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PTJ Physio Therapy and Rehabilitation Journal

Abstract sections: Objective, Methods, Results, Conclusions, Impact Statement

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Sections within the manuscript: Introduction, Methods (include subsection “Role of the Funding Source” to specify any roles played by the funders, or add the statement “The funders played no role in the design, conduct, or reporting of this study”), Results, Discussion (include subsection “Limitations”).

Tables/figures: No more than 6 (combined total); additional tables and figures can be provided as supplemental material.

Effects of a Twelve-Week Aerobic Exercise on Functional Work Capacity in HIV Positive Clients on Antiretroviral Therapy at GMH-Bombo Hospital in Uganda

Mwebaze Nicholas¹, Constance A.N. Nsibambi², Edward Ojuka³, Mshilla Maghanga⁴

¹Programme Officer – Quality Improvement, UPDF, Ph.D. Candidate, Kyambogo University

²Department of Sport science, Kyambogo University, Kampala, Uganda (Assc Prof)

³Department of Physiology, Lira University, Lira Uganda (Assc Prof)

⁴Faculty of Business & Development Studies, Gulu University, Gulu City Uganda

Corresponding Author

Mwebaze Nicholas

Faculty of Sports Science, Kyambogo University

Tel: +256-772924070

nicmwebazeru@yahoo.com

Abstract

Objective

Methods

A quasi-experimental study was conducted among HIV positive clients who had been on treatment for at least 12 months. Volunteers were randomly assigned to: a control group (Group 1), where no treatment was administered, and an experimental group (Group 2), where a twelve weeks moderate intensity aerobic exercise was administered. Both groups were assessed using a physical activity readiness questionnaire (PAR-Q). Thereafter, assessment of functional work capacity. After the12 weeks of intervention a post-test was done.

Results

The results also indicate that there was a lowered heart rate for the experimental group in post-test compared to control group with a significant difference between the mean of the post-test to the pre-test of -3.222 (2.53 – 5.76) compared to that of the control group of only 0.21 (5.51 – 5.30). with a P-value of < 0.001 showing a significant improvement in functional work capacity

Conclusion

Impact Statement

Introduction

HIV has in the recent decades been a worldwide epidemiological priority with about 34 million people living with HIV and 2.5 million of them have developed clinical symptoms of the disease. With some regional differences, HIV prevalence in Uganda is more than 1.5 people, (Yebra et al. 2015)

Although prevention is known as the greatest solutions for reducing the incidence of HIV, for those who are infected already, antiretroviral therapy (ART) has become a widespread intervention, and because of its success has transformed the condition from fetal to chronic disease. However, there are collateral things that affect the quality of life of patients, together with metabolic, somatic and psychological disorders, (Mangona et al. 2015).

Some of the ways to deal with the direct effects of HIV and the secondary effects of ART exercise has been shown to provide many health benefits, starting from increased aerobic capacity to mood improvement. It is expected that people with HIV can reap some of the benefits of exercise, as the general population O’Brien et al 2016. For example, in a meta-analysis by O’Brien et al., (2016), it a showed a significant improvement in change of VO2max of 2.63ml/kg/min for those who participated in the aerobic exercises compared to none-exercising control group, a significant improvement in VO2max of 2.40 ml/kg/min for participants in the constant aerobic exercise group compared with the control group. For participants who were on ART also posted a significant improvement in cardiorespiratory status (maximum oxygen consumption and exercise time). Panagiota et al. 2022 accessed the impact of supervised aerobic execise on clinical physiological and mental parameters of people living with HIV, improved lung function was noted and a heterogeneity concerning VO2max.

