Aims: Hydrotherapy, i.e. exercise in warmwater , as a rehabilitation program has been considered potentially dangerous in patients with chronic heart failure (CHF) due to the increased venous return caused by the hydrostatic pressure. However, hydrotherapy has advantages compared to conventional training. We studied the applicability of an exercise programme in a temperature-controlled swimming pool, with specific reference to exercise capacity, muscle function, quality of life and safety.
Methods and results: Twenty-five patients with CHF (NYHA II–III, age 72.1″6.1) were randomised into either 8 weeks of hydrotherapy (ns15), or into a control group (ns10). The training programwas well tolerated with no adverse events. Patients in the hydrotherapy group improved their maximal exercise capacity (q6.5 vs.y5.9 W, Ps0.001), isometric endurance in knee extension (q4 vs.y9 s, Ps0.01) together with an improvement in the performance of heel-lift (q4 vs. y3 n.o., Ps-0.01), shoulder abduction (q12 vs. y8 s, Ps0.01) and shoulder flexion (q6 vs. q4, Ps0.01) in comparison to patients in the control group.
Conclusion: Physical training in warm water was well tolerated and seems to improve exercise capacity as well as muscle function in small muscle groups in patients with CHF. This new approach broadens the variety of training regimes for older patients with CHF.
The European Journal of Heart Failure 5(2003)527535
1388-984203$ - see front matter2003 European Society of Cardiology. Published by Elsevier Science B.V. All rights reserved.
Hydrotherapya new approach to improve function in the older patient
with chronic heart failure
Asa Cider *, Maria Schaufelberger , Katharina Stibrant Sunnerhagen , Bert Anderssona,aba
Department of Cardiology, Institution for Community Medicine, The Sahlgrenska Academy at Goteborg University,a
Sahlgrenska University Hospital, Goteborg, Sweden
Department of Rehabilitation Medicine, Institution for Community Medicine, The Sahlgrenska Academy at Goteborg University,
Sahlgrenska University Hospital, Goteborg, Sweden
Received 15 April 2002; received in revised form9 December 2002; accepted 7 January 2003
Aims:Hydrotherapy, i.e. exercise in warmwater, as a rehabilitation programhas been considered potentially dangerous in
patients with chronic heart failure(CHF)due to the increased venous return caused by the hydrostatic pressure. However,
hydrotherapy has advantages compared to conventional training. We studied the applicability of an exercise programme in a
temperature-controlled swimming pool, with specific reference to exercise capacity, muscle function, quality of life and safety.
Methods and results:Twenty-five patients with CHF(NYHA IIIII, age 72.1"6.1)were randomised into either 8 weeks of
hydrotherapy(ns15), or into a control group(ns10). The training programwas well tolerated with no adverse events. Patients
in the hydrotherapy group improved their maximal exercise capacity(q6.5 vs.y5.9 W,Ps0.001), isometric endurance in knee
extension(q4 vs.y9s,Ps0.01)together with an improvement in the performance of heel-lift(q4 vs.y3 n.o.,Ps-0.01),
shoulder abduction(q12 vs.y8s,Ps0.01)and shoulder flexion(q6 vs.q4,Ps0.01)in comparison to patients in the
control group.Conclusion:Physical training in warm water was well tolerated and seems to improve exercise capacity as well as
muscle function in small muscle groups in patients with CHF. This new approach broadens the variety of training regimes for
older patients with CHF.
2003 European Society of Cardiology. Published by Elsevier Science B.V. All rights reserved.
Keywords:Exercise; Hydrotherapy; Water immersion; Elderly; Rehabilitation; Muscle function
A major problem for patients with chronic heart
failure(CHF)is their limited capacity to perform daily
activities. Conventional physical training, such as cycle
training or peripheral muscle training, has been found
to improve physical function and well being in these
. The prevalence of CHF increases with age
and the majority of patients 65 years or olderw
However, most previous studies have investigated the
effect of exercise in patients who are 65 years old or
. Further, elderly patients often have other
disabling diseases that diminish their ability to exercise.
