Older Adults' Views of Cardiac Rehabilitation Programs: Is it Time to Reinvent?

In spite of the documented benefits of cardiac rehabilitation program (CRP) participation, older adults are not likely to participate. Older adults' expectations of and experiences with CRPs are not known. It is also not known whether women and men differ in their expectations and experiences. This descriptive study used a convenience sample of 40 older adults who had experienced an acute cardiac event to identify patients' views of CRPs. Focus groups revealed that older adults do not have an accurate understanding of what to expect in CRPs, and that older adults' experiences in CRPs were generally positive. Older adults suggested CRPs could be improved by including more socialization opportunities, offering varied forms of exercise, enhancing teaching about stress management, and adapting teaching strategies. In this study, "strength of physician referral" was identified as the main reason for participating or not participating in a CRP. Older men feared physical pain with exercise and older women expressed a need for emotional support. A major finding in this study was the report of adverse events (i.e., exhaustion, collapse) during exercise experienced by individuals who did not go to a CRP. Because the majority of adults participating in CRPs are older, transforming CRPs to meet the needs of these older adults is important. Future research on the effectiveness of alternative CRP models will provide evidence to ensure the delivery of quality, cost-effective care.

A 19-week exercise program for people with chronic stroke enhances bone geometry at the tibia: a peripheral quantitative computed tomography study

BACKGROUND

We assessed the impact of a 19-week exercise program on bone health in chronic stroke.

RESULTS

Those who underwent the program reported significantly more gain in tibial trabecular bone content and cortical bone thickness on the affected side.

CONCLUSION

Regular exercise is thus beneficial for enhancing bone health in this population.

Blood glucose changes in diabetic children and adolescents engaged in most common sports activities

Circulating insulin levels decrease and substrate glycogenolysis-mediated conversion into glucose increases just a few minutes after normal subjects start exercising, but during sustained physical activity muscles massively utilize blood glucose, thus causing glycogenolysis to increase further until the end of the session. After that, in order to get liver and muscle glycogen stores up to pre-exercise levels again, blood glucose is mostly utilized, thus causing late-onset hypoglycaemia in the absence of any extra carbohydrate supply and rebound hyperglycaemia after a while. This and other patho-physiological mechanisms are dealt with in the present paper, and practical hints are provided to the clinician to cope with children-specific adaptation phenomena to exercise in t1DM.

Managing insulin therapy during exercise in type 1 diabetes mellitus

BACKGROUND

Exercise is integral to the life of T1DM subjects. Several factors influence the metabolic response to exercise in these patients. Despite physical and psychological benefits of exercise, its hypo- and hyperglycemic effects may cause discouragement from participation in sports and games.

AIM

To use existing evidence from literature to provide practical indications for the management of insulin therapy in subjects with T1DM who practice sports or physical activities.

METHODS

Bibliographic research was performed on PubMed and the main Systematic Review and Guidelines database were also searched.

RESULTS

Existing guidelines are useful but the exact adjustments of insulin dose must be made on an individual basis and these adjustments can be made only by "trial and error" approach.

CONCLUSIONS

These clinical indications may be a starting point from which health care providers can find practical advices for each patient.

Self-monitoring adherence to physical activity in children and adolescents with type 1 diabetes

Monitoring blood glucose is essential for good diabetes control and even more important when participating in sports. Many variables can have an effect on blood sugar response to aerobic or anaerobic activities. A moderate exercise produces an average fall in plasma glucose of approximately 40% of baseline values. The majority of hypoglycaemia episodes occurs in children with pre-exercise plasma glucose concentrations < 120 mg/dl, therefore it is advisable to achieve a blood glucose level of at least 120 mg/dl if not higher before starting an exercise in order to prevent hypoglycaemia episodes. Since 15 g of oral glucose result in only about a 20-mg/dl rise in glucose concentrations, 30-45 g of oral glucose may be more appropriate to treat hypoglycaemia during exercise. A sufficient adherence to the physical activity prescribed by the health care professionals it easy to find in the children with Type 1 diabetes. According our experience, 60 per cent of the children report to spend on average 1 hour daily for exercise, proving so to consider physical activity beneficial in the treatment of diabetes mellitus. Glycate haemoglobin levels in these motivated patients were better than in children exercising sporadically and shortly either at school or in the spare time. Although the health care professionals effort, only half of the patients referred to monitor blood glucose levels before, after or before and after the exercise. Only one third of the patients reported to regularly adjust insulin dosage to own response to physical activity. Two third of the patients referred to consume added carbohydrate to avoid hypoglycaemia.

Physical exercise and diabetes during childhood

Active life and physical fitness may represent the most effective strategies to prevent chronic diseases and to improve growth and development for children, including those with diabetes. Observational studies have demonstrated the association between life style and prevention of chronic diseases in the general population. These studies have been showed a reduction of morbidity for vascular diseases in trained subjects who present adequate cardiovascular fitness and practise regular exercise. The exercise-related protective effects may be mediated in part through components of the metabolic syndrome: improved insulin sensitivity, decreased weight and visceral fat accumulation, reduced low density lipoprotein (LDL) and triglycerides, increased high density lipoprotein (HDL), decreased blood pressure. These effects are more significant in patients with type 1 diabetes (T1DM), because hyperglycemia-related morbidity and mortality are associated with chronic complications. In particular, improved insulin sensitivity may determine a better glucose profile which in turn may positively influence the diabetes-related microvascular complications. Furthermore, improved blood pressure and normalization of lipid profile may also contribute to the prevention of vascular complications. Nonetheless, physical activity can improve psychological well-being by increasing self-esteem and enhancing quality of life. Although patients with T1DM may participate in all kind of sports and physical activities, there are several potential adverse events, including hypoglycemic and hyperglycemic episodes, that can occur. Thus, patients and health professionals have to know in details the physiological effect of physical exercise and its metabolic events in order sport to be healthy and enjoyable for all children, adolescents and young adults with T1DM.