The Duke Activity Status Index (DASI), which was created by Ravani, et al. (2012) as a quick and low-cost substitute for VO₂max, measures a person’s capacity for exercise by asking twelve (12) questions about their ability to undertake activities of daily living. Participants in the DASI were expected to select “yes” or “no” for each question. The DASI score is calculated by multiplying the total number of “yes” replies by 0.43, adding 9.6, and calculating the estimated maximum oxygen consumption (VO₂max) with 81% reliability. There is a range of 0 to 58.2 points in the final score. The functional capacity scores improve with higher scores (Tolulope et al 2021). Ferguson and Shulman (2021) found a weak connection between peak VO₂max and the DASI score. The DASI’s predictive power for a peak VO₂ > 15 mL/kg/min is moderate. Four or five questions in a condensed, modified version of the DASI questionnaire (m-DASI) may be sufficient to identify patients with at least modest functional capacity.

The DASI has criterion validity of 0.34 when associated with measured VO₂peak, indicating that it can predict functional capacity in individuals with chronic obstructive pulmonary disease. A small number of studies suggest that there is a moderate link between the VO₂ peak and the DASI in the perioperative context (Riedel et al., 2021). When measuring a patient’s functional capacity for heart failure, DASI scores also showed a strong correlation with peak oxygen uptake (Grodin et al., 2015). In this study the DASI score was associated with improved functional work capacity if the score increases it indicates improvement. Specifically, DASI was used to triangulate the results of functional work capacity in HIV positive people got where RPE was used with an assumption that improvement in oxygen uptake VO₂max will mean improvement functional work capacity.

Methods (Include Role of funding of this study)

Research Design

A quasi-experimental research design was used in the study. Quasi-experimental study designs, often known as nonrandomized, pre-post intervention studies, are widely utilized in the medical informatics field (Harris et al., 2006). This is different from experimental design because; experimental design has a high level of controls over the variables. While quasi experimental lacks the same controls and random assignments because often cannot assign participants randomly due to ethical or practical constraints. Like in this case HIV positive clients that may have stigma and need to incur some costs to come to the facility daily for exercises.

This study design consists of studying the experimental and control samples at two different points in time in order to establish change in a phenomenon or variables in order to establish the impact of an intervention (Estrada & Ferrer, 2019). Using one or more experimental variables is what this is all about (Seel and Nobert, 2012). This design provided an opportunity for the variables to be measured at the start of the study and after subjecting the experimental group to a twelve weeks’ aerobic exercise. All groups were given a pre-test, the experimental group underwent aerobic exercise, and there was no treatment given to the control group at all just a follow-up call to ensure they didn’t feel abandoned. After that, each group received a post-test. This provided an opportunity to determine the clinical effects of aerobic exercise on immune markers, psychological indicators, and the ability of HIV-positive clients receiving ART to perform their jobs.

To measure the effect of the independent variable (IV) on the dependent variable (DV), the same manipulations as in a real experiment were made. There was a control group, though, and the participants were assigned at random only after being chosen for the study through volunteerism and purposeful selection. The participants were selected according to particularly required characteristics like being on treatment for 12 months or more and being adults who can commit time to participate in the exercise this was necessary in the research situation (Martínez-Mesa & González-Chica, 2016). The age group was selected considering the nature of the participants being HIV positive clients with stigma and the transport cost involved to come to the facility at least three times a week.

3.2 Location of the Study

The study was conducted at General Military Hospital (GMH) Bombo in Nyimbwa sub-county in Luwero District, central Uganda which is 33.8 kilometre (kms) (21miles) from Kampala the capital city of Uganda. The district is located between latitudes 20 north of the equator and east between 320 and 330, to the north of Kampala. The Luwero district encompasses an area of roughly 2577.49 square kilometres.  The district is bounded to the south by Mukono and Wakiso, to the west by Nakaseke, to the north by Nakasongola, and to the east by Kayunga District. The hospital is situated in Bombo Town Council, on the grounds of Bombo Military Barracks, the Land Forces of the UPDF’s headquarters. It is roughly 32 kilometres north by road of Mulago National Referral Hospital. Bombo Military Hospital’s coordinates are 0°35’11.0″N, 32°32’10.0″E (a longitude: 32.536111; latitude: 0.586389). Approximately 800 meters separate the facility from the Mile 21 Trading Center when one branches right at the Bombo Army Secondary School signpost. The hospital is a military facility that provides referral services to the UPDF’s several medical units. Yet, the hospital treats residents of the surrounding areas due to the great need in those communities.

