Indian Journal of Medical Specialities

: 2020  |  Volume : 11  |  Issue : 1  |  Page : 15--20

Effect of exercise training on dimensions of quality of life and fatigue in people with congestive heart failure class II and III: A randomized controlled trial

Ali Hasanpour-Dehkordi1, Mitra Yadollahi2, Shahriar Salehi Tali3, Reza Ghanei Gheshlagh4,  
1 Social Determinants of Health Research Center, School of Allied Medical Sciences, Shahrekord University of Medical Sciences, Sanandaj, Iran
2 Department of Operative Dentistry, School of Dentistry, Shahrekord University of Medical Sciences, Sanandaj, Iran
3 Department of Medical-Surgical, Nursing and Midwifery, Shahrekord University of Medical Sciences, Sanandaj, Iran
4 Department of Nursing, Faculty of Nursing and Midwifery, Kurdistan University of Medical Sciences, Sanandaj, Iran

Correspondence Address:
Dr. Ali Hasanpour-Dehkordi
Social Determinants of Health Research Center, School of Allied Medical Sciences, Shahrekord University of Medical sciences, Shahrekord


Background: Improved living conditions and increased life expectancy have led to aging in societies. Increased incidence of chronic heart disease is one of the most important economic, social, and health challenges of the 21st century. Aim: This study aimed to examine the effect of exercise training on dimensions of quality of life and mental status in people with congestive heart failure Class II and III. Materials and Methods: This study was carried out on patients with chronic heart failure. For this purpose, 52 eligible patients were chosen and randomly divided into case and control groups. The participants in the case group were asked to follow an exercise program three sessions per week in the morning for 24 weeks. This exercise program comprised 5–10 min of warming, 20–30 min of exercise, and 5 min of cool-down. Data were collected by the SF-36 questionnaire and analyzed by the SPSS version 18. Results: The results revealed that there was a significant difference in the mean score of various dimensions of quality of life including NYHA functional Classes II (P = 0.032) and III (P = 0.027), fatigue, BP, and general health in Classes II (P < 0.001) and III (P = 0.021) between the two groups before and after the intervention. Conclusion: Given that exercise leads to improvement of physical functioning, role-physical, role-emotional, social functioning, mental status, general health, and lower levels of fatigue and body pain in patients with congestive heart failure, it is recommended that patients incorporate regular exercise into their daily routines.

How to cite this article:
Hasanpour-Dehkordi A, Yadollahi M, Tali SS, Gheshlagh RG. Effect of exercise training on dimensions of quality of life and fatigue in people with congestive heart failure class II and III: A randomized controlled trial.Indian J Med Spec 2020;11:15-20

How to cite this URL:
Hasanpour-Dehkordi A, Yadollahi M, Tali SS, Gheshlagh RG. Effect of exercise training on dimensions of quality of life and fatigue in people with congestive heart failure class II and III: A randomized controlled trial. Indian J Med Spec [serial online] 2020 [cited 2021 Jan 28 ];11:15-20
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Full Text


Congestive heart failure (CHF) patients are at increased risk of hospital admissions and death, which can lead to numerous social and economic problems for patients, health-care systems, and society.[1] The prevalence of heart failure in Iran is 8%, which is higher than that reported from Asia and across the world, and the cost of the disease is estimated to be 400 billion rials per year which is alarming, so preventive measures should be taken to lower the costs.[2],[3] CHF leads to reduced muscle mass and strength as well as intolerance to exercise. CHF patients cannot fulfill their daily routines appropriately and depend on others. Furthermore, CHF adversely influences different aspects of quality of life (physical, psychological, social, well-being perception, and public health).[4] Dyspnea and fatigue can restrict their daily lives and result in exercise intolerance.[5] The general health conditions and quality of life in these patients could be changed by physical signs of psychological problems, food, drugs' side effects, and social constraints.[6] Hence, disease-associated challenges lead to seclusion and social loneliness in patients.[7] Moreover, the individuals undergo mental and psychological pressures and will face physical obstacles and finally repeated hospitalizations.[8],[9] Dyspnea and fatigue results in stress, anxiety, decrease of consciousness, poor general health, and quality of life.[10] Patients with heart failure can experience restrictions in doing daily activities such as walking and going shopping. Various measures have been taken in most experimental studies so far to control heart failure (reducing the frequency of hospitalization and addressing the physical, psychological, economic, and social problems of patients). There are many choices for controlling heart failure, one of which is exercise.[11] Prevalence of heart failure is increasing, and it adversely impacts on the public health. Nowadays, attention to physical activity in these patients is very important therefore, the present study was conducted to investigate the Impact of exercise training on dimensions of quality of life and the level of fatigue in patients with CHF Class II and III coming to hospital affiliated to Shahrekord University of Medical Sciences at the southwest of Iran.

