation in both systolic and diastolic pressures (still within normal range)compared to land exercisers, and other studies have shown reduction in resting pressures

Blood Pressure Elevation

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Hypertension & Hot Tubs

Immersion period

Immersion time in minutes

Water temperature = 40° C

Shin, Wilson, Wilson; CMAJ, Dec 9, 2003; 169(12):1265-8


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• Dyslipidaemia has long been associated with development of coronary heart disease

• Regular exercise produces an increase in HDL-C and decrease in triglycerides

• Regular aquatic exercisers typically show lower total cholesterol and LDL-C levels, but there seems to be less effect upon HDL-C levels, unlike age-matched runners

Serum Lipids

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• Insulin resistance typically precedes Type 2 Diabetes

• Aquatic exercisers have shown increased insulin sensitivity and lower fasting insulin levels, even despite increased % body fat

• In Type 1 Diabetes, regular swimming has shown a reduction in hemoglobin A1c and reduction in glycosylated hemoglobin in Type 2 DM

• This suggests that regular aquatic exercise may have a beneficial effect upon glycemic control and reduce risk of diabetes

Carbohydrate metabolism and insulin sensitivity

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• Competitive swimmers have higher % body fat than competitive land endurance athletes. This is especially pronounced in ultra-endurance athletes

• Several studies have shown no significant effect upon weight or % body fat in longer term aquatic exercisers and swimmers

• Work in our lab at WSU showed comparable reduction in weight and % body fat in a cohort of aquatic exercisers compared to land exercisers over a 15 week exercise intervention

Body Weight and % Body Fat


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Comparative % of Overweight body mass

Chase, Sui, Blair: Comparison of the Health Aspects of Swimming with Other Types of Physical Activity and Sedentary Lifestyle Habits, IJARE, (2) 2008

322 15,206 2928 16,729118 4,218 1,522 4,660

BMI 25.0-29.9Cooper Institute Aerobics Center Longitudinal Study 1970-2005

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Relationship between % Max O2 Uptake Reserve, % Max HR & RPE

20 1006040 80% Maximal Heart Rate

20

100

60

40

80

% M

axim

al O

2U

ptak

e R

eser

ve

RPE

Very, very hard

Very hard

Hard

Somewhat hard

Fairly Light

Very Light

Very, very light 7

9

11

13

15

17

19

Threshold Intensity

0.5

12345

67

5

8910

1

2

3

4

5

Bor

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AC

SM

Bre

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n/W

ilde

r

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CRF and Aquatic Exercise• At similar intensity, duration and frequency water

exercise is equivalent to land exercise in CRF benefit, strength, lipid alterations, and body composition

• A 40-min. session of aquatic exercise can easily achieve a training intensity level sufficient to gain the health benefits of exercise (50-65% of Peak MET’s, 65-70% Max heart rate)

• Shallow and deep water exercise both can provide this benefit

• Interestingly, trained swimmers show increased CRF, but poorer treadmill performance than trained runners.


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Congestive Heart Failure

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Classification of Heart FailureNew York Heart Association

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Aquatic Therapy Effects on CHF

Tei & Tanaka, J Cardiol 1996:27:29-30

4 week therapy course

Neck depth immersion at 41° C (105.8° F)


22Cider A, Schaufelberger M, Sunnerhagen KS, Andersson B, Eu J Heart Failure 5 (2003) 527-535

25 pts with CHF (15 treated, 10 controls,) 8 weeks training at 3 times/week, 45 min/session at 40-70% HRR

Aquatic Exercise in CHF

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Cider A, Svealv BG, Tang MS, Eur J Heart Failure, 8:3, 308-313, 200

13 subjects, 13 controls, 33-34°C, in-pool echocardiography

Warm Water Immersion in CHF

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Swimming and the Cardiac Patient

• Swimming produces a highly variable exercise response

• Skill levels vary widely

• Upper body strength is critical, producing increasing cardiac demand

• Failure to identify symptoms of ischemia are worrisomely common

• Asymptomatic ischemia may lead to potentially dangerous arrhythmias

• Thus, swimming should be recommended with caution in the cardiac patient, esp. those with ST-depression & limited skills

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Immersion, Exercise and the CHF Patient

• For NYHA Class I, II and III candidates, an aquatic exercise program seems to be well tolerated and beneficial

• Precautions: recent infarct (<3 mo.), unstable rhythm disorders, uncompensated failure or active myocarditis

• Such programs can improve strength and endurance, reduce CHF symptoms, and QOL

• Many physicians are unaware of this potential benefit

Cardiac Physiology Pulmonary Physiology

Renal Physiology Neurophysiology MSK Physiology

The Physics of H2O

Aquatic Forces & Physiology


Renal Hormone Changes during Immersion

Epstein, Murray; Renal effects of head out immersion in humans: a 15-year update; Physiological Re

Ch

an

ge

s in

%

Renal Function during Immersion

Ch

an

ge

s in

%

Imm

ersi

on E

nd

Epstein, Physiol Rev 72:577, 1992

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AQUAtic Exercise Effects on Chronic Kidney disease

Pechter U, Ots M, Mesikepp S, et al. Beneficial effects of water-based exercise in patients with chronic kidney disease. Int J Rehabil Res. Jun 200

Vertical aquatic exercise 30 min/session twice weekly for 12 weeks in moderate CRF pts.


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• 9. Gabrielsen A, Bie P, Holstein-Rathlou NH, et al. Neuroendocrine and renal effects of intravascular volume expansion in compensated heart failure. Am J Physiol Regul Integr Comp Physiol. Aug 2001;281(2):R459-467.

