Introduction

Evidence-Based Physical Therapy (EBP) uses the best research evidence with clinical expertise and user’s preferences to produce the most appropriate and effective care. At week 43 in 2024, we had Blended Intensive program (BIP) in Czech Republic, Charles University about EBP. This BIP program opened with welcome words of the president of The European Network of Physiotherapy in Higher Education (ENPHE) and followed with the basis of EBP and teachers who highlighted the main challenges at different Physical Therapy fields.

More than 43 physiotherapy students and 9 teachers from five universities (Savonia University of Applied Sciences, Finland, Universidade da Coruña, Spain, Charles University Prague, Universidad Europea de Madrid, Spain and CEERRF, France (Picture 1), actively participated this week and shared experiential group dynamics and social activities. Students worked together and wrote articles devoted to the following themes: Evidence Based in sport, prevention, injuries, neurological diseases, respiratory diseases, cardiovascular diseases, children and older adults. In this learning task, students practiced conducting a mini review and using PEDro scale to assess the quality of a studies. In the following you can consult the work presented by the students on atrial fibrilation.

Picture 1. Students and teachers participate in BIP week.

Background

Treatment strategy in recently diagnosed cases of atrial fibrillation (AF) includes identification and solution of reversible risk factors with anticoagulation therapy followed by beta-blockers. Patients with atrial fibrillation report symptoms as fatigue, decreased exercise tolerance, dyspnea, palpitations and a decrease in quality of life.

Non-pharmacological therapy includes ablation therapy, a hospital procedure which inactivates small areas of tissue in the heart responsible for the abnormal electrical signals associated with AF. Pacemaker placement is considered in severe causes resulting in heart failure in atrial fibrillation. We are looking for the effects of implementing physical exercise in the treatment of patients with atrial fibrillation and its impact on patients’ quality of life (QOL).

Methods

A bibliographic research was made on PubMed though MeSH Terms and filters with the final equiation of “(atrial fibrillation[All Fields] OR atrial fibrillation[MeSHT erms]) AND ((training[All Fields] OR training[MeSH T erms]) OR (“exercise”[All Fields] OR “exercise”[MeSH T erms])) AND (quality of life[All Fields] OR “quality of life”[MeSH Terms]) (atrial fibrillation[Title/Abstract] AND (atrial fibrillation[All Fields] OR atrial fibrillation[MeSH Terms])) AND ((training[Title/Abstract] AND (training[All Fields] ORtraining[MeSH Terms])) OR (exercise[Title/Abstract] AND (“exercise”[All Fields] OR “exercise”[MeSH Terms]))) AND (quality of life[Title/Abstract] AND (quality of life[All Fields] OR “quality of life”[MeSH Terms])) + “Filters applied: Randomized Controlled Trial.” A total of 62 studies were found, 51 were excluded and 8 of them were assessed for eligibility ending with 6 studies included in the mini review. (Picture 2).

Picture 2. Students giving a presentation.

Main results of the studies

Reed et al. 2022: Both training methods were equally effective, but the High-intensity interval training group (HIIT) achieved results in less than half the time. Twice-weekly 23-minute HIIT was as efficacious as twice-weekly 60-minute cardiovascular rehabilitation in improving functional capacity, general and disease-specific QOL, resting heart rate, and physical activity levels in patients with persistent and permanent AF.

Osbak et al. 2012: Exercise training in atrial fibrillation patients improved exercise capacity, QoL, and physical strength without significant muscle mass increase. Short-term training led to a 13% increase in walking capacity and a 9% improvement in exercise capacity. Long-term training enhanced capillary and arteriole density in muscles, supporting the inclusion of exercise in cardiac rehabilitation.

Malmo et al. 2016: Twelve weeks of HIIT reduced AF time in patients with paroxysmal or persistent AF, improving symptoms, exercise capacity, heart function, lipid levels, and QoL. The benefits persisted four weeks post-intervention, suggesting HIIT as a valuable tool in managing symptomatic AF phases.

Osbak et al. 2011: A 12-week aerobic exercise program improved physical capacity and QoL in patients with permanent AF. Participants showed better exercise capacity, walking distance, and reduced resting heart rates. The study supports structured aerobic exercise in AF rehabilitation programs.

Borland et al. 2020: This trial compared physiotherapist-led exercise-based cardiac rehabilitation (PT-X) with physical activity on prescription (PAP) in permanent AF patients. PT-X involved group and home-based exercises, while PAP involved active walking. PT-X significantly improved physical fitness, though HR-QoL and lab tests did not differ between groups.

Joensen et al (2019): Education and physical training may have short-term, but not long-term, beneficial effects on quality of life and physical exercise capacity in patients with atrial fibrillation.

