Challenges and Lessons Learned for Acute Inpatient Rehabilitation of Persons With COVID-19: Clinical Presentation, Assessment, Needs, and Services Utilization

OBJECTIVE

The aim of the study was to present: (1) physiatric care delivery amid the SARS-CoV-2 pandemic, (2) challenges, (3) data from the first cohort of post-COVID-19 inpatient rehabilitation facility patients, and (4) lessons learned by a research consortium of New York and New Jersey rehabilitation institutions.

DESIGN

For this clinical descriptive retrospective study, data were extracted from post-COVID-19 patient records treated at a research consortium of New York and New Jersey rehabilitation inpatient rehabilitation facilities (May 1-June 30, 2020) to characterize admission criteria, physical space, precautions, bed numbers, staffing, employee wellness, leadership, and family communication. For comparison, data from the Uniform Data System and eRehabData databases were analyzed. The research consortium of New York and New Jersey rehabilitation members discussed experiences and lessons learned.

RESULTS

The COVID-19 patients (N = 320) were treated during the study period. Most patients were male, average age of 61.9 yrs, and 40.9% were White. The average acute care length of stay before inpatient rehabilitation facility admission was 24.5 days; mean length of stay at inpatient rehabilitation facilities was 15.2 days. The rehabilitation research consortium of New York and New Jersey rehabilitation institutions reported a greater proportion of COVID-19 patients discharged to home compared with prepandemic data. Some institutions reported higher changes in functional scores during rehabilitation admission, compared with prepandemic data.

CONCLUSIONS

The COVID-19 pandemic acutely affected patient care and overall institutional operations. The research consortium of New York and New Jersey rehabilitation institutions responded dynamically to bed expansions/contractions, staff deployment, and innovations that facilitated safe and effective patient care.

Rehabilitation and In-Hospital Mortality in COVID-19 patients

BACKGROUND

COVID-19 guidelines endorse early rehabilitation to improve outcomes in hospitalized patients, but the evidence-base to support this recommendation is lacking. We examined the association between early rehabilitation and in-hospital deaths in COVID-19 patients.

METHODS

Single center retrospective study involving 990 COVID-19 patients (42·4% women, mean age 67.8 years) admitted between March 1, 2020 and May 31, 2020 to a community hospital. Association of rehabilitation during hospitalization with in-hospital mortality was examined using logistic regression analysis adjusted for demographics, length of stay, body mass index, comorbid illnesses, functional status as well as for COVID-19 presentations, treatments, and complications.

RESULTS

Over the 3-month study period, 475 (48·0%) in-patients were referred for rehabilitation. Patients who received rehabilitation were older (73·7 ± 14·0 vs. 62·3 ± 17·2). There were 61 hospital deaths (12·8%) in the rehabilitation group and 165 (32·0%) in the non-rehabilitation group. Receiving rehabilitation was associated with an 89% lower in-hospital mortality (OR 0·11, 95% CI 0·06-0·19) after adjusting for multiple confounders and COVID-19 disease markers. In sensitivity analyses, the results were significant in sub-populations defined by age group, sex, race, length of hospitalization, or pulmonary presentations. Each additional rehabilitation session was associated with a 29% lower risk of in-hospital mortality (OR per session 0·71, 95% CI 0·64-0·79) in the fully adjusted model.

CONCLUSION

Among hospitalized COVID-19 patients, receiving early rehabilitation was associated with lower in-hospital mortality. Our findings support implementation of rehabilitation services for COVID-19 patients in acute care settings, but further research from randomized clinical trials is needed.

Psychosis risk individuals show poor fitness and discrepancies with objective and subjective measures

Exercise is a promising intervention for individuals at clinical high-risk for psychosis (CHR). However, these youth may not be reliable reporters on fitness. There have been no investigations that utilized objective fitness assessment in this population. The present study objectively characterizes the level of fitness in CHR youth, compares the accuracy of self-report measures to objective fitness indices, and explores clinical factors that may influence the accuracy of self-reported measures of fitness. Forty CHR individuals completed an exercise survey and objective indices of fitness (i.e., VO2max and BMI). Forty healthy volunteers completed objective indices of fitness and a structured clinical interview ruling out the presence of psychiatric illness. CHR youth showed greater BMI and lowered VO2max compared to healthy volunteers. In the CHR group, self-report items (perceived fitness) did not reflect objective indices of fitness, whereas specific exercise behaviors (intensity of exercise) showed stronger correlations with objective fitness measurements. Exploratory analyses suggested that symptoms (grandiosity and avolition) related to errors in self-perception. Results indicate that CHR individuals are less fit than controls as indexed by objective measures of fitness and that it is important to consider unique population clinical characteristics when employing self-report data.

