Effects of Tai Chi on Symptoms Effects of Tai Chi on Symptoms of Depression and Fatigue in of Depression and Fatigue in
Heart Failure PatientsHeart Failure Patients
Laura S. Redwine, Suzi Hong, Sarah Linke, Stephanie Cammarata, Ines Pandzic,
and Paul J. Mills
Holistic MedicineChinese philosophical tradition
contains a strong preventive element linked to balance: between humankind and nature, and between mind and body (Zhou, 1983).
A sound mind in a sound body is essential to longevity
Origins of Tai Chi
• Around 500 A.D. Indian Buddhist monk Bodhidarma developed Shaolin boxing to strengthen the monks at the monastery in Honan who were weakened by long hours of meditation and physical neglect
• Martial skills were also needed to protect the monks who sometimes came under attack in the remote mountains
End of the Sung Dynasty (960-1278 A.D.) Chang San-feng applied the concepts of Yin-Yang, proper breathing, and Taoist philosophy to Shaolin boxing.
Of the five animals; tiger, dragon, leopard, snake, and crane, the movements of the snake and crane are most able to overcome strong and unyielding opponents. Flexibility and suppleness in place of strength.
Roll Back
The practice of Tai Chi teaches us that by yielding we can overcome forceful attacks.
Low impact, mindfully meditative movements with integrated breathing techniques that generate an aerobic work-out
The level of intensity is adjustable by using larger or smaller movements.
Many tai chi interventions, have been examined specifically for elderly and frail individuals
Characteristics of Tai Chi
Tai chi serves as an aerobic exercise of moderate intensity
in older adults
• HR generally increases by 55% to 70% of maximum when adjusted to age
• Increased oxygen consumption and lactate accumulation in older adults
At 109-years-old, one of the China's oldest men Lu Zijing from central China's Hubei Province demonstrates Tai-Chi in Hong Kong. December 3, 2001 (Kin Cheung / Reuters)
Tai chi Benefits in Older Adults
• 30% higher VO2 peak and work rate – bicycle ergometry
• Reduced blood pressure, cholesterol and age-related decline of venous compliance
• Reduced SNS activity: acute pre-ejection fraction (estimate of SNS-driven myocardial contractility time)
• Increased apparent parasympathetic activity
Tai Chi and Quality of Life Older adults -
– Increases emotional well-being and self-efficacy– More vigorous and less tension, depression,
anger and fatigue– Improved functional status: such as walking,
posture control capacity and reductions in falls
Tai Chi and HFYeh et al, (2004; 2007), (N = 15/group) -
improvements in:– Physical function, 6 min walk – Quality of life (KCCQ)– Sleep (PSQI)– HF severity BNP
• Barrow et al, (2007) (N = 25/group) improvements in quality of life and emotional well-being (POMS)
Chronic Heart Failure
Heart failure (HF) affects 5-6 million Heart failure (HF) affects 5-6 million Americans and is increasing in Americans and is increasing in
epidemic proportions as the epidemic proportions as the population agespopulation ages
What is HF? A progressive condition: heart muscle
becomes weaker and gradually loses the ability to pump enough blood. Blood, water, and other fluids build up in tissues, veins, and organs, causing congestion and damage.
NHLBI
Comorbid depressive disordersComorbid depressive disorders are are present in up to 40% of patients present in up to 40% of patients with HFwith HF (Jiang et al, 2004; Norra et al. et al, 2008)(Jiang et al, 2004; Norra et al. et al, 2008)..
Cardiac Rehospitalization and/or Death
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yes no
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Depression Symptoms and Morbidity/Mortality in HF
Somatic symptoms of depression such as fatigue and sleep disturbances are common in HF patients
May lead to physical inactivity and a spiraling decline in physical and cardiac function (Whooley et al, 2007).
.0111.39 (1.08-1.79)
.089.81 (.64-1.03)Ancillary adjusted multivariate analysis**
<.0011.63 (1.28-2.08)
.258.87 (.68-1.11)Adjusted multivariate analysis (CAD)*
<.0011.71 (1.36-2.14)
.068.79 (.62-1.02)Unadjusted multivariate analysis
pHR (95% C I)
pHR (95% C I)C ardiovascular prognosis
S omatic/Affective
C ognitive/Affective
S ymptom Dimension from Two-Factor Model
Measure
Depressive Symptom Dimensions and Cardiovascular Prognosis in Women with Myocardial Ischemia.