For example, it may be difficult or impossible for a
*Corresponding author. Physiotherapy Department, SUySahlgren-
ska, S-413 45 Goteborg, Sweden. Tel.:q4631-3421195; fax:q
E-mail address:firstname.lastname@example.org(A. Cider).
patient with severe orthopaedic problems to cycle on an
Hydrotherapy, exercise in warmwater, is an alterna-
tive method of exercising since the buoyancy effect
reduces loading. Exercises to improve mobility, strength,
as well as cardiovascular fitness can easily be provided
. Immersion in warm water has been used
in bathing resorts in Europe in the beginning of the last
century to reduce heart failure symptoms and enhance
function and well being in patients with CHF. However,
it has recently been advocated that patients with CHF
should refrain fromexercise in water due to the
. Immersion in water to the
sternal notch causes an increased venous return resulting
in both cardiovascular and renal effectsw
. In healthy
people the thoracic blood volume, central venous pres-
sure, cardiac output, and diureses increases during water
. Vagal tone measured by power spectrum
528A. Cider et al. The European Journal of Heart Failure 5 (2003) 527535
Baseline characteristics of the 25 patients with chronic heart failure
Age(years)70.2"5.2 75"6.4 ns
Sex FyM5y11 3y6
Weight(kg)75"15 74"11 ns
Duration of CHF(years)5.3"2.6 6.0"5.2 ns
Etiology of CHF 12y2y1y0
NYHA class(IIyIII)3y12 1y9
Beta blockers(n)13 7
FyM, femaleymale; LVEF, left ventricular ejection fraction; NYHA New York Heart Association Classification, IHD, ischemic heart disease;
DCM, dilated cardiomyopathy; VD, valvular disease; HT, hypertension; ACE, angiotensin converting enzyme; nssP00.2.
. Neurohormonal effects of water
immersion, such as a decrease in renal sympathetic
activity, a reduction in angiotensin II and aldosterone
levels, and an increase in renin activity are also seen in
patients with CHF as well as healthy peoplew
temperature, water depth and the posture of the body
influence the physiological reactions to immersionw
Tei et al.w
assessed the effect of warmwater
immersion(418C swimming pool)and found an
improvement in hemodynamics in patients CHF. Water
immersion resulted in increased pre-load, ejection frac-
tion, stroke volume, and cardiac output, and decreased
Patients with CHF are suffering fromreduced quality
of life due to several factors; these include a decreased
physical function, dyspnea and fatiguew
studies have shown conflicting results, with improved
exercise capacity not always being associated with
improved quality of lifew
The purpose of this study was to assess the applica-
bility of an exercise programme in a temperate con-
trolled swimming pool in older patients with CHF. The
hypothesis was that training in warmwater could be a
feasible alternative of physical training for patients with
CHF, resulting in enhanced physical performance, mus-
cle function and quality of life.
Twenty-five patients(8 women)with stable CHF in
NYHA functional class II III, ejection fraction-45%,
and 60 years of age or older were recruited. Medication
for heart failure had to be stable for the previous 3
months. Exclusion criteria were diabetes, peripheral
arterial disease, chronic pulmonary disease and status
post stroke, or other disabling diseases that might inter-
fere with the exercise protocol. After baseline testing,
the patients were randomised, using a 2:1 ratio, in astratified order to 8 weeks of hydrotherapy(ns15),or
to a control period(ns10). The patients were stratified
according to age over 70 years, NYHA-class III and
female gender. Baseline characteristics of the study
population are given in Table 1. The study complied
with the declaration of Helsinki. The Ethics Committee
of Goteborg University approved the research protocol
and informed consent of the subjects was obtained.
2.2. Test procedures
2.2.1. Exercise tolerance
Ergometer exercise tests were conducted in an upright
position. A ramp protocol was utilised with a 10-W
increase every minute until exhaustion. Peak oxygen
Opeak)and peak carbon dioxide production2
(VCOpeak)was measured breath-by-breath using a V-2
max system(Sensor Medics, USA). Inspiratory flows
and expiratory oxygen(O)and carbon dioxide(CO)
concentrations were determined. All patients were fam-
iliarised with the test procedure through a submaximal
exercise test(13 on RPE-scale)1 week prior to the first
2.2.2. Six-minute walking test
A standardised 6-min walking testw
was used to
assess exercise capacity related to activities of daily
living. The patients were asked to walk as far as possible
during 6 min on a pre-marked 30-m walkway. Heart
rate was recorded using a Sport-tester(Polar Electro Oy,
Kempele, Finland). Perceived exertion and rate of dysp-
nea was rated using the Borg scalew
. The test was
carried out twice separated by1hofrestatthebaseline
test procedure. The value of the second test was used
in the study.