Effect of the COVID-19 Pandemic on Postacute Care Decision Making

The response to the coronavirus disease 2019 (COVID-19) pandemic in the United States has resulted in rapid modifications in the delivery of health care. Key among them has been surge preparation to increase both acute care hospital availability and staffing while using state and federal waivers to provide appropriate and efficient delivery of care. As a large health system in New York City, the epicenter of the pandemic in the United States, we were faced with these challenges early on, including the need to rapidly transition patients from acute care beds to provide bed capacity for the acute care hospitals. Rehabilitation medicine has always played an essential role in the continuum of care, establishing functional goals while identifying patients for postacute care planning. During this crisis, this expertise and the overwhelming need to adapt and facilitate patient transitions resulted in a collaborative process to efficiently assess patients for postacute care needs. We worked closely with our skilled nursing facility, home care partners, and an acute inpatient rehabilitation hospital to adapt their admissions processes to the patient population with COVID-19, all the while grappling with varying access to vital supplies, testing, and manpower. As the patient criteria were established, rapid pathways were created to postacute care, and we were able to create much needed bed capacity in our acute care hospitals.

Suicide Reduction in Schizophrenia via Exercise (SUnRISE): study protocol for a multi-site, single-blind, randomized clinical trial of aerobic exercise for suicide risk reduction in individuals with schizophrenia

BACKGROUND

Suicide risk among individuals with schizophrenia (SZ) is intractably high, with over 40% of individuals attempting to take their own lives during their lifetime and an estimated 5-10% completing suicide. At present, available pharmacological and psychotherapeutic treatments offer limited risk reduction benefits, and thus, there remains an urgent need to explore novel interventions that will ameliorate this risk. Aerobic exercise (AE) has been shown to improve a number of predictors of suicide risk (e.g., depressed mood, sleeping difficulties). As individuals with SZ display a highly sedentary lifestyle, AE may reduce suicide risk.

METHODS

Employing a multi-site, single-blind, randomized clinical trial design, we will examine the impact of AE on risk for suicide and related variables in individuals with SZ. Participants will be randomized to one of two 12-week exercise interventions: AE or a stretching and toning (ST) control intervention. Primary outcome measures will include suicide risk (Columbia Suicide Severity Rating Scale, C-SSRS) and aerobic fitness (VO2max), along with additional measures of suicide risk, mood, emotion regulation, sleep, cognition, and physical activity, with assessments completed at baseline and after 6 and 12 weeks of interventions.

DISCUSSION

It is hypothesized that AE will reduce suicide risk among individuals with SZ. This study may offer support for a more efficacious treatment method for this population in addition to the pre-existing pharmacological and psychotherapeutic treatment regimens.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT03270098 . Registered on September 1, 2017.

What Now for Rehabilitation Specialists? Coronavirus Disease 2019 Questions and Answers

Recognizing a need for more guidance on the coronavirus disease 2019 (COVID-19) pandemic, members of the Archives of Physical Medicine and Rehabilitation Editorial Board invited several clinicians with early experience managing the disease to collaborate on a document to help guide rehabilitation clinicians in the community. This consensus document is written in a “question and answer” format and contains information on the following items: common manifestations of the disease; rehabilitation recommendations in the acute hospital setting, recommendations for inpatient rehabilitation and special considerations. These suggestions are intended for use by rehabilitation clinicians in the inpatient setting caring for patients with confirmed or suspected COVID-19. The text represents the authors’ best judgment at the time it was written. However, our knowledge of COVID-19 is growing rapidly. The reader should take advantage of the most up-to-date information when making clinical decisions.

Redefining Pathways into Acute Rehabilitation during the COVID-19 Crisis

The coronavirus disease 2019 (COVID‐19) pandemic has necessitated drastic changes across the spectrum of health care, all of which have occurred with unprecedented rapidity. The need to accommodate change on such a large scale has required ingenuity and decisive thinking. The field of physical medicine and rehabilitation has been faced with many of these challenges. Healthcare practitioners in New York City, the epicenter of the pandemic in the United States, were among the first to encounter many of these challenges. One of the largest lessons included learning how to streamline admissions and transfer process into an acute rehabilitation hospital as part of a concerted effort to make acute care hospital beds available as quickly as possible.