Progressive resistance exercise in physical therapy: a summary of systematic reviews

Progressive resistance exercise (PRE) is a method of increasing the ability of muscles to generate force. However, the effectiveness and safety of PRE for clients of physical therapists are not well known. The purpose of this article is to review the evidence on positive and negative effects of PRE as a physical therapy intervention. Electronic databases were searched for systematic reviews on PRE and any relevant randomized trials published after the last available review. The search yielded 18 systematic reviews under major areas of physical therapy: cardiopulmonary, musculoskeletal, neuromuscular, and gerontology. Across conditions, PRE was shown to improve the ability to generate force, with moderate to large effect sizes that may carry over into an improved ability to perform daily activities. Further research is needed to determine the potential negative effects of PRE, how to maximize carryover into everyday activities, and what effect, if any, PRE has on societal participation.

[The influence of induced severe myocardial ischemia on coronary disease course]

The aim is to study influence of short-term episodes ischemic of myocardium in a combination with intravenous introduction of creatine phosphate on current of ischemic heart disease at the patients with distal stenoses of coronary arteries. We survey 86 patients, which were divided into two groups: basic, which are receiving neoton in a combination with ischemic training and control who are receiving standard antianginal therapy. The research proceeded within 5 years. The authentic improvement of tolerance to physical effort, quality of life, decrease anginal attacks and normalization systolic and diastolic cardiac function of the basic group is marked.

Is physical training contraindicated in patients with deep vein thrombosis during cardiac rehabilitation?

Deep vein thrombosis is a potential complication in patients admitted to cardiac rehabilitation programs after acute coronary syndromes, episodes of acute congestive heart failure, and cardiac revascularization. A common clinical problem in these patients is to decide whether to start or continue physical training or not, given the risk of pulmonary embolism. Until definite evidence becomes available, careful patient selection and inpatient supervision may avoid the a priori withdrawal of such an important core component of cardiac rehabilitation programs.

Rehabilitation decreases exercise-induced oxidative stress in chronic obstructive pulmonary disease

The effect of exercise at different intensities as well as the effect of intensive supervised pulmonary rehabilitation on oxidative stress were studied for chronic obstructive pulmonary disease (COPD). Eleven patients with COPD and 11 healthy age-matched control subjects performed a maximal and submaximal exercise cycle ergometry test at 60% of peak workload. Patients with COPD performed these tests before and after 8 wk of pulmonary rehabilitation. Measurements were done before, immediately after, and 4 h after both exercise tests. At rest, increased oxidative stress was observed in patients compared with control subjects, as measured by urinary malondialdehyde (MDA; p < 0.05) and hydrogen peroxide (H2O2) in breath condensate (p < 0.05). In healthy control subjects, a significant increase in urinary MDA was observed 4 h after both exercise tests (p = 0.05), whereas H2O2 significantly increased immediately after maximal exercise (p < 0.05). In patients with COPD, before rehabilitation, reactive oxygen species-induced DNA damage in peripheral blood mononuclear cells, urinary MDA, and plasma uric acid were significantly increased after both exercise tests (p < 0.05), whereas no significant increase was observed in plasma MDA. In contrast, exhaled H2O2 was only significantly increased after maximal exercise (p < 0.02). Although after rehabilitation peak workload was increased by 24%, a similar oxidative stress response was found. Remarkably, a decrease in reactive oxygen species-induced DNA damage was detected after exercise at submaximal intensity despite increased exercise duration of 73%. In summary, patients with COPD had increased pulmonary and systemic oxidative stress both at rest and induced by exercise. In addition, pulmonary rehabilitation increased exercise capacity and was associated with reduced exercise-induced oxidative stress.

[Adapted exercise important after stroke. Acute and long-term effects of different training programs]

Following stroke, persons experience deficits in motor control, reduced muscle strength, disuse atrophy, reduced cardiovascular fitness and elevated energy expenditure during locomotion. Recent exercise studies with few subjects, report beneficial outcomes after strength and low intensity aerobic exercise training. Progressive strength and aerobic exercise programmes from 3 to 6 months produced gains in functional recovery and health-related functional status such as motor function, peak isokinetic torque, balance, endurance, peak aerobic capacity and overall fitness without exacerbating spasticity. Increased access to community-based physical activity programmes is recommended to prevent deconditioning and to improve health related quality of life in persons after stroke. Well-functioning rehabilitation from acute care, through special rehabilitation units to community-based physical activity programmes is important.

Trampoline use as physiotherapy for cystic fibrosis patients

Physicians and physiotherapists who care for CF patients have recommended the use of trampolines as a physiotherapeutic tool for enhancing cardiopulmonary performance, encouraging sputum production, and improving general well-being. Despite some therapeutic and recreational benefits associated with trampoline use, papers in the general pediatric population mostly document an increased incidence of injuries, ranging from minor trauma to spinal cord injuries and even death. The aim of this review is to examine the accumulated published data regarding the use of trampolines, to assess their potential contributions and disadvantages for CF patients, and to define whether trampoline use should be recommended. An extensive search in the published medical literature retrieved approximately 60 articles that primarily dealt with trampolines, out of which only two dealt with CF. The preponderance of these articles are reports pertaining to injuries related to the use of trampolines, with only a few describing the medical, physiologic, and/or psychological benefits of trampolines. Based on the accumulated data, the presumed benefits of trampoline use for CF patients are not proven. Furthermore, the suggested benefits could be acquired using other types of exercise. Weighing the known risks of trampolines against the potential benefits that are not unique to this modality suggests that the use of trampolines for CF should not be recommended.