 Materials and Methods

Design and sample

Ethical approval (Code No. 85-9-1) was obtained from the Ethics Committee of the University and the study protocol was registered as IRCT201306251376831 in the Iranian Registry of Clinical Trials by Clinical Research Center of Iran's Ministry of Health and Medical Education. This clinical trial was performed after the necessary approval was obtained from the Deputy of Research and Technology of Shahrekord University of Medical Sciences, Iran. In view of the previous studies and by the formula of sample size calculation, the needed sample size for this study was calculated at 52 individuals who were selected by the convenience sampling method. Of these, 12 were in CHF Class II and 40 were in CHF Class III. Then, based on random allocation rule, the participants were randomly divided into case (Class II and III) and control (Class II and III) groups. Written consent form was obtained from all patients for participation in the study.

Inclusion criteria

The inclusion criteria included patients suffering from chronic heart disease, age of 60 ± 5 years, volunteering to participate in the study, as well as the diagnosis of congestive heart failure by a cardiologist, clinical symptoms, echocardiography, left ventricular ejection fraction ≤40%, the ability to do the exercise in question after pharmacotherapy, the physician's approval, lack of other chronic diseases (rheumatoid arthritis, fractures, etc.), as well as lack of traveling and heart transplantation until 3 months after the exercise program.

Class II

Heart rate abnormality (tachycardia), jugular venous elevation, lung crackles, wheezing, and third heart sound.

Class III

Alveolar pulmonary edema, interstitial pulmonary edema, bilateral pleural effusion, and cardiothoracic ratio higher than 0.50.

Exclusion criteria

The exclusion criteria included coronary artery bypass surgery during the study, withdrawing from the study at any stage of this study, and percutaneous transluminal coronary angioplasty/coronary artery bypass grafting surgery in the previous year.

Exercise was performed three sessions per week for 24 weeks, for 40 min in the morning consisting of 5–10 min of warm-up, 25–30 min of exercise (walking), and 5 min of cool-down for the experimental group. Aerobic exercise was done by trained personnel in the sports facilities or gyms in the hospitals affiliated with Shahrekord University of Medical Sciences under the supervision of nursing and medical teams. Exercise continued until the heart rate reached 60% of heart rate reserve. At the completion of the sixth session, exercise (walking) duration increased to 30–35 min and heart rate to 70% of heart rate reserve. Each patient exercised based on his/her resistance and ability. Exercising was stopped when patients felt physically tired or had severe dyspnea, fatigue, dizziness, or other issues that might endanger their health with reference to Rhoten Fatigue Scale. To assess the reproducibility of gas exchange parameters, the cardiopulmonary test was carried out 3–5 days before starting the protocol for all patients again to serve as baseline. The evaluation was also repeated at the completion of the research. Furthermore, the patients' blood pressure and heart rates were frequently measured before and after the study. Patients in the control group were given educational support, but no exercise protocol was administered. Nevertheless, patients in both the groups received their medications as prescribed by the cardiologist.


The quality of life questionnaire (SF-36), the demographic questionnaire, and echocardiography were used to collect the data. To determine the patients' quality of life, Persian version of the SF-36 was used to assess physical functioning, role limitations because of physical problems, role limitations because of emotional problems, social condition, physical pain, energy, vitality, mental health, and general health in the elderly with cardiac diseases. Validity and reliability of the Persian version of this questionnaire had already been confirmed.[12] Questionnaires were completed by all patients, and vital signs and echocardiography parameters were recorded by a nurse at baseline and 24 weeks after the completion of the study. The patients' fatigue was measured by visual analog scale, which is a 10-point Likert scale in which 1 represents energetic (no fatigue), 5 does moderate fatigue, and 10 does severe fatigue.

Data analysis

Statistical analysis was performed using independent t test, student t test and ANOVA. Significance level was considered at <0.05. data are presented as mean± standard deviation.


Demographic data and functional variables in the two groups are summarized in [Table 1]. Most of the patients were male, retired, or unemployed. At baseline, no significant difference was observed in blood pressure, pulse, physical functioning, role-physical, role-emotional, social functional, mental status, general health, fatigue level, and body pain between the two groups.{Table 1}

Although the findings indicated that in different functional classes (II and III), there was no change in physical functioning in the control group, bodily pain and fatigue increased significantly, and all other parameters worsened significantly. However, in cases (intervention group), bodily pain and fatigue decreased significantly, and all other parameters improved significantly [Table 2].{Table 2}

Besides, the results indicated that blood pressure and pulse increased significantly and general health declined significantly in the control group, but in the case group, blood pressure and pulse decreased significantly and general health increased significantly.