Footwear-Generated Dynamic Biomechanical Manipulation and Perturbation Training for Chronic Nonspecific Low Back Pain

BACKGROUND

Home-based therapy optimizing biomechanics and neuromuscular control is increasingly recognized as a treatment option for chronic nonspecific low back pain (CNSLBP). However, its impact on pain, function, and gait is limited among patients in a metropolitan area.

OBJECTIVE

To evaluate the change of pain, function, and gait parameters with home-based therapy with the use of footwear-generated biomechanical manipulation and perturbation training in a population with CNSLBP in a metropolitan area.

DESIGN

Prospective observational study.

SETTING

Outpatient rehabilitation clinic at an academic teaching hospital.

PARTICIPANTS

One hundred sixteen patients with CNSLBP for more than 6 months.

INTERVENTION

Six months of home-based therapy with a biomechanical device using 4 modular elements attached to a foot-worn platform.

MAIN OUTCOME MEASURES

Instrumental gait analysis (gait velocity, step length, single limb support phase % of gait cycle), Numeric Rating Scale for pain, and Oswestry Disability Questionnaire Index for pain and function.

RESULTS

Only 43 patients (37.1%) completed the study. Among 43 patients, mean gait velocity increased from 86.6 ± 20.7 to 99.7 ± 22.1 cm/s (P < .0001) in 6 months. Mean left step length increased from 51.1 ± 8.4 to 54.8 ± 9.8 cm (P < .0001). Mean right step length increased from 51.0 ± 7.9 to 55.4 ± 9.0 cm (P < .0001). Mean single limb support increased from 36.4 ± 2.8 to 37.2 ± 2.5%, (P = .208) in the right side and from 36.6 ± 3.0 to 37.8 ± 4.4%, (P = .019) in the left side. Median Oswestry Disability Questionnaire Index score improved from 28 (18-44; interquartile range) to 17 (10-35) (P = .045). Mean Numeric Rating Scale for back pain improved from 7.7 ± 1.8 to 3.3 ± 3.1 (P < .0001).

CONCLUSION

At 6 months, patients with CNSLBP undergoing home-based therapy with footwear-generated biomechanical manipulation and perturbation training demonstrated significant improvement of objective gait parameters, pain, and function.

LEVEL OF EVIDENCE

IV.

Custom Fabrication of a 3-Dimensionally Printed Helmet for Improved Socialization and Subjective Self-Assessment in a Case of Acquired Cranial Defect: A Case Presentation

Traumatic injury and subsequent residual cosmetic deformity are subject of intense scrutiny for their effects on objective health measures assessing patient morbidity and mortality. Although these remain principal concerns of all members of the treatment team, of less immediate yet lasting importance to the patient are the social costs of such disfigurement. Subjective feelings of unease and embarrassment can hinder social reintegration and encourage deteriorating psychosocial health. The following presents a case of one such individual who sustained traumatic brain injury and associated pneumocephalus and osteomyelitis requiring surgical debridement with bifrontal craniectomy and lobotomy. Postoperative management was cosmetically improved by the application of a custom-fabricated, 3-dimensionally printed helmet used in place of generic over-the-counter hardware, and the associated improvement reported in patient satisfaction is reported.

LEVEL OF EVIDENCE

V.

The Impact of Hypomania on Aerobic Capacity and Cardiopulmonary Functioning-A Case Report