Particle Repositioning Manoeuvre in Benign Paroxysmal Positional Vertigo: Is It Really Safe?

OBJECTIVE

A prospective study to determine the safety of the particle repositioning manoeuvre (PRM) by analyzing the various complications of the procedure.

SETTINGS

Outpatient Department of Otorhinolaryngology, Nehru Hospital, Chandigarh, India.

METHODS

Thirty patients with the classic findings of benign paroxysmal positional vertigo (BPPV) were included in the study. Clinical symptoms prior to the procedure were noted. Twenty-nine of them were subjected to PRM, and postprocedural instructions were given to all patients. Various side effects during and following the procedure were recorded. They were classified into early and late based on the period and into major and minor based on severity. All patients were reviewed after 3 days, 7 days, and 1 month.

RESULTS

Of the 29 patients, 19 patients (65.52%) had heaviness in the head, with 11 each (37.93%) reporting nausea and imbalance and 9 (31.03%) reporting instability during the procedure. A major complication, asystole, was noted in one patient. The percentage of side effects remained more or less the same in the early phase following the procedure. Only 5 of 29 patients were entirely asymptomatic. Ninety percent were relieved of symptoms by the end of 7 days, with no major complication recorded.

CONCLUSIONS

PRM is an easy, effective, and relatively safe procedure. The risk of major complications with PRM, such as arrhythmias and asystole, highlights the need to consider other management modalities for BPPV in certain medically unfit patients.

UK BEAM Trial Team. United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: effectiveness of physical treatments for back pain in primary care

OBJECTIVE

To estimate the effect of adding exercise classes, spinal manipulation delivered in NHS or private premises, or manipulation followed by exercise to "best care" in general practice for patients consulting with back pain. [See figure].

DESIGN

Pragmatic randomised trial with factorial design.

SETTING

181 general practices in Medical Research Council General Practice Research Framework; 63 community settings around 14 centres across the United Kingdom.

PARTICIPANTS

1334 patients consulting their general practices about low back pain.

MAIN OUTCOME MEASURES

Scores on the Roland Morris disability questionnaire at three and 12 months, adjusted for centre and baseline scores.

RESULTS

All groups improved over time. Exercise improved mean disability questionnaire scores at three months by 1.4 (95% confidence interval 0.6 to 2.1) more than "best care." For manipulation the additional improvement was 1.6 (0.8 to 2.3) at three months and 1.0 (0.2 to 1.8) at 12 months. For manipulation followed by exercise the additional improvement was 1.9 (1.2 to 2.6) at three months and 1.3 (0.5 to 2.1) at 12 months. No significant differences in outcome occurred between manipulation in NHS premises and in private premises. No serious adverse events occurred.

CONCLUSIONS

Relative to "best care" in general practice, manipulation followed by exercise achieved a moderate benefit at three months and a small benefit at 12 months; spinal manipulation achieved a small to moderate benefit at three months and a small benefit at 12 months; and exercise achieved a small benefit at three months but not 12 months.

A handicap in treatment and follow-up of ankylosing spondylitis: sports hematuria

A 19-year-old male patient with a 7-year history of ankylosing spondylitis (AS) was admitted to our clinic. After completion of the laboratory and radiologic investigations, we prescribed an exercise program besides his medical therapy. After these exercises, he complained of painless dark urine sometimes with passage of clot that disappeared the following day. To investigate this hematuria related with exercise, further laboratory and radiologic studies were carried out. After exclusion of the other causes of hematuria, we concluded that the diagnosis was sports hematuria.

Exercise prescription using resting heart rate plus 20 or perceived exertion in cardiac rehabilitation

PURPOSE

For patients starting a cardiac rehabilitation program, exercise intensity often is set 20 beats per minute above the standing resting heart rate (RHR+20) or in a range of 11 to 13 on Borg's Scale for Rating of Perceived Exertion (RPE 11-13). The purpose of this study was to determine the actual exercise intensity, expressed as a percentage of peak oxygen uptake reserve (%VO2R) using these techniques.

METHODS

For this study, 11 new referrals to a phase 2 cardiac rehabilitation program voluntarily underwent a symptom-limited exercise test and a field test that consisted of self-paced over-the-ground walking for 10 minutes at levels corresponding to RPE 11-13 and RHR+20. During both tests, gas exchange data were obtained via the Cosmed K4b and heart rate via the Polar monitor.

RESULTS

The mean %VO2R at RHR+20 (41.8 +/- 12.3%) and RPE 11-13 (71 +/- 15.3% mL.kg.min) were significantly different. Exercise at RHR+20 resulted in 4 of the 11 patients (36%) exercising at less than 40% VO2R, 6 of the patients (55%) exercising at 40% to 60% VO2R, and 1 of the patients (9%) exercising at more than 60% VO2R. Exercise at RPE 11-13 resulted in 1 of the 11 patients (9%) exercising at less than 40% VO2R, 1 of the patients at exercising at 40% to 60% VO2R (9%), and 9 of the patients (82%) exercising at more than 60% VO2R.

CONCLUSIONS

The results of this study indicate that using RHR+20 or RPE 11-13 to prescribe exercise intensity during over-the-ground walking for phase 2 cardiac rehabilitation patients results in substantial intersubject variability and raises questions about the safety and efficacy of these approaches.