2.2.3. Muscle strength and endurance
For measurement of the torque, a KINetic COMmun-
icator II(Kin-Com)(Chattanooga Group Inc., P.O. Box
489, Hixson, TN), was used. This equipment is a
529 A. Cider et al. The European Journal of Heart Failure 5 (2003) 527535
hydraulically driven and microcomputer-controlled
device that operates in an isokinetic mode, i.e. an equal
speed and a perfect adjusted resistance through the
whole movement. The test was preceded by a 5-min
warm-up on a test bicycle. The subjects sat with a hip
angle of 908, and the tested leg was attached to the
lever arm of the dynamometer. The left and the right
leg were randomly tested first. Knee extension and
isometric strengths were measured at a 608-knee angle.
Isokinetic concentric and eccentric strength were meas-
ured at 60 and 1808ys for knee extensors for both legs.
Isometric endurance was measured on the right leg as
the time the person could keep 40% of his voluntary
maximum strength at 608-knee angle, with a follow-up
of 5 min to evaluate the recovery process with a
maximum voluntary isometric contraction every minute.
On the left leg, isokinetic endurance was evaluated as
the reduction of torque(in percent)between the first
and the last three extensions in a series of 50 maximal
contractions with an angle of 1808ys. Handgrip strength
was recorded using Grippit(AB Detector, Goteborg,
Sweden). The maximum grip force and the mean value
of the 10-s sustained grip was assessed. The test proce-
dures have been described previouslyw
, bilateral isometric shoulder abduc-
tion and unilateral isotonic shoulder flexion were also
measured as described in Appendix A.
2.2.4. Assessment of quality of life
Quality of life was measured using two instruments,
the Short Form-36 Health Survey Questionnaire(SF-
and the Minnesota living with heart failure
2.2.5. Training programme
The training programme comprised of 45-min sessions
in a heated pool(33348C), three times a week over
an 8-week period.
The patients trained as a group following a low to
moderate exercise level, i.e. 40 70% of maximal heart
rate reserve. The basis posture was standing with water
just below neck level. The exercise regime was designed
to include muscles utilised in activities of daily living
such as walking, dressing and household activities. The
programme focused on peripheral muscle training but
central circulatory exercises were also included. The
purpose was to improve aerobic capacity, peripheral
muscle strength and endurance. The physiotherapist used
music to facilitate the correct pace of exercise. A heart
rate recorder, Sport-tester(Polar Electro Oy, Kempele),
was used to monitor the intensity. Details of the exercise
programme are given in Appendix B. The control group
was instructed to live their life as normal for 8 weeks
and were not allowed to increase their habitual physical
activity during this period.2.2.6. Statistics
SPSS9.0 for Windows(Chicago, IL)was used
to analyse the data.
Ratio and interval data are given as mean("1 S.D.
or 95% CI)and ordinal data as median and range.
Wilcoxons rank sumtest was used for comparisons of
paired observations within each study-group. The
Mann Whitney U-test was used to assess differences
between groups. A sign rank test was used to compare
ordinal data. AP-value(0.01 was considered signifi-
cant as a method to correct for multiple comparisons.
An intension to treat design was used on all data, except
for the compliance rate in the exercise group.
The training programwas well tolerated, and there
were no serious adverse events. Three patients reported
mild fatigue after exercising during the first 2 weeks of
the training period. One patient who had a history of
paroxysmal artrial fibrillation had to finish the exercise
programme due to a new episode of arrhythmia. The
average adherence(total number of attended sessions)
was 95%. Heart rate reserve during training is presented
in Fig. 1.
3.1. Exercise tolerance
Patients in the hydrotherapy group showed a greater
improvement in their maximal exercise capacity(q6.5
vs.y5.9 W,Ps0.001), maximal oxygen uptake(q1.0
vs.y2.0 mlykgymin,Ps0.02)and 6-min walk test(q
29.7 vs.q6.3 m,Ps0.055)compared to the control
group(Fig. 2 and Table 2).