3.3 Target Population

The target population consisted of General Military Hospital-Bombo individuals who were HIV positive especially those who were 20 years of age or older, male or female, and receiving treatment for at least a year. Of the 4150 patients undergoing ART treatment at GMH, that client category made up the bulk (DHIS2, 2019). The age range was chosen based on the presumption that most of the participants were adults who could dedicate time for the aerobic exercise sessions and were not enrolled in school.

3.4 Sampling Procedure and Sample Size

3.4.1 Study sample size

After health education sessions that took more than six months about the study, out of 4150 clients 3300 met the inclusion criteria and 135 volunteers were willing participants in the study as per the defined criteria and were enrolled. This gave an adequate sample as compared with Yemen’s formula of determining the sample size using a level of confidence of 10%. The formula is defined as follows:

……………………………………………………………………………………….(1)

Where:

N is the population size

n is the sample size

e Margin of error

the formulae gave the study n = 99 participants.

135 were participants who were involved in the study. This was regarded as a good sample since it was greater than the 99 minimum calculated from Yemen’s formulas. Yemen’s formulas work best when a large population is involved and a representative sample size is desired by the researcher (Chanuan et al., 2021).

3.4.2 Sampling procedure

Purposive sampling procedure was employed the participants were sampled on the basis of their duration on treatment, and absence of signs and symptoms that would not allow them to take part in exercise. According to Odiya (2009), participants were selected purposively, because they had detailed information regarding the implications of aerobic exercise on clinical outcomes of HIV positive clients on ART in Uganda taking a case of General Military Hospital-Bombo since they have been take the care for at least 12 months and therefore they had the necessary information required for the study. The technique was used to sample respondents of 20 years and above and should have been on care for 12 months and more to select both the experimental and the control groups. The age range was selected with an assumption that majority of them were out of schools and would allocate time for the aerobic exercise classes.

3.5 Research Instruments

The following instruments were employed for data collection:

Modified Physical Activity Readiness Questionnaire (PAR-Q)

Kothari (2010) defines a questionnaire as a short-printed form, with questions given to respondents to fill in order to collect data often relating to the problem. The survey was conducted using a questionnaire consisting of close-ended questions designed for the respondents to elicit respondents’ perceptions, opinions, views, and feelings about “the implications of aerobic exercise on clinical outcomes of HIV positive clients on ART in Uganda taking a case of General Military Hospital-Bombo”. This instrument was used to collect information from HIV positive clients because it is less expensive to administer (Willem, et al, 2017) and convenient for the literate respondents who are able to complete it objectively and within a short time.

Rate of perceived exhaustion scale

Rate of Perceived Exhaustion scale (RPE), (Appendix VIII) was used to determine maximum oxygen consumption (VO₂max) which is a common measure of functional work capacity. Nystoriak and Bhatnagar (2018), alludes that regular exercise benefits cardiovascular system like, strengthening the heart muscle. It is a fifteen-point category scale introduced by Borg in 1971. In this study a 10-minute moderate intensity aerobic dance at 150 beats per minute was used to check the RPE for clients using the RPE scale by (Eston and Williams, 1986).

Self-report physical activity status

Duke Activity Status Index (DASI) (Appendix IX) was also used to compare with the results of functional work capacity. Another method McCarthy et al., (2015) uses to test VO₂max in physical activity and functional capacity in women is the DASI. The primary outcome measures included cardiac risk factors, CAD, and functional capacity as assessed by core laboratory-determined parameters during symptom-limited exercise treadmill testing. Measured physical activity using postmenopausal progesterone and oestrogen levels. Functional capacity as determined by the Duke Activity Status Index (DASI) questionnaire was connected with functional capacity as assessed in metabolic equivalents (METS) (McCarthy et. al., 2015). This helped to reinforce the results got from RPE scale.