Einsatz von Kraftausdauertraining und Muskelaufbautraining in der kardiologischen Rehabilitation

While aerobic endurance training has been a substantial part of international recommendations for cardiac rehabilitation during the last 30 years, there is still a rather reserved attitude of the medical community to resistance exercise in this field. Careful recommendations for resistance exercise in cardiac patients was only published a few years ago. It has been taken for granted that strength exercise elicits a substantial increase in blood pressure and thus imposes, especially in cardiac patients, a risk of potentially fatal cardiovascular complications. Results of the latest studies show that the existing recommended overcaution is not justified. Strength exercise can indeed result in extreme increases of blood pressure, but this is not the case for all loads of this kind. The actual blood pressure response to strength exercise depends on the isometric component, the exercise intensity (load or resistance used), muscle mass activated, the number of repetitions in the set and/or the duration of the contraction as well as involvement of Valsalva maneuver. Intra arterially performed blood pressure measurements during resistance exercise in patients with heart disease showed that strength training carried out at low intensities (40-60% of MVC) and with high numbers of repetitions (15-20) only evokes a moderate increase of blood pressure comparable with blood pressure measures induced by moderate endurance training. If used properly and performed accurately, individually dosed, medically supervised and controlled through experienced sport therapists, a dynamic resistance exercise is-at least for a certain group of patients-not associated with higher risks than an aerobic endurance training and can in addition to endurance training improve muscle force and endurance, have a positive influence on cardiovascular function, metabolism, cardiovascular risk factors as well as psychosocial well-being and overall quality of life. However, with respect to currently available data, resistance exercise cannot be generally recommended for all groups of patients. The appropriate kind and execution of training is highly dependent on current clinical status, cardiac capacity as well as possible accompanying diseases of the patient. Most of the studies carried out up to date included small samples of middle-aged male patients with almost normal levels of aerobic endurance performance and good left ventricular function. Data is missing for risk groups, older patients and women. Therefore, an integration of dynamic resistance exercises in cardiac rehabilitation can only be recommended without hesitation for CHD patients with high physical capacity (good myocardial function, revascularized). Since patients with myocardial ischemia and/or low left ventricular functioning might develop wall motion disturbances and/or dangerous ventricular arrhythmia when performing resistance exercises, prevalence of the following conditions is recommend: moderate to high LV-function, high physical performance (>5-6 metabolic equivalents= >1.4 watts/kg body weight) in absence of angina pectoris symptoms or ST-depression, by maintained current medication. In the proposed recommendations, a classification of risks for resistance training in cardiac rehabilitation is being made based on current data and is complemented by specific recommendations for particular groups of patients and detailed guidelines for setup and completion of the therapy program.

The implications of physical activity in patients with chronic heart failure

The clinical syndrome of chronic heart failure is increasingly prevalent. It can be considered a multiorgan disorder that may exert a negative physical and psychological influence on a patient. Medication and surgical intervention have important roles to play and have certainly improved both morbidity and mortality in this field, but clearly these interventions alone are not enough. Excessive resource utilization for this group of patients has provided added impetus to research into non-pharmacological interventions. These encompass dietary and other lifestyle measures, including smoking cessation and exercise. Exercise has been shown to favourably affect the functional capacity and quality of life. There is also emerging evidence that it reduces mortality. In the absence of contraindications, regular endurance exercise coupled with strength training is undoubtedly beneficial. As with other cardiovascular research, there is a trend towards recruiting middle-aged males. This effectively means that practitioners need to be cautious when evaluating and/or implementing research evidence. By addressing the implications of physical activity for deconditioned patients with chronic heart failure, a holistic therapeutic regimen is fostered. This has been shown to improve the quality of life of patients and to enhance the quality of service delivered to this patient group.

Therapeutic effect of TENS on post-IMF trismus and pain

The study set out to investigate the therapeutic effect of Transcutaneous Electrical Nerve Stimulation (TENS) in the alleviation of pain and post-IMF trismus, in patients undergoing jaw exercises to hasten mouth opening after being treated for fractures of the mandible. Two groups of patients, with 10 patients in each group, were used for the study. The groups were the experimental and the control groups. They were all treated for mandibular fractures, and had their jaws immobilized for 6 weeks, immediately after which they were started on jaw exercises. The Inter-incisal distances and number of acceptable wooden spatulae that the jaws could accommodate were noted and recorded. The experimental group was then placed on the TENS therapy for 20 minutes, after which the new inter-incisal distances and the number of acceptable wooden spatulae were recorded. The control group had no TENS therapy; the patients only waited for 20 minutes without any stimulation, before the new inter-incisal distances and the number of acceptable wooden spatulae were measured and recorded. It was observed that the inter-incisal distance and the number of acceptable wooden spatulae significantly increased in patients in the experimental group compared to the control group. It was concluded that TENS could be useful in relieving the pain associated with forced mouth-opening exercises aimed at overcoming trismus caused by muscle spasm, which is associated with prolonged immobilization of the jaws for the treatment of facial fractures.

Abdominal compartment syndrome as a consequence of rectus sheath hematoma

Abdominal compartment syndrome is a well-documented entity arising from multiple and various causes. The rise of intra-abdominal pressure by the increase in volume of the peritoneal and retroperitoneal contents has been shown in the resuscitation and evaluation of surgical patients. However, the incidence of constriction of the abdomen causing intra-abdominal hypertension is unknown. Previously limited to burn eschar and externally applied devices (such as MAST trousers), external compression leading to abdominal compartment syndrome has been a limited entity. We report the first documented case of an expansive abdominal wall mass, a rectus sheath hematoma, leading to impending abdominal compartment syndrome.