Background: Hypomanic episodes are characterized by increased goal-directed behavior and psychomotor agitation. While the affective, cognitive, and behavioral manifestations of such episodes are well-documented, their physiological influence on aerobic capacity and cardiopulmonary functioning are unknown. Methods: We describe a case report of an individual with schizophrenia who experienced a hypomanic episode while serving as a control participant (wait list) in a single-blind, randomized clinical trial examining the impact of aerobic exercise (AE) on neurocognition in people schizophrenia. As part of the trial, participants completed two scheduled clinical assessments and cardiopulmonary exercise tests (VO₂max) at baseline and 12 weeks later at end of study. All participants received standard psychiatric care during the trial. Following a baseline assessment in which he displayed no evidence of mood lability, the subject returned on Week-12 for his scheduled follow-up assessment displaying symptoms of hypomania. He was able to complete the follow-up assessment, as well as third assessment 2 weeks later (Week-14) when his hypomanic symptoms ebbed. Results: While not engaging in AE, the subject's aerobic capacity, as indexed by VO₂max, increased by 33% from baseline to Week-12. In comparison, participants engaged in the aerobic exercise training increased their aerobic capacity on average by 18%. In contrast, participants in the control group displayed a small decline (-0.5%) in their VO₂max scores. Moreover, the subject's aerobic capacity increased even further by Week-14 (49% increase from baseline), despite the ebbing of his hypomania symptoms at that time. These changes were accompanied by increases in markers of aerobic fitness including peak heart rate, respiratory exchange rate, peak minute ventilation, watts, and peak systolic blood pressure. Resting systolic and diastolic blood pressure, and peak diastolic blood pressure remained unchanged. Conclusions: Our findings suggest that hypomania produce substantial increase in aerobic capacity and that such elevations may remain sustained following the ebbing of hypomanic symptoms. Such elevations may be attributed to increased mobility and goal-directed behavior associated with hypomania, as individuals in hypomanic states may ambulate more frequently, for longer duration, and/or at higher intensity. Our results provide a first and unique view into the impact of hypomania on aerobic capacity and cardiopulmonary functioning.

Primary graft dysfunction: Long-term physical function outcomes among lung transplant recipients

BACKGROUND

Adults with primary graft dysfunction (PGD) after lung transplantation are at increased risk for pulmonary and functional impairment. No prior studies have described the long-term (within 1.5 years of transplant) cardiopulmonary exercise testing (CPET) results in adults with grade 3 PGD. The objective of this study was to compare the functional outcomes of lung transplant patients with and without grade 3 PGD via CPET and six-minute talk tests (6MWD).

METHODS

243 adults underwent lung transplantation between 2003 and 2010, 128 (53%) of whom underwent CPET and 6MWD within 12-18 months of transplantation. The primary measure of exposure was grade 3 PGD at 72 h, however grade 3 PGD within 72 h was also assessed. In addition, the impact of potential confounding variables was explored.

RESULTS

Approximately one-third (32%) of the 243 patients experienced grade 3 PGD within 72 h; among these, 15 (6%) had grade 3 PGD at the 72 h time point. There were no differences in CPET or 6MWD between those with and without grade 3 PGD at 72 h despite a longer length of hospital stay and lower pulmonary function. Similar results were seen for patients with and without grade 3 PGD within 72 h, with the exception of a lower heart rate on CPET.

CONCLUSIONS

Participants with grade 3 PGD are able to achieve functional outcomes comparable to those without PGD.

High attenuation areas on chest computed tomography in community-dwelling adults: the MESA study

Evidence suggests that lung injury, inflammation and extracellular matrix remodelling precede lung fibrosis in interstitial lung disease (ILD). We examined whether a quantitative measure of increased lung attenuation on computed tomography (CT) detects lung injury, inflammation and extracellular matrix remodelling in community-dwelling adults sampled without regard to respiratory symptoms or smoking.We measured high attenuation areas (HAA; percentage of lung voxels between -600 and -250 Hounsfield Units) on cardiac CT scans of adults enrolled in the Multi-Ethnic Study of Atherosclerosis.HAA was associated with higher serum matrix metalloproteinase-7 (mean adjusted difference 6.3% per HAA doubling, 95% CI 1.3-11.5), higher interleukin-6 (mean adjusted difference 8.8%, 95% CI 4.8-13.0), lower forced vital capacity (FVC) (mean adjusted difference -82 mL, 95% CI -119--44), lower 6-min walk distance (mean adjusted difference -40 m, 95% CI -1--80), higher odds of interstitial lung abnormalities at 9.5 years (adjusted OR 1.95, 95% CI 1.43-2.65), and higher all cause-mortality rate over 12.2 years (HR 1.58, 95% CI 1.39-1.79).High attenuation areas are associated with biomarkers of inflammation and extracellular matrix remodelling, reduced lung function, interstitial lung abnormalities, and a higher risk of death among community-dwelling adults.

Analysis of Skeletal Muscle Torque Capacity and Circulating Ceramides in Patients with Advanced Heart Failure

BACKGROUND

Heart failure (HF)-related exercise intolerance is thought to be perpetuated by peripheral skeletal muscle functional, structural, and metabolic abnormalities. We analyzed specific dynamics of muscle contraction in patients with HF compared with healthy, sedentary controls.