.

Exercise protocol

Rate of Perceived Exertion (RPE) for functional work capacity

RPE scale (Appendix VIII) is used by YMCA of the USA in predicting VO₂max and access cardiorespiratory endurance see details in (Appendix XX). This test was compared with other laboratory tests and found to give consistence results (Zinoubi et al., 2018). Additionally, it was suggested that RPE be utilized as a rough indicator of exercise intensity. Monoen et al. (2017) have demonstrated that the repeatability of work capacity based upon an RPE at 13 and 17 is as excellent as that based upon a heart rate of 130 and 170 beats/min in both healthy volunteers and cardiac patients. Also, it was noted that HR, RPE, and VO₂max percentage were closely related (Zinoubi et al., 2018). Adult studies have found that, for the majority of participants, an RPE between 12 and 14 corresponds to 60–80% VO₂max (Zinoubi et. al. 2018) when performing running or cycling exercises. In their investigation, comparable RPE levels were noted at 60% VO₂max. This was therefore a useful method to estimate work capacity since it had a linear relationship with VO₂max.

Duke Activity Status Index (DASI) (Appendix IX)

To triangulate the results of functional work capacity DASI was used in this study. DASI determines exercise capacity it uses 12 questions to assess a person’s ability to perform activities of daily living. These questions need a yes or no the participants were asked to answer the questions to ascertain their capacity to do daily work. Several researchers have employed the DASI, such as (McCarthy, et. al., 2015) who measured women’s functional ability and physical activity. The primary outcome measures included cardiac risk factors, CAD, and functional capacity as assessed by core laboratory-determined parameters during symptom-limited exercise treadmill testing. Measured physical activity using postmenopausal progesterone and oestrogen levels. Functional capacity as determined by the Duke Activity Status Index (DASI) questionnaire and the intervention physical activity questionnaire (PEPI-Q) were linked with functional capacity as determined by metabolic equivalents (METS) (McCarthy et al., 2015).

Data Collection Procedure

Measuring functional work capacity using rate of perceived exertion (RPE)

This was done by using Borg RPE scale which uses a scale of six to twenty. This was designed to give a fairly good estimate of the actual heart rate and after getting the score you multiply by 10 to get the estimate. The clients were taken through a 10-minute non-stop exercise by the instructors guided by music of 150 beats per minute and then the research assistants helped them to complete the RPE scale. There after the results were kept ready for analysis. The researcher also used the Duke Activity Status Index (DASI) to compare with the results of functional work capacity. DASI a self-administered the clients were provided with this questionnaire and asked to complete it with assistance from the research assistant.

Data Analysis and Presentation

The data collected using a PAR-Q was analysed using predictive analytics to determine the participants’ engagement in physical activities. Where the information given in the questionnaire were categorised, classified, summarised, tabulated and thereafter participants that did not meet the criteria were replaced. Quantitative data was analysed using two sample t-test to compare the means for two different samples namely experimental and control group. A p-value ≤ 0.05 was considered statistically significant. All analysis was performed using the Statistical Package for Social Sciences (SPSS) version 20.0.

Results

Functional work capacity was measured using the seven-point Borg Rate of Perceived Exertion (RPE) see details in (Appendix XX) Scale and Duke Activity Status Index (DASI). The results are presented in the following sub-sections. The aerobic exercises considered included the intensity of the exercise, the duration and the type using a 5 phase of aerobics classes. This objective was guided by the hypothesis that, “there is no significant effect of aerobic exercise on the functional work capacity of HIV positive clients on ART”.