Quality evaluation

We assessed the quality of the studies, finding that the risk of bias due to missing outcome data was high for Joensen et al (2019) and showed some concerns for Reed et al (2022) and Osbak et al. (2011) The bias in measurement of the outcome was moderate for Osbak et al (2011) and the overall risk of bias was moderate for Joensen et al (2019), Osbak et al (2011) and Malmo et al (2016).

Conclusion

In our review, moderate and supervised exercise improves symptoms and quality of life in patients with atrial fibrillation. Exercise seems to improve overall QoL metrics abs the type of exercise is not as important. Secondary outcomes improved across the board, but further investigation is needed.

Authors:

Maria Jose Atristain Vega, physiotherapy student, Charles University, Czech Republic

Xiana Rosales Conde, physiotherapy student, University of A Coruña, Spain

Lucie Hecklová, physiotherapy student, Charles University, Czech Republic

Daniel Del Río Frade, physiotherapy student, University of A Coruña, Spain

José Antonio Ginés, physiotherapy student, Universidad Europea de Madrid, Spain

David Pajovic, physiotherapy student, CEERRF, France

Marja Äijö, PT, PhD Principal Lecturer of gerontology and rehabilitation, Savonia, University of Applied Sciences, Kuopio, Finland

Dagmar Pavlu, Physiotherapist, Assoc. Prof. Charles University, Czech Republic

Ivana Vláčilová, Physiotherapist, PhD., Charles University, Czech Republic

Veronica Robles García, PhD. PT. OT. Lecturer, University of A Coruña, A Coruña, Spain

Beatriz Martínez Toledo, PT. Lecturer at University of A Coruña, A Coruña, Spain

Montserrat Fernández Pereira, PT, Lecturer at University of A Coruña, A Coruña, A Coruña, Spain

Zeltia Naia, PhD, MSc, PT Professor, University of A Coruña, A Coruña, Spain

Lorena Canosa Carro, PT, MSc, PhD. Lecturer at Universidad Europea de Madrid, Spain

Adrien Pallot, PT, MSc, Lecturer at CEERRF, France

References:

Borland M, Bergfeldt L, Bollano LE, Andersson L, Rosenkvist A, Jakobsson M, Olsson K, Corin M, Landh L, Sveälv BG, Täng MS, Wigh JP, Lundwall A, Cider Å. Exercise-based cardiac rehabilitation improves physical fitness in patients with permanent atrial fibrillation – A randomized controlled study. Eur Rev Aging Phys Act 2022 Apr 29;19(1):14. doi:10.1186/s11556-022-00293-1.

Hegbom F, Sire S, Heldal M, Orning OM, Stavem K, Gjesdal K. Short-term exercise training in patients with chronic atrial fibrillation: effects on exercise capacity, AV conduction, and quality of life. J Cardiopulm Rehabil. 2006 Jan-Feb;26(1):24-9. doi:10.1097/00008483-200601000-00005.

Joensen AM, Dinesen PT, Svendsen LT, Hoejbjerg TK, Fjerbaek A, Andreasen J, Sottrup MB, Lundbye-Christensen S, Vadmann H, Riahi S. Effect of patient education and physical training on quality of life and physical exercise capacity in patients with paroxysmal or persistent atrial fibrillation: A randomized study. J Rehabil Med. 2019 Jun 18;51(6):442-450. doi:10.2340/16501977-2551. PMID: 30931484.

Malmo V, Nes BM, Amundsen BH, Tjonna AE, Stoylen A, Rossvoll O, Wisloff U, Loennechen JP. Aerobic Interval Training Reduces the Burden of Atrial Fibrillation in the Short Term: A Randomized Trial. Circulation. 2016 Feb 2;133(5):466-73. doi:10.1161/CIRCULATIONAHA.115.018220.

Osbak PS, Mourier M, Henriksen JH, Kofoed KF, Jensen GB. Effect of physical exercise training on muscle strength and body composition, and their association with functional capacity and quality of life in patients with atrial fibrillation: a randomized controlled trial. J Rehabil Med. 2012 Nov;44(11):975-9. doi:10.2340/16501977-1039. PMID: 22951598.

Reed JL, Terada T, Vidal-Almela S, Tulloch HE, Mistura M, Birnie DH, Wells GA, Nair GM, Hans H, Way KL, Chirico D, O’Neill CD, Pipe AL. Effect of High- Intensity Interval Training in Patients With Atrial Fibrillation: A Randomized Clinical Trial. JAMA Netw Open. 2022 Oct 3;5(10):e2239380. doi:10.1001/jamanetworkopen.2022.39380. PMID: 36315143; PMCID: PMC9623436.