aquatic exercise benefits in heart and kidney health · aquatic exercise benefits in heart and...
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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
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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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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
tive
Ris
k of
All-
Cau
se D
eath
11/5
62 M
ale
Sw
imm
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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CORONARY HEART DISEASE RISK FACTORS
• 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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CORONARY HEART DISEASE RISK FACTORS
• 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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CORONARY HEART DISEASE RISK FACTORS
• 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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CORONARY HEART DISEASE RISK FACTORS
• 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
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Threshold Intensity
0.5
12345
67
5
8910
1
2
3
4
5
Bor
g
AC
SM
Bre
nne
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)
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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
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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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