3.2. Muscle function
Patients in the hydrotherapy group significantly
improved their ability to perform heel-lift, shoulder
flexion and shoulder abduction(Fig. 3). There was also
a significant improvement in isometric endurance in
knee extension. There was no significant difference
between the two groups in isokinetic peak torque at
608ys and in isokinetic endurance in the right leg. There
were no other significant differences regarding isokinetic
and isometric strength in knee extension or in handgrip
3.3. Quality of life
Quality of life improved significantly within the
training group as measured by the total score and the
physical dimension of the LHFQ(Table 4). In SF-36
there was no significant improvement after 8 weeks of
training(Fig. 4). There were no statistically significant
530A. Cider et al. The European Journal of Heart Failure 5 (2003) 527535
Fig. 1. Average(CI 95%)heart rate reserve(%)during the training session(ns15)in the swimming pool.
Fig. 2. Changes in exercise performance achieved after training(*P(0.05, **P(0.01, within group comparison with baseline). Training group
(j)(ns15), and control group(h)(ns10).
This is the first study to demonstrate that hydrotherapy
can improve maximal performance as well as muscle
function in small muscle groups in patients with CHF.
Furthermore, the training programme was well tolerated
and associated with an improvement in quality of life.4.1. Adherence
The adherence was high. One patient was excluded
from the training programme because of an episode of
paroxysmal atrial fibrillation. As the patient had a
history of paroxysmal atrial fibrillation we do not believe
the water training was the cause of the tachycardia. The
531 A. Cider et al. The European Journal of Heart Failure 5 (2003) 527535
The effect on exercise capacity after training in water
BeforeAfterP-value withinP-value vs. the
the group control group
Exercise capacity(W)T84"23 91"24 0.01-0.001
C74"25 70"22 0.1
Oxygen uptake(mlykgymin)T 14.3"2.7 15.3"3.2 ns 0.02
C 14.3"3.0 12.5"2.7 0.1
Six-min walk(m)T 421"115 450"94 0.02 0.055
C 329"98 335"95 0.4
T, training group(ns15), C, control group(ns10),nssP00.2.
Fig. 3. Changes in muscle function achieved after training(*P(0.05, **P(0.01, within group comparison with baseline). Training group(j)
(ns15)and control group(h)(ns10).
patients enjoyed the training sessions and wished to
continue exercising in water after the study period was
over. Since exercise and physical activity improve func-
, it is of great importance that life long exercise
adherence be maintained. Long-term adherence appears
to be difficult to maintain without professional support
. Therefore, it could be beneficial to offer patients
a wider variety and more engaging training options.
Hydrotherapy is often a very well appreciated way of
exercising for older peoplew
4.2. Exercise capacity
In our study there was a 6% increase in peak V
the training group and a 16% decrease in peak VOin2
the control group. Several other studies have described
an increment of 10 30% in peak V
exercise on a level of 40 80% of VOpeak in patients2
. The explanation for this might be that we
included elderly patients in our study. A similar decrease
in peak V
Owas seen in another study with elderly2
. The improvement in the 6-min walk testwas comparable with several previous studies conducted
on land in patients with CHFw
4.3. Muscle function
The lack of improvement in knee extensors might be
explained by the difficulty to achieve enough resistance
in water to improve quadriceps strength and endurance.