Duke Activity Status Index (DASI) Results – descriptive and inferential

To further assess whether exercise had an effect on VO₂ max, the DASI was used. The participants were required to rate DASI questions using the scale: Extremely Difficult or unable to perform activities = (0); Quite a bit difficulty = (1); Moderate difficulty = (2); A little a bit of difficulty = (3); and No difficulty at all = (4). The findings were as presented in Table 4.13 shows the results of the DASI rating

Table 4.13 confirms that the participants in DASI were expected to select “yes” or “no” for each question. The DASI score is calculated by multiplying the total number of “yes” replies by 0.43, adding 9.6, and calculating the estimated maximum oxygen consumption (VO₂ max). There is a range of 0 to 58.2 points in the final score. The functional capacity scores improve with higher scores (Tolulope et al 2021). Total of the questionnaire answers equals DASI. (mL/kg/min) x VO₂ max = 0.43 x DASI + 9.6. METs (in metabolic equivalents) = VO₂ max / 3.5. This study considered the middle points to determine improvement in functional work capacity.

Table 4.14 VO₂max values calculated from DASI

Source: Primary Data, 2023

For the Experimental Group, the VO₂ max (in mL/kg/min) significantly improved from 25.13 to 34.19 mL/kg/min while that of the control group only changed slightly from 18.51 to 22.26 mL/kg/min. As indicated the DASI score ranges from 0 to 58.2 points, the higher the scores, the better the functional work capacity. Table 4.14. Figure 4.10 shows a clear variation the pre-and post-test result of experimental group. The results show an improvement in oxygen consumption as indicate on the left side of Figure 4.10 where the experimental group are on the left and the control group on the right. The blue line on figure 4.10 is pre-test while the pink is post-test. These findings are consistent with those of O’Brien et al. (2016), who discovered that engaging in aerobic exercise, or a mix of aerobic and resistive exercise, three times a week for five weeks or more, is safe and can enhance the quality of life, strength, body composition, and cardiorespiratory fitness in adults living with HIV.

Figure 4.10 showing VO₂max results

Source: Primary Data (2023)

The inferential analysis on DASI was conducted by undertaking a paired-sample T-test using the SPSS version 20 and the results were as presented in the next two subsequent tables.

Table 4.15: Paired Samples Statistical Results

Source: Primary Data (2023)

The first thing to check was whether there was a difference in the mean values of the pre-test results compared to the post-test results. The results of the experimental group show a significant difference between the mean of the post-test to the pre-test of 1.26 (3.88 – 2.62) compared to that of the control group of only 0.17 (2.53 – 2.36) as shown in table 4.15. The paired correlations results were as shown in Table 4.16

Table 4.16: Paired Samples Correlation

Source: Primary Data (2023)

According to the pre-test and post-test Duke results in both the experimental and control groups were found not to be correlated. This indicates that there is no linear relationship between the pre-test and post results in that, the post-test Duke results for any given subject was not related to the corresponding pre-test reading. Following the above test, next it was important to establish whether the calculated sample mean falls into the confidence interval and whether the results are statistically significant or not. The results were as presented in Table 4.17

Table 4.17: Paired Samples Results

Source: Primary Data, 2023

As shown in Table 4.17, the calculated mean of the experimental group was 1.257 while the 95% confidence interval of the difference ranged from 1.069 to 1.445. This shows that the calculated mean indeed falls within the confidence interval. The calculated mean for the control group was equally within the 95% confidence interval considering that it was 0.163 and the interval ranged from -0.088 to 0.414. The t-test of the experimental group was established to be statistically significant as the p-value of <0.001 is less than 0.05. The results are: t(47) = 13.457, p < 0.001. The t-test of the control group was, however, not statistically significant as the results were: t(40) = 1.309, p = .198 which is > 0.05