The present study results indicated that in the case group, the fatigue level in different functional classes of CHF (II and III) decreased after the intervention compared to that in the control group. Our results also determined that exercise could reduce the severity of fatigue and increase the tolerance of physical activity in patients with pulmonary arterial hypertension. This indicates the potential importance of physical exercises as a complementary therapy. The aerobic exercises used in this study are often recommended or prescribed to the general population.[13] In addition, our findings showed that the patients' physical functioning enhanced after exercise, so that they were able to do their daily activities comparably more easily. The results of other studies indicate that regular and continuous physical activities increase social communication, self-satisfaction and satisfaction with others, sexual relations, and relationships with friends.[14] The findings in this study indicated that exercise training led to an improvement of role-physical and role-emotional status among patients, so that they expressed their feelings more easily, communicated with others, experienced less loneliness and isolation, and generally developed a good rapport with others.[15] In this study, the patients in the experimental group had better social functioning and energy as compared with the control group. In other words, the exercise enhanced self-esteem, freshness, and vitality and improved mental conditions in the patients. In agreement with the findings of the present study, the results of some studies indicate that regular and continuous physical activities increase social communication, self-satisfaction and satisfaction with others, sexual relations, and relationships with friends.[16],[17],[18],[19] After the study, the mean score of physical pain in different functional classes of CHF was significantly different between the case and control groups. Consistent with the present study, the findings of other studies have revealed that pain intensity decreases after exercise.[20] Furthermore, the results have shown that there is no statistically significant difference in depression between the two groups.[21],[22] Symptoms of CHF overlap with depression and often make it possible to detect the latter. Both CHF and depression are characterized by fatigue, loss of energy, low appetite, sleep disturbance, mental retardation, and lack of concentration. Symptoms of depression may be present in 85% of patients with CHF. In addition, major clinical depression was found in 26% of cases that is significantly higher than the general population's depression levels (2.1%).[23] In this study, the findings indicated that exercise training led to a significant increase in the scores of all aspects of quality of life in different functional classes of CHF in the case group compared with the control groups, so that it was higher in Class I than Class II, whereas in the control group, quality of life decreased in most dimensions, especially in Class II.

Furthermore, previous studies revealed that exercise training improved health and different dimensions of quality of life.[24],[25] Georgiou et al. showed that exercise training had a significant impact on the decrease of length of hospital stay and consequently hospital costs and physician referral. In addition, exercise training causes improvement of health and increase in longevity.[26] Another study revealed that exercise training lowered mortality, the length of hospital stay, and readmission in patients with fibrillation and cardiac arrhythmias in health-care centers.[27] Moreover, research findings show that exercise training causes enhancement of cardiac output without additional charge to the pulmonary arteries. The results of one study showed that exercise training significantly increased physical functioning, reduced feeling of inability, increased left ventricular ejection fraction, enhanced exercise training tolerance, and promoted quality of life and health.[11] The current study revealed that exercise training reduced systolic and diastolic pressure and pulse rate in patients with CHF Class II and III. The results of another study indicated that the heart receive more oxygen following exercising and therefore cardiac output increased in the case group. However, in the control group, no significant change was observed in the results.[28] The results of some studies have shown that there is a direct correlation between the quality of life dimensions and pain and fatigue, so that pain, emotional distress, and fatigue deteriorate all dimensions of quality of life.[29],[30]

Chronic diseases seriously affect individuals' overall health and quality of life.[31] Exercise is not suitable for all cases of heart failure, and before the start of the exercise, patients must be examined by a physician to be allowed to do exercise.[17],[22] Any variations in the lifestyles of patients with heart failure or changes in their physical activities should be made under the direct guidance of a nurse or a cardiologist; otherwise, it results in physical damage or deterioration of the patients' health.

Peak training capacity, measured by VO2 peak, is the best predictor of survival in patients with CHF. Increased performance in these patients is associated with improved quality of life and may also improve with the prognosis. Therefore, exercise programs designed to improve capacity in patients with CHF should specifically target functional capacity limitations in these patients.[32] The optimal exercise dose is needed to decrease disease-related symptoms. Effective strategies for self-efficacy of chronic diseases include developing relationships with a provider, maintaining positive attitudes, and having a supporting person. Problem-solving and critical thinking with health-care providers help patients manage a chronic illness that requires various day-to-day decisions for optimal disease control.[33],[34]


Our results revealed that quality of life was adversely affected by congestive heart failure. Given that exercise training leads to improvement of physical functioning, role-physical, role-emotional, social functioning, mental status, general health, and lower levels of fatigue and body pain, it is recommended that regular exercise be incorporated into the daily routines of elderly patients.

Limitation of the study

Our results were obtained in controlled conditions, and therefore, unsupervised exercise program should not be advised according to these results.

Financial support and sponsorship

This research was funded by the Deputy of Research and Technology of Shahrekord University of Medical Sciences.

Conflicts of interest

There are no conflicts of interest.


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