The quadriceps muscle is a large muscle group and it
can be difficult to construct sufficient resistance for
such a large muscle group in water. This has also been
seen in patients with polio exercising in waterw
There was a significant improvement in isometric endur-
ance in knee extensors. This result is difficult to explain
since very few of the exercises were focusing on
isometric exercises. However, an increase in peripheral
vasodilatation would increase oxygen supply to the
skeletal muscles, which might facilitate this muscular
improvement. Our training programme focused both on
peripheral muscle training and on central circulatory
exercises in order to improve poor muscle function as
well as aerobic capacity. In a recent paper McKelvie
532A. Cider et al. The European Journal of Heart Failure 5 (2003) 527535
The effect on muscle function after training in warm water
Knee extension inBeforeAfterP-valueP-value
Kin-Comwithin the vs. the control
Peak torque T 133"39 134"39 ns 0.03
(608ysNm)right leg C 105"31 98"36 0.07
Peak torque T 138"44 137"41 ns ns
(608ysNm)left leg C 128"51 114"35 ns
Peak torque T 76"27 94"29 0.1 0.06
(1808ysNm)right leg C 76"25 73"26 ns
Peak torque T 90"27 94"29 ns ns
(1808ysNm)left leg C 72"24 79"25 ns
Endurance decline in % T 53"750"8 0.05 ns
of normal value left leg C 50"10 46"9 0.1
Peak torque T 151"50 153"51 ns ns
608(N)right leg C 119"41 117"41 ns
Peak torque T 158"54 163"54 0.09 ns
608(N)left leg C 128"31 140"47 ns
Endurance(s)T97"24 101"33 ns 0.01
right leg C 106"27 97"23-0.05
Peak force(N)T 315"96 328"92 0.1 ns
Right hand C 284"89 288"108 ns
Peak force(N)T 288"88 298"74 ns ns
Left hand C 269"90 283"105 ns
Clinical endurance tests
Shoulder flexion(n.o)T29"735"10-0.01 0.01
C31"18 35"24 ns
Shoulder abduction(s)T78"21 90"23 0.02 0.01
C71"23 63"16 0.09
T, training group(ns15); C, control group(ns10),nssP00.2; n.o, number of.
The effect on disease specific quality of life after training in warmwater
LHFQBeforeAfterP-value withinP-value vs. the
the group control group
Total score T 33.3"15.9 24.5"16.9 0.01 ns
C 32.7"21.7 27.8"16.8 0.1
Physical dimension T 15.0"5.1 10.6"6.4 0.01 ns
C 16.8"9.8 15.0"8.7 ns
Emotional dimension T 6.5"4.1 5.3"5.7 ns ns
C 6.0"6.2 5.1"5.0 ns
LHFQ, Minnesota living with heart failure questionnaire; T, training group(ns15); C, control group(ns10);nssP00.02.
advocated the combination of aerobic exercise and
peripheral muscle training to achieve optimal training
effects in patients with CHF. The decrease in ergometer
performance and muscle function tests in our control
group may be explained as a consequence of normal
disease progression in elderly patients andyor a random
error in a small study population.4.4. Quality of life
In our study we observed a significant improvement
in the total score and in the physical dimension of
LHFQ. According to the LHFQ, which is a disease
specific instrument, our patients physical function
improved. On the contrary, Owenw
could not show
533 A. Cider et al. The European Journal of Heart Failure 5 (2003) 527535
Fig. 4. The results of health related quality of life measured by SF-36. Training group(ns15)before(h)and after(j), control group(ns10)
before(3)and after(Y). Physical functioning(PF), role limitations due to physical problems(RP), bodily pain(BP), general health(GH),
energyyvitality(VT), social functioning(SF), role limitations due to emotional problems(RE), mental health(MH).
any improvement after 5 months of exercise in elderly
patients. Others have shown an improvement in SF-36
scores after an exercise programme on landw
conflicting results are probably attributable to small
4.5. Effects of warm water immersion
It might beneficial for patients with CHFw
hot water immersion is also associated with other effects
than increased pre-load, i.e. increased stroke volume,
cardiac index, ejection fraction, reduced peripheral resis-
tance, increased diuresis, as well as positive effects in
neurohormonal secretion. We have preliminary results
showing that water immersion at 33 348C induces an
increase in stroke volume, ejection fraction and cardiac
output in elderly patients with CHFw
on changes of stroke volume and cardiac output during
water immersion in healthy older persons are conflicting.
Small or absent increments have been reportedw
One report has compared hot water immersion with
sauna studying afterload reduction in patients with CHF.
Similar effects as we found were recorded in both the
healthy control group and the patients with CHF. How-
ever, the investigators used a very hot water temperature
. A change in renal and neurohormone
levels in both healthy subjects and in patients with CHFhas also been reported, as a result of water immersion.
The plasma concentration of antidiuretic hormone was
decreased and diuresis was increased during water
immersion to the sternal notch. Likewise, the concentra-
tion of renin, angiotensin II, aldosterone and the renal
sympathetic outflow were decreased by water immersion
In summary, the physiological reactions caused by
warm water immersion, resemble those used in modern
pharmacological treatment of CHF, except for the
increased pre-load. The reduced peripheral resistance in
combination with an increased cardiac function and
positive effects on the neurohormonal profile might
explain that water training in thermo-neutral water seems
to be a safe and effective exercise alternative for patients
4.6. Study limitations
Clinical muscle endurance testing has not been eval-
uated for reliability and validity in patients with CHF,
but similar tests have been evaluated in healthy people
and patients with rheumatic diseasesw
. Due to the
limited size of our study, the results could not be
generalised for all patients with CHF. Although we
randomised the patients and tried to stratify for age,
NYHA-class, gender and baseline function.