[Arrhythmias newly provoked by exercise training in patients who underwent cardiac surgery]

We investigated the incidence and the varieties of arrhythmia during exercise training in patients who underwent cardiac surgery. Subjects were 1293 patients who underwent cardiac surgery and enrolled our cardiac rehabilitation program. According to the charts and cardiac rehabilitation records, we evaluated the incidence and the varieties of arrhythmia provoked by exercise training in patients after cardiac surgery retrospectively. The arrhythmias related to the exercise training were provoked in 12 times, and the incidence was only 0.09% (12/13646). Atrial fibrillation was the most common arrhythmia, and the incidence was 41.6% (5/12) in these patients. Moreover, these arrhythmias occurred within 2 weeks after surgery. Although most patients recovered to the sinus rhythm spontaneously, 3 patients needed medical treatment or cardioversion. We concluded that the arrhythmia provoked by exercise training in patients after cardiac surgery were rare, non-fatal, and common in the early recovery phase after surgery. However, the supervised exercise training was required in those patients, particularly in early recovery phase of cardiac surgery.

Randomized clinical trial of therapeutic exercise in subacute stroke

BACKGROUND AND PURPOSE

Rehabilitation care after stroke is highly variable and increasingly shorter in duration. The effect of therapeutic exercise on impairments and functional limitations after stroke is not clear. The objective of this study was to determine whether a structured, progressive, physiologically based exercise program for subacute stroke produces gains greater than those attributable to spontaneous recovery and usual care.

METHODS

This randomized, controlled, single-blind clinical trial was conducted in a metropolitan area and 17 participating healthcare institutions. We included persons with stroke who were living in the community. One hundred patients (mean age, 70 years; mean Orpington score, 3.4) consented and were randomized from a screened sample of 582. Ninety-two subjects completed the trial. Intervention was a structured, progressive, physiologically based, therapist-supervised, in-home program of thirty-six 90-minute sessions over 12 weeks targeting flexibility, strength, balance, endurance, and upper-extremity function. Main outcome measures were postintervention strength (ankle and knee isometric peak torque, grip strength), upper- and lower-extremity motor control (Fugl Meyer), balance (Berg and functional reach), endurance (peak aerobic capacity and exercise duration), upper-extremity function (Wolf Motor Function Test), and mobility (timed 10-m walk and 6-minute walk distance).

RESULTS

In the intention-to-treat multivariate analysis of variance testing the overall effect, the intervention produced greater gains than usual care (Wilk's lambda=0.64, P=0.0056). Both intervention and usual care groups improved in strength, balance, upper- and lower-extremity motor control, upper-extremity function, and gait velocity. Gains for the intervention group exceeded those in the usual care group in balance, endurance, peak aerobic capacity, and mobility. Upper-extremity gains exceeded those in the usual care group only in patients with higher baseline function.

CONCLUSIONS

This structured, progressive program of therapeutic exercise in persons who had completed acute rehabilitation services produced gains in endurance, balance, and mobility beyond those attributable to spontaneous recovery and usual care.

[From bench to bicycle. Risk assessment in connection with sports activities and exercise programs in the primary and secondary prevention of cardiovascular diseases]

BACKGROUND

Due to encouraging results of studies investigating the effects of physical activity and training on cardiovascular diseases and due to the integration of preventive strategies into disease management programs by public health organizations, it is expected that a larger population, including cardiovascular patients, will increasingly participate in physical activity, fitness programs, and sports. However, a reduction in cardiovascular events and all-cause mortality by regular physical activity is accompanied by an increased mortality during exertion, as yet, there is no satisfactory definition of risk for all cardiovascular diseases and patient groups.

RISK EVALUATION

A cost-effective preparticipation screening has to consider both the low incidence of events resulting from different diseases which requires subtle diagnostics and the intention of granting the larger population simple access to exercise programs and sports. There is a substantial difference in the risk profile for fatal events in athletes and young fitness program participants on the one hand and older (> 35 years) exercising people with a higher incidence of common cardiovascular diseases on the other. Additionally, a potential exercise-induced progression of chronic heart diseases should be excluded. New imaging techniques, laboratory markers, and genetic indicators will hopefully improve the quality of risk assessment.

CONCLUSION

Establishing standards for diagnostics and risk assessment as well as different types of exercise and training programs, all of which need to be transformed into national guidelines, could help to reduce risks without limiting access to physical exercise and therapy. However, an element of risk will remain if rational cost-effectiveness ratios are to be applied.

A home-based resistance-training program using elastic bands for elderly patients with orthostatic hypotension

Falls are a common hazard in the elderly. Orthostatic hypotension (OH) is prevalent in older patients and contributes to the high incidence of falls. Our aim was to test whether a home-based resistance-training program (HBRT) using elastic resistance bands could safely and effectively increase muscle strength and functional ability, and attenuate the orthostatic fall in blood pressure. Eight subjects (> 60 yrs) underwent orthostatic provocations; muscle strength testing (isometric and dynamic), and a functional test of gait and mobility (Timed Up & Go), at baseline and following 8 weeks of training. Ten exercises were assigned and customized to each participant. At 8 weeks, significant increases occurred in dynamic strength in the chest press ( p = 0.017), quadriceps extension ( p = 0.017), and leg press (p = 0.025); no significant differences occurred in isometric strength or in blood pressures. Functional mobility increased in 7 of 8 subjects. There were no falls during the investigation period.