NHLBI-Sponsored WISE Study (Linke et al, 2009 – in press, Arch Gen Psychiatry)
Depression and InflammationHeart Failure
High inflammation levels
Fatigue and sickness behavior
Depression symptoms
Morbidity and Mortality
Reduced physical/ social activities
(e.g. Dantzer; A. Miller)
Immune Activation in HF
Celis et al, 2008
Cizza et al, 2008 Biological Psychiatry
Inflammation and Exercise
• Aerobic exercise training in C AD patients- reduction in inflammatory factors – C RP, IL-1 , IL-6, INF levels, and increase in IL-
1 0 (Goldhammer, 2005)
• Regular exercise induces anti-inflammatory effects – elevated levels of anti-inflammatory cytokines
and suppression of TNF-α production (Petersen and Pedersen, 2006)
Although HF produces debilitating symptoms and loss of quality of
life, until recently there have been few behavioral
interventions
Medicare states: “the evidence on the benefits for congestive heart failure is not sufficient for coverage expansion for cardiac rehabilitation for these patients.”
Standard Exercise and HF
Historically HF patients were counseled to limit physical activities.
Whereas recent studies have shown moderate exercise can be performed safely in properly evaluated NYHA II-III HF patients (McKelvie et al, 2008).
HF-ACTION (N = 2331) (O’Connor et al, 2009):
• Possibly reduced morbidity and mortality– Exercise studies in HF have been conducted
on relatively young patients (e.g. average age of 59 in HF-ACTION) with little comorbidity.
• Also, for home-exercise walking less than half of HF patients are eligible for the study (Jolly et al, 2007).
Determine if tai chi vs usual care reduces symptoms of depression
and fatigue in HF patients?
Determine if there are concomitant alterations in pro-inflammatory
cytokines
Objectives:
Methods
• 40 HF patients (37-81 years; mean age=58.8, SD=4.2) – tai chi (n = 15), standard exercise (n = 10), usual
care (n = 15)• Beck Depression Inventory (BDI): sub scales
Cognitive/affective and Somatic/affective • Fatigue (MFSI)• Intracellular expression of cytokines measured
pre- and post- intervention
BDI Scores pre- to post- Intervention (N = 15/group)
(F(1,29)=4.8, p = .036) BDI at Time 1 range = 0-31
Subjects with BDI scores > 10 (N = 6/group)
(F(1,11)=14.4, p = .001)
HF Patients with BDI >10• Reduced BDI scores of an average of 30%
in tai chi group. – Thirty-eight percent (38%) of tai chi
participants and none of the controls improved by at least one SD.
• Control subjects had an average increase in BDI scores of 25% – further evidence that subclinical depression
should be treated because of a greater risk of developing MDD at one year
F(1,29)= 4.9, p = .037
Somatic Symptoms of Depression and Tai Chi
• Somatic symptoms of depression in HF– Friedman Test: rank order of 21 BDI items
for baseline BDI scores; fatigue, and effort required to perform work = top two items ranked
• 33% of tai chi and none of control subjects improved by at least one SD in BDI somatic symptom scores
(F(1, 28) = 4.2, p =.05)
Tai Chi Affects on Fatigue and Depression
∆ MFSI physical fatigue (beta = .510, p = .027) and ∆ MFSI mental fatigue (beta = .588, p = .019)
associated with changes in total BDI scores.
– Tai chi may improve quality of life by improving somatic symptoms of depression.
(1, 27) = 6.9, p = .01 for IL-10 n.s. for IFN gamma, and IFN/IL-10 ratio
Tai Chi and Standard Exercise: IL-10 expression
Tai Chi, Standard Exercise, Usual Care and IL-10
• Tai chi training is associated with an increase in anti-inflammatory cytokine stimulation.
• Increases in IL-10 with exercise including tai chi may reduce pro-inflammatiory activity and lead to reduced HF disease progression.
Summary• Tai chi training was assoc with reduced
depression symptoms.– Of clinical interest for HF pts > 10 BDI
• Somatic symptoms, particularly fatigue appear to be a major component of depression symptoms in HF patients
• Tai Chi reduced somatic symptoms of depression and fatigue measures
• Tai chi and exercise were assoc with increased anti-inflammatory cytokine IL-10
Limitations• Too small a sample size to differentiate
tai chi from standard exercise for depression symptoms.
• No attention control condition.
• No measure used to determine distinguishing characteristics between tai chi and standard exercise.– E.g. Mindfulness questionnaires
Future Directions
• Echocardiogram, and other standard measures used in HF trials
• Longer follow-up• Look at larger cohort of older adults with
HF• Delineate differences between standard
exercise and tai chi