534A. Cider et al. The European Journal of Heart Failure 5 (2003) 527535
Physical training in warmwater was well tolerated
and seems to be associated with significant improvement
in exercise capacity and muscle function in small muscle
groups in patients with CHF. Hydrotherapy may be a
useful alternative for many elderly patients with CHF
and simultaneously other disorders that impede mobility.
Furthermore, our elderly patients might be more repre-
sentative of the general CHF population than many
This study was supported by Vardalstiftelsen VD-98,
Askers foundation, The Cardiac research found SUy
Sahlgrenska, Renee Eanders foundation, and Hjalmar
Svenssons foundation, LSR memorial foundation, and
Gustav V memorial foundation. We wish to express our
deep appreciation to Ms Marita Hedberg, BSc, for
assistance with the muscle function test, Ms Bente
Gruner Swealv and Margareta Scharin Tang, BSc, for
assistance with echocardiographic measurements.
Appendix A: Clinical muscle endurance test
Unilateral isotonic heel-lift.Touching the wall for
balance with the fingertips and the arms elevated to
shoulder height, the subjects performed a maximal heel-
lift on a 108tilted wedge, one lift every other second
using a metronome(Taktell Piccolo, West Germany).
The contra lateral foot was held slightly above the floor.
The number of maximal heel-rises was counted for each
Bilateral isometric shoulder abduction.The patients
sat comfortably on a stool with their back touching the
wall and with a 1-kg weight in each hand. They were
asked to elevate both shoulders in 908abduction and to
keep this position as long as possible.
The time the patients could keep the shoulders in 908
angle of abduction was recorded.
Unilateral isotonic shoulder flexion.The patients sat
comfortably on a stool with their back touching the wall
holding a weight(2 kg for women and 3 kg for men)
in the arm, which should be tested. The pace, 20
contractions per minute were held using a metronome.
The patient were asked to elevate one shoulder from0
to 908flexion as many times as possible.
Appendix B: Exercise programme
The exercise programme performed in warm water
for patients with heart failure. Music pace(beats per
Walking forwards, backwards and to the side with
increasing speed(108 bymin).
Walking and jogging in combination with arm
movements in alternating directions(120 bymin).
Flexibility and endurance training
Standing: bilateral arm movements in front of the
body drawing a lying eight. Arms stretched out
at surface in front of the body, shoulder extension
and flexion(60 bymin).
Arms stretched out at surface in abduction, small
fast abduction movements was performed with the
arms bilaterally. Elbows and upper arms held
towards thorax. Flexion movements with wrist
flexors and lower arms and then the opposite in
Jumps in place: contra lateral knee towards contra
lateral elbow. Body twisting with the arms working
under surface in the opposite direction. Jog in place
with high knees while swimming breaststrokes with
the arms(130 bymin).
Endurance and strength training
Eight exercises each performed for 2 min(60 by
Sitting: reciprocal knee flexion and extension
using a chair with water level to the sternal
Standing: unilateral knee extension and flexion
with a hip angle of approximately 458.
Standing: unilateral hip flexion and extension
(fast small movements).
Standing: reciprocal shoulder flexion and exten-
sion with paddles.
Standing: bilateral shoulder abduction(908)fast
small movements with weights.
Standing: reciprocal shoulder flexion and exten-
sion with floating weights.
Standing: bilateral elbow extension(upper arms
held towards thorax)with floating weights.
Standing: unilateral heel-lift with water level to
Jumps in place: contra lateral knee towards contra
lateral elbow. Bicycling forwards and backwards
with the legs in a supine position(120 bymin).
Jumps in place: ski jumps with reciprocal arm
movements. WalkingyJumping side to side(120
Stretching exercises for leg and armmuscles.
Supine position with floating devises and soft
535 A. Cider et al. The European Journal of Heart Failure 5 (2003) 527535
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