CONCLUSIONS

A HBRT program using elastic resistance bands effectively increases dynamic muscle strength in elderly individuals with OH. Although no changes occurred in orthostatic blood pressures, which could be attributed to the limited length of the program, this therapy may be recognized as a safe method to improve strength, functional ability, and promote physical activity - variables that can reduce the incidence of falls and enhance the quality of life in this population.

Arrhythmias during acute and chronic exercise in chronic heart failure

Exercise can induce or prevent arrhythmias depending upon several factors, related to patient's clinical characteristics and to exercise modalità (type, intensità, frequency, duration). In the present paper, the author reviews the mechanisms of arrhythmias during acute and chronic exercise in heart failure, and focuses on the relationship between exercise training programs and arrhythmias in chronic heart failure.

Quantifying the magnitude of torque physiotherapists apply when stretching the hamstring muscles of people with spinal cord injury

OBJECTIVE

To quantify the magnitude of stretch that physiotherapists apply to the hamstring muscles of people with spinal cord injury (SCI).

DESIGN

Repeated-measures design.

SETTING

SCI unit in Australia.

PARTICIPANTS

Fifteen individuals with motor complete paraplegia or tetraplegia.

INTERVENTION

Twelve physiotherapists manually administered a stretch to the hamstring muscles of each subject. The stretch was applied by flexing the hip with the knee extended.

MAIN OUTCOME MEASURE

Applied hip flexor torque.

RESULTS

Therapists applied median hip flexor torques of between 30 and 68Nm, although some torques were as large as 121Nm. The stretch applied by different therapists to any 1 subject varied as much as 40-fold.

CONCLUSION

There is a large range of stretch torques provided by physiotherapists to patients with SCI. Some therapists provide stretch torques well in excess of those tolerated by individuals with intact sensation.

Complications from therapeutic modalities: results of a national survey of athletic trainers

OBJECTIVE

To understand better the frequency and type of complications encountered by athletic trainers.

DESIGN

A descriptive questionnaire.

SETTING

Athletic training facilities at the high school, college, and professional levels, as well as physical therapy clinics.

PARTICIPANTS

A total of 3012 certified athletic trainers employed in above-mentioned settings.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Frequency and types of complications encountered for different modalities were computed. Primary modality type used and frequency of complications in different settings were explored.

RESULTS

Of the 3012 surveyed, 905 (30%) responded, 26% of whom reported a complication; 362 total complications were documented. Cryotherapy accounted for 42% of complications, with allergic reactions (n=86), burns (n=23), and intolerance/pain (n=16) most commonly listed. Electric stimulation accounted for 29% of complications, with skin irritation (n=41), burns (n=40), and intolerance/pain (n=18) most commonly listed. Therapeutic heat accounted for 22% of complications; therapeutic exercise accounted for 7% of complications.

CONCLUSIONS

Compared with documented complications in the peer-reviewed literature, our survey results differed vastly with regard to the complications encountered. This may reflect a learning phenomenon, a shift in modality usage, or a general underreporting of complications.

A prehabilitation program for physically frail community-living older persons

OBJECTIVES

To describe the development and implementation of a preventive, home-based physical therapy program (PREHAB) and to provide evidence for the safety and interrater reliability of the PREHAB protocol.

DESIGN

Demonstration study.

SETTING

General community.

PARTICIPANTS

Ninety-four physically frail, community-living persons, aged 75 years or older, who were randomized to the PREHAB program in a clinical trial.

INTERVENTIONS

The PREHAB program built on the physical therapy component of 2 previous home-based protocols. A total of 223 assessment items were linked to 28 possible interventions, including progressive balance and conditioning exercises, by using detailed algorithms and decisions rules that were automated on notebook computers.

MAIN OUTCOMES MEASURES

The percentages of participants who were eligible for and who completed each intervention, the extent of progress noted in the balance and conditioning exercises, adherence to the training program, and adverse events.

RESULTS

Participants who completed the PREHAB program and those who ended it prematurely received an average of 9.7 and 7.2 interventions during an average of 14.9 and 9.5 home visits, respectively. With few exceptions, the completion rate and interrater reliability for the specific interventions were high. Despite high self-reported adherence to the training program, the majority of participants did not advance beyond the initial Thera-Band level for the upper- and lower-extremity conditioning exercises, and only about a third advanced to the highest 2 levels of the balance exercises. Adverse events were no more common in the PREHAB group than in the educational control group.

CONCLUSION

Our results support the feasibility and safety of the PREHAB program, but also show the special challenges and pitfalls of such a strategy when it is implemented among persons of advanced age and physical frailty.

The initial effects of low-volume strength training on balance in untrained older men and women

Evidence indicates that leg weakness in older adults is associated with decreased control of balance. The gender-specific implications of strength training on control of balance in older men and women remains unknown. This study examined the initial adaptations to 12 weeks of low-volume, single-set-to-failure strength training and its effect on quadriceps strength and control of multidirectional balance in previously untrained older men (n = 11) and women (n = 11) 59-83 years of age. Leg strength increased 23-30% (p < 0.001) across genders; however, the effect on balance varied between genders. No significant changes were noted in the women, whereas 37% (p < 0.014) more sway in the medial-lateral direction was noted in the men, with no change in the anterior-posterior direction. These results demonstrate that this training protocol may not be effective for improving balance and may lead to worsening of balance in older men.

Sporadic inclusion body myositis: pilot study on the effects of a home exercise program on muscle function, histopathology and inflammatory reaction

OBJECTIVE

To evaluate the safety and effect of a home training program on muscle function in 7 patients with sporadic inclusion body myositis.

DESIGN

The patients performed exercise 5 days a week over a 12-week period.