METHODS

Isometric and isokinetic muscle parameters were measured in the dominant upper and lower limbs of 45 HF patients and 15 healthy age-matched controls. Measurements included peak torque normalized to body weight, work normalized to body weight, power, time to peak torque, and acceleration and deceleration to maximum strength times. Body morphometry (dual energy X-ray absorptiometry scan) and circulating fatty acids and ceramides (lipodomics) were analyzed in a subset of subjects (18 HF and 9 controls).

RESULTS

Extension and flexion time-to-peak torque was longer in the lower limbs of HF patients. Furthermore, acceleration and deceleration times in the lower limbs were also prolonged in HF subjects. HF subjects had increased adiposity and decreased lean muscle mass compared with controls. Decreased circulating unsaturated fatty acids and increased ceramides were found in subjects with HF.

CONCLUSIONS

Delayed torque development suggests skeletal muscle impairments that may reflect abnormal neuromuscular functional coupling. These impairments may be further compounded by increased adiposity and inflammation associated with increased ceramides.

Use of Active-Play Video Games to Enhance Aerobic Fitness in Schizophrenia: Feasibility, Safety, and Adherence

OBJECTIVE

Active-play video games have been used to enhance aerobic fitness in various clinical populations, but their use among individuals with schizophrenia has been limited.

METHODS

Feasibility, acceptability, safety, and adherence data were obtained for use of aerobic exercise (AE) equipment by 16 individuals with schizophrenia during a 12-week AE program consisting of three one-hour exercise sessions per week. Equipment included exercise video games for Xbox 360 with Kinect motion sensing devices and traditional exercise equipment.

RESULTS

Most participants (81%) completed the training, attending an average of 79% of sessions. The proportion of time spent playing Xbox (39%) exceeded time spent on any other type of equipment. When using Xbox, participants played 2.24±1.59 games per session and reported high acceptability and enjoyment ratings, with no adverse events.

CONCLUSIONS

Measures of feasibility, acceptability, adherence, and safety support the integration of active-play video games into AE training for people with schizophrenia.

Left and Right Ventricular Functional Dynamics Determined by Echocardiograms Before and After Lung Transplantation

Impaired cardiac function is considered a contraindication for lung transplantation (LT). Because right ventricular (RV) function is expected to improve after LT, poor left ventricular (LV) function is often the determinant for LT eligibility. However, the changes in cardiac function before and after LT have not yet been elucidated. Therefore, we reviewed echocardiograms obtained from 67 recipients before and after LT. In a subset of 49 patients, both RV and LV longitudinal strains based on 2-dimensional speckle tracking echocardiography were analyzed. The cardiopulmonary exercise tests were also reviewed. All patients showed significant improvements in their exercise capacity after LT. RV echo parameters improved in all patients after LT (RV fractional area change: 36.7 ± 5.6% to 41.5 ± 2.7%, RV strain: -15.5 ± 2.9% to -18.0 ± 2.1%, RV E/E': 8.4 ± 1.8 to 7.7 ± 1.8; all p <0.05). Overall, the left ventricular ejection fraction (LVEF) did not change (58.7 ± 6.0% to 57.5 ± 9.7%, p = 0.385); however, 20 patients (30%) showed >10% decrease in LVEF after LT (61.5 ± 6.1% to 47.3 ± 4.2%, p <0.001) and an increase in LV E/E' (11.8 ± 1.8 to 12.9 ± 2.2, p = 0.049). Multivariate logistic regression analysis revealed that pre-LT LV E/E' was associated with decrease in LVEF after LT (odds ratio 1.381, 95% confidence interval 1.010 to 1.947, p = 0.043). Furthermore, patients with strain data showed that lower pre-LT LV strain was independently associated with LVEF decrease after LT (odds ratio 1.293, 95% confidence interval 1.088 to 1.614, p = 0.002). Although RV function improves after LT, LV systolic and diastolic functions deteriorate in a sizable proportion of patients. Impaired LV diastolic function before transplant appears to increase the risk of LVEF deterioration after LT.

Supplementation of l-Alanyl-l-Glutamine and Fish Oil Improves Body Composition and Quality of Life in Patients With Chronic Heart Failure

BACKGROUND

Skeletal muscle dysfunction and exercise intolerance are clinical hallmarks of patients with heart failure. These have been linked to a progressive catabolic state, skeletal muscle inflammation, and impaired oxidative metabolism. Previous studies suggest beneficial effects of ω-3 polyunsaturated fatty acids and glutamine on exercise performance and muscle protein balance.