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• 15. Kauppinen K. Sauna, shower, and ice water immersion. Physiological responses to brief exposures to heat, cool, and cold. Part II. Circulation. Arctic Med Res. 1989;48(2):64-74.

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• 17. Kurabayashi H, Machida I, Kubota K. Improvement in ejection fraction by hydrotherapy as rehabilitation in patients with chronic pulmonary emphysema. Physiother Res Int. 1998;3(4): 284-291.

• 18. Larsen AS, Johansen LB, Stadeager C, Warberg J, Christensen NJ, Norsk P. Volume-homeostatic mechanisms in humans during graded water immersion. J Appl Physiol. 1994;77(6):2832-2839.

• 19. Lollgen H, von Nieding G, Koppenhagen K, Kersting F, Just H. Hemodynamic response to graded water immersion. Klin Wochenschr. 1981;59(12):623-628.

• 20. Magder S, Linnarsson D, Gullstrand L. The effect of swimming on patients with ischemic heart disease. Circulation. May 1981;63(5):979-986.

• 21. McMurray RG FC, Avery KE, Sheps DS. Exercise Hemodynamics In Water and On Land In Patients With Coronary Artery Disease. Cardiopulmonary Rehabilitation. 1988;8:69.

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• 23. Meyer K, Bucking J. Exercise in heart failure: should aqua therapy and swimming be allowed? Med Sci Sports Exerc. Dec 2004;36(12):2017-2023.

• 24. Meyer K, Leblanc MC. Aquatic therapies in patients with compromised left ventricular function and heart failure. Clin Invest Med. 2008;31(2):E90-97.

• 25. Mussivand T, Alshaer H, Haddad H, et al. Thermal therapy: a viable adjunct in the treatment of heart failure? Congest Heart Fail. Jul-Aug 2008;14(4):180-186.

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• 30. Schmid JP, Noveanu M, Morger C, et al. Influence of water immersion, water gymnastics and swimming on cardiac output in patients with heart failure. Heart (British Cardiac Society). Jun 2007;93(6):722-727.

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Renal Bibliography1. Bichet DG, Groves BM, Schrier RW. Mechanisms of improvement of water and sodium excretion by immersion in decompensated cirrhotic patients. Kidney Int.

1983;24(6):788-794.

2. Cantin M, Genest J. The heart and the atrial natriuretic factor. Endocr Rev. 1985;6(2):107-127.

3. Cantin M, Genest J. The heart as an endocrine gland. Clin Invest Med. 1986;9(4):319-327.

4. Epstein M. Cardiovascular and renal effects of head-out water immersion in man: application of the model in the assessment of volume homeostasis. Circ Res. 1976;39(5):619-628.

5. Epstein M. Renal effects of head-out water immersion in humans: a 15-year update. Physiol Rev. 1992;72(3):563-621.

6. Epstein M, Levinson R, Loutzenhiser R. Effects of water immersion on renal hemodynamics in normal man. J Appl Physiol. 1976;41(2):230-233.

7. Epstein M, Lifschitz MD, Hoffman DS, Stein JH. Relationship between renal prostaglandin E and renal sodium handling during water immersion in normal man. Circ Res. 1979;45(1): 71-80.

8. Gabrielsen A, Bie P, Holstein-Rathlou NH, et al. Neuroendocrine and renal effects of intravascular volume expansion in compensated heart failure. Am J Physiol Regul Integr Comp Physiol. Aug 2001;281(2):R459-467.

9. Gauer OH, Henry JP, Behn C. The regulation of extracellular fluid volume. Annu Rev Physiol. 1970;32:547-595.

10.Goetz KL, Bond GC, Bloxham DD. Atrial receptors and renal function. Physiol Rev. 1975;55(2):157-205.

11.Grossman E, Goldstein DS, Hoffman A, Wacks IR, Epstein M. Effects of water immersion on sympathoadrenal and dopa-dopamine systems in humans. Am J Physiol. 1992;262(6 Pt 2):R993-999.

12. Jahn H, Schmitt R, Schohn D, Dale G. Hemodynamic modifications induced by head out water immersion in nonuremic and uremic subjects. Contrib Nephrol. 1984;41:189-198.

13.Larsen AS, Johansen LB, Stadeager C, Warberg J, Christensen NJ, Norsk P. Volume-homeostatic mechanisms in humans during graded water immersion. J Appl Physiol. 1994;77(6):2832-2839.

14.Norsk P, Bonde-Petersen F, Christensen NJ. Catecholamines, circulation, and the kidney during water immersion in humans. J Appl Physiol. 1990;69(2):479-484.

15.O'Hare JP, Heywood A, Summerhayes C, et al. Observations on the effect of immersion in Bath spa water. Br Med J (Clin Res Ed). 1985;291(6511):1747-1751.

16.Pechter U, Maaroos J, Mesikepp S, Veraksits A, Ots M. Regular low-intensity aquatic exercise improves cardio-respiratory functional capacity and reduces proteinuria in chronic renal failure patients. Nephrol Dial Transplant. Mar 2003;18(3):624-625.

17.Pechter U, Ots M, Mesikepp S, et al. Beneficial effects of water-based exercise in patients with chronic kidney disease. Int J Rehabil Res. Jun 2003;26(2):153-156.

18.Rim H, Yun YM, Lee KM, et al. Effect of physical exercise on renal response to head-out water immersion. Appl Human Sci. 1997;16(1):35-43.

19.Tajima F, Sagawa S, Iwamoto J, Miki K, Claybaugh JR, Shiraki K. Renal and endocrine responses in the elderly during head-out water immersion. Am J Physiol. 1988;254(6 Pt 2):R977-983.


aquatic exercise benefits in heart and kidney health · aquatic exercise benefits in heart and...

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