Considering that the p-value of the experimental group in this case was <.001 which was less than the alpha level (.005) since a 95% level of significance was considered in this test, the null hypothesis that, “There is no significant effect of aerobic exercise on the functional work capacity of HIV positive clients on ART”, is rejected and this means that the aerobic exercises statistically significantly increased oxygen consumption (functional work) capacity of the HIV positive clients.  The results imply that oxygen consumption in the experimental group increased and therefore the functional work capacity. The clients living on HIV in the experimental group found the post-test exercise easy despite the fact that it was the same intensity compared to the clients in the control group. Therefore, well-structured aerobic exercises improve functional work capacity for HIV positive clients on ART in Uganda.  It is known that oxygen uptake kinetics determines exercise tolerance by determining the rate of carbohydrate (CHO) oxidation and/or the rate of heat storage in exercise, (Burnley & Jones 2007). This clearly explains how oxygen consumption improves functional work capacity. These results agree with a study of Riedel et al. (2021), where there was an improvement in functional work capacity measured using the DASI, and that of (O’Brien et al., 2016).  Where the participants exhibited a greater improvement in functional work capacity.

The study’s findings, which as summarized, are consistent with those of O’Brien et al. (2016), who found that doing aerobic exercise three times a week for at least five weeks can improve an adult with HIV’s strength, body composition, cardiorespiratory fitness, and quality of life. The findings corroborate previous findings by Warburton et al. (2006) and Penedo (2005) that exercise does, in fact, have a good effect on strength, cardiovascular function, and psychological status even in non-patients. In a similar vein, O’Brien et al. (2008) had also shown that persons with HIV could benefit from aerobic exercise.

The results of this study were also consistent with those of Stanley et al. (2017), who also showed that exercise improves the general health and wellbeing of the HIV population, and of Jaggers et al., (2014), who found that exercise and physical activity are safe and effective ways to improve the metabolic profile, cardiorespiratory fitness, and quality of life in people living with HIV. The argument of O’Brein et al. (2016) based on other studies as a concern exercising is that the exercise does not positively restrict viral replication or improve the immune system of PLHIV, but instead, it can elicit improvements in cardiorespiratory fitness, strength, body composition, and overall quality of life. In fact, according to Aweto et al. (2016), aerobic exercise improves the functioning of the pulmonary system and also alleviates respiratory and depressive symptoms in younger HIV positive clients. Apparently though, in 2017 Stanley et al. (2017) in their study to examine the effectiveness of a 12-weeks exercise on quality of life and CD4 cells of HIV population established that there was an insignificant change in the quality of life of the HIV positive clients. At the same time, according to Stanley et al., (2017), there seems to be no study that has indicated that moderate intensity exercise can lead to deterioration in the health status of HIV sero-positives on HAART.

Table 4.38: Summary Results of Hypotheses Testing

Source: Primary Data (2023)

The results above show that all the study hypotheses were rejected implying that aerobic exercises according to this study were very useful in HIV positive clients on ARVs. In summary, therefore, aerobic exercise significantly improves the functional work capacity of HIV positive clients on ART

Discussion

It was also found out that the clients in the experimental group had their heart rate lower when exposed to the same exercise intensity as in the pre-test. This is true because as one exercises the heart becomes stronger and it is able to pump enough blood and therefore no need of pumping many times. This therefore means the blood supply the muscles can be adequate hence improved functional work capacity.

Limitations

The clients that volunteered to take part in the study were selected using purposive sampling and thereafter, they were asked to volunteer to participate in the study. The clients that would be the best choice could have been left out by the selection criteria. The study was focused on one intervention exercise which may not be the only factor that affected the clinical outcome in question, the dependent variable of exercise may not be the one of the variables that influences clinical outcomes.

The ART clinic at General Military Hospital Bombo was where the individuals were enrolled, hence the sample did not accurately represent the entire HIV-positive population receiving ART. The researcher did not evaluate the participants’ nutritional intake because it was beyond his control. Therefore, the researcher is unable to determine the exact degree to which these patients’ diets influenced the variables (particularly CD4 cell and FWC) examined in this study. This specific constraint, nevertheless, may have been mitigated in some way by the baseline uniform values of these variables.

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