METHODS

Safety was assessed by clinical examination, repeated muscle biopsies and serum levels of creatine kinase. Muscle strength was evaluated by clinical examination, dynamic dynamometer and by a functional index in myositis.

RESULTS

Strength was not significantly improved after the exercise, however none of the patients deteriorated concerning muscle function. The histopathology was unchanged and there were no signs of increased muscle inflammation or of expression of cytokines and adhesion molecules in the muscle biopsies. Creatine kinase levels were unchanged. A significant decrease was found in the areas that were positively stained for EN-4 (a marker for endothelial cells) in the muscle biopsies after training.

CONCLUSION

The home exercise program was considered as not harmful to the muscles regarding muscle inflammation and function. Exercise may prevent loss of muscle strength due to disease and/or inactivity.

A randomized controlled trial of resistance exercise training to improve glycemic control in older adults with type 2 diabetes

OBJECTIVE

To determine the efficacy of high-intensity progressive resistance training (PRT) on glycemic control in older adults with type 2 diabetes.

RESEARCH DESIGN AND METHODS

We performed a 16-week randomized controlled trial in 62 Latino older adults (40 women and 22 men; mean +/- SE age 66 +/- 8 years) with type 2 diabetes randomly assigned to supervised PRT or a control group. Glycemic control, metabolic syndrome abnormalities, body composition, and muscle glycogen stores were determined before and after the intervention.

RESULTS

Sixteen weeks of PRT (three times per week) resulted in reduced plasma glycosylated hemoglobin levels (from 8.7 +/- 0.3 to 7.6 +/- 0.2%), increased muscle glycogen stores (from 60.3 +/- 3.9 to 79.1 +/- 5.0 mmol glucose/kg muscle), and reduced the dose of prescribed diabetes medication in 72% of exercisers compared with the control group, P = 0.004-0.05. Control subjects showed no change in glycosylated hemoglobin, a reduction in muscle glycogen (from 61.4 +/- 7.7 to 47.2 +/- 6.7 mmol glucose/kg muscle), and a 42% increase in diabetes medications. PRT subjects versus control subjects also increased lean mass (+1.2 +/- 0.2 vs. -0.1 +/- 0.1 kg), reduced systolic blood pressure (-9.7 +/- 1.6 vs. +7.7 +/- 1.9 mmHg), and decreased trunk fat mass (-0.7 +/- 0.1 vs. +0.8 +/- 0.1 kg; P = 0.01-0.05).

CONCLUSIONS

PRT as an adjunct to standard of care is feasible and effective in improving glycemic control and some of the abnormalities associated with the metabolic syndrome among high-risk older adults with type 2 diabetes.

Clinical practice guideline on the use of manipulation or mobilization in the treatment of adults with mechanical neck disorders

PURPOSE

An evidence-based clinical practice guideline was developed to ascertain the risks and benefits for manipulation or mobilization in treating mechanical neck disorders with or without radicular findings or cerviogenic headache. Pain, function, patient satisfaction and adverse events were appraised.

METHODS

The practice guideline development cycle/model and Cochrane reviewing process, critiquing past reviews, randomized trials and surveys were used.

RESULTS

Manipulation and mobilization alone showed similar effects as placebo, wait period, or control group, and appeared similar in benefit for pain relief. While high-technology exercises were superior to manipulation alone for improving long-term pain scores, manipulation plus low-technology exercise had the same effect. Patient satisfaction scores favoured manipulation plus low-technology exercise over manipulation alone, and high-technology exercise alone. Multi-modal care including some combination of manipulation or mobilizations and exercise was superior to control, other physical medicine methods, and rest. Based on weak evidence, estimates for serious complication for manipulation ranged from one in 20,000 to five in 10,000,000.

RECOMMENDATIONS

Stronger evidence suggests a multi-modal management strategy using mobilization or manipulation plus exercise is beneficial for relief of mechanical neck pain. Weaker evidence suggest less benefit to either manipulation/mobilization done alone than when used with exercise. The risk rate is uncertain.

Effects of a controlled exercise trial on pain in nursing home residents

OBJECTIVES

To report preliminary data relevant to the effects of an exercise and toileting intervention on pain among incontinent nursing home (NH) residents.

DESIGN

A randomized controlled intervention trial.

SETTING AND PARTICIPANTS

Fifty-one incontinent residents in one skilled NH.

INTERVENTION

The intervention was implemented by research staff for a total of 4 times a day (every 2 hours), 5 days a week, for 32 weeks. Residents were provided with incontinence care and assistance to either walk or, if nonambulatory, wheel their chairs, and to repeat sit-to-stand movements.

MEASUREMENTS

Pain was measured in two ways at baseline and again at 32 weeks: (1) a count of the number of verbal expressions and pain behaviors during a standardized physical performance assessment; and (2) a modified Geriatric Pain Measure administered in a one-on-one interview format.

RESULTS

There were significant differences between intervention and control groups on all physical performance measures over time, with the intervention group remaining stable and the control group showing a significant decline in sit-to-stand, walking, and wheelchair propulsion endurance. Both groups showed mild to moderate pain at baseline according to each of the two pain measures, while there were no significant changes in pain reports between groups over time based on either measure. There was, however, a trend for pain to increase in the intervention group.

CONCLUSIONS

No significant changes in pain reports were attributable to exercise despite significant improvements in physical performance. In fact, there was a tendency for pain reports to increase with exercise. These preliminary findings suggest that exercise alone may be ineffective for pain management among incontinent NH residents. Care providers should consider that exercise to improve physical function may increase pain symptoms, requiring preemptive analgesia, other pain control strategies, or modified exercise techniques for this frail segment of the NH population.

Locomotion in simulated microgravity: gravity replacement loads

BACKGROUND

When an astronaut walks or runs on a treadmill in microgravity, a subject load device (SLD) is used to return him or her back to the treadmill belt. The gravity replacement load (GRL) in the SLD is transferred, via a harness, to the pelvis and/or the shoulders. This research compared comfort and ground reaction forces during treadmill running in a microgravity locomotion simulator at GRLs of 60%, 80%, and 100% of body weight (BW). Two harness designs (shoulder springs only (SSO) and waist and shoulder springs (WSS)) were used.

HYPOTHESES

1) The 100% BW gravity replacement load conditions would be comfortably tolerated and would result in larger ground reaction forces and loading rates than the lower load conditions, and 2) the WSS harness would be more comfortable than the SSO harness.

METHODS

Using the Penn State Zero Gravity Locomotion Simulator (ZLS), 8 subjects ran at 2.0 m x s(-1) (4.5 mph) for 3 min at each GRL setting in each harness. Subjective ratings of harness comfort, ground reaction forces, and GRL data were collected during the final minute of exercise.

RESULTS

The 100% BW loading conditions were comfortably tolerated (2.3 on a scale of 0-10), although discomfort increased as the GRL increased. There were no overall differences in perceived comfort between the two harnesses. The loading rates (27.1, 33.8, 39.1 BW x s(-1)) and the magnitudes of the first (1.0, 1.4, 1.6 BW) and second (1.3, 1.7, 1.9 BW) peaks of the ground reaction force increased with increasing levels (60, 80, 100% BW respectively) of GRL.

CONCLUSIONS

Subjects were able to tolerate a GRL of 100% BW well. The magnitude of the ground reaction force peaks and the loading rate is directly related to the magnitude of the GRL.

Manual therapy, physical therapy, or continued care by a general practitioner for patients with neck pain. A randomized, controlled trial

BACKGROUND

Neck pain is a common problem, but the effectiveness of frequently applied conservative therapies has never been directly compared.

OBJECTIVE

To determine the effectiveness of manual therapy, physical therapy, and continued care by a general practitioner.

DESIGN

Randomized, controlled trial.

SETTING

Outpatient care setting in the Netherlands.

PATIENTS

183 patients, 18 to 70 years of age, who had had nonspecific neck pain for at least 2 weeks.

INTERVENTION

6 weeks of manual therapy (specific mobilization techniques) once per week, physical therapy (exercise therapy) twice per week, or continued care by a general practitioner (analgesics, counseling, and education).

MEASUREMENTS

Treatment was considered successful if the patient reported being "completely recovered" or "much improved" on an ordinal six-point scale. Physical dysfunction, pain intensity, and disability were also measured.

RESULTS

At 7 weeks, the success rates were 68.3% for manual therapy, 50.8% for physical therapy, and 35.9% for continued care. Statistically significant differences in pain intensity with manual therapy compared with continued care or physical therapy ranged from 0.9 to 1.5 on a scale of 0 to 10. Disability scores also favored manual therapy, but the differences among groups were small. Manual therapy scored consistently better than the other two interventions on most outcome measures. Physical therapy scored better than continued care on some outcome measures, but the differences were not statistically significant.

CONCLUSION

In daily practice, manual therapy is a favorable treatment option for patients with neck pain compared with physical therapy or continued care by a general practitioner.

Skeletal muscle damage and recovery

Muscular strength is essential for recovery after an acute illness. Disuse atrophy of muscle begins within 4 hours of the start of bed rest resulting in decreases in muscle mass, muscle cell diameter, and the number of muscle fibers. Strenuous exercise of atrophic muscle can lead to muscle damage including sarcolemmal disruption, distortion of the myofibrils' contractile components, and cytoskeletal damage. Assessment of skeletal muscle for disuse atrophy is done clinically at the bedside through strength assessment. Examination of the muscle itself can be conducted through the use of nuclear magnetic resonance imaging, whereas muscle strength can be quantified with a computerized dynamometer. Biochemical markers, including creatine kinase and troponin, also are available for the assessment of skeletal muscle damage. Activity management in the critical care environment focuses on an individualized plan, developed in cooperation with the recovering patient, with the goal of preserving and improving atrophic skeletal muscle.

Prescribing exercise for people with fibromyalgia

Fibromyalgia (FM) is a costly and debilitating pain syndrome which is commonly encountered by advanced practice nurses working in acute care settings. Fibromyalgia affects nearly 6 million people in the United States, approximately 80% to 90% of whom are women. Symptoms of FM include widespread and localized pain, disrupted sleep, fatigue, visceral pain and other pain syndromes, neurological symptoms (eg, dizziness, numbness, tingling, impaired cognition), and exercise-induced pain. Difficulties remaining active with FM may lead to extreme deconditioning, inability to remain employed, and eventually even impaired ability in complete activities of daily living. Exercise that combats deconditioning without triggering pain is, therefore, a key component in treating FM. Clinicians who understand FM pain and associated symptoms can minimize the negative impact of deconditioning by prescribing disease-specific exercise for people with FM.

[Training of back and neck in the year of 2002]

The aim of this review was to determine the relevance of exercise therapy in the total treatment strategy of low back pain (LBP). The review is based on the results of randomised clinical trials, meta-analysis, consensus reports, and medical technology assessments. There is strong evidence for the effectiveness of exercise therapy for subacute and chronic LBP. There is some evidence that exercise is not effective for acute LBP. The most effective exercise programme and the optimal combination of exercise and other effective treatment modalities for different subgroups of LBP patients remain to be determined. Insights regarding the biological mechanisms of the positive effect of exercise are not yet established.