METHODS AND RESULTS

In a randomized double-blind, placebo-controlled trial, 31 patients with heart failure were randomized to either l-alanyl-l-glutamine (8 g/d) and polyunsaturated fatty acid (6.5 g/d) or placebo (safflower oil and milk powder) for 3 months. Cardiopulmonary exercise testing, dual-energy x-ray absorptiometry, 6-minute walk test, hand grip strength, functional muscle testing, echocardiography, and quality of life and lateral quadriceps muscle biopsy were performed at baseline and at follow-up. Oxidative capacity and metabolic gene expression were analyzed on muscle biopsies. No differences in muscle function, echocardiography, 6-minute walk test, or hand grip strength and a nonsignificant increase in peak VO2 in the treatment group were found. Lean body mass increased and quality of life improved in the active treatment group. Molecular analysis revealed no differences in muscle fiber composition, fiber cross-sectional area, gene expression of metabolic marker genes (PGC1α, CPT1, PDK4, and GLUT4), and skeletal muscle oxidative capacity.

CONCLUSIONS

The combined supplementation of l-alanyl-l-glutamine and polyunsaturated fatty acid did not improve exercise performance or muscle function but increased lean body mass and quality of life in patients with chronic stable heart failure. These findings suggest potentially beneficial effects of high-dose nutritional polyunsaturated fatty acids and amino acid supplementations in patients with chronic stable heart failure.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01534663.

The Impact of Aerobic Exercise on Brain-Derived Neurotrophic Factor and Neurocognition in Individuals With Schizophrenia: A Single-Blind, Randomized Clinical Trial

Individuals with schizophrenia display substantial neurocognitive deficits for which available treatments offer only limited benefits. Yet, findings from studies of animals, clinical and nonclinical populations have linked neurocognitive improvements to increases in aerobic fitness (AF) via aerobic exercise training (AE). Such improvements have been attributed to up-regulation of brain-derived neurotrophic factor (BDNF). However, the impact of AE on neurocognition, and the putative role of BDNF, have not been investigated in schizophrenia. Employing a proof-of-concept, single-blind, randomized clinical trial design, 33 individuals with schizophrenia were randomized to receive standard psychiatric treatment (n = 17; "treatment as usual"; TAU) or attend a 12-week AE program (n = 16) utilizing active-play video games (Xbox 360 Kinect) and traditional AE equipment. Participants completed assessments of AF (indexed by VO2 peak ml/kg/min), neurocognition (MATRICS Consensus Cognitive Battery), and serum-BDNF before and after and 12-week period. Twenty-six participants (79%) completed the study. At follow-up, the AE participants improved their AF by 18.0% vs a -0.5% decline in the TAU group (P = .002) and improved their neurocognition by 15.1% vs -2.0% decline in the TAU group (P = .031). Hierarchical multiple regression analyses indicated that enhancement in AF and increases in BDNF predicted 25.4% and 14.6% of the neurocognitive improvement variance, respectively. The results indicate AE is effective in enhancing neurocognitive functioning in people with schizophrenia and provide preliminary support for the impact of AE-related BDNF up-regulation on neurocognition in this population. Poor AF represents a modifiable risk factor for neurocognitive dysfunction in schizophrenia for which AE training offer a safe, nonstigmatizing, and side-effect-free intervention.

Effect of lung transplantation on heart rate response to exercise

OBJECTIVES

To evaluate if patients have a change in percent of predicted heart rate reserve used at peak exercise (%HRR) after lung transplantation, even at matching workloads.

BACKGROUND

Lung disease of obstructive, restrictive, and mixed types may be associated with an autonomic imbalance. Lung transplantation may improve the effects of pulmonary disease on cardiac function. However, the effect of lung transplantation on heart rate responses during exercise has not been investigated in detail.

METHODS

Retrospective review of patients who underwent lung transplantation. Pre and post transplant cardiopulmonary exercise tests were reviewed.

RESULTS

The %HRR significantly improved by a median of 37% (p < 0.001) following lung transplantation. When matching workloads were analyzed, the %HRR also decreased from a median of 36% to 24% (p < 0.001).

CONCLUSIONS

Corresponding to an increase in peak exercise capacity, percentage of heart rate reserve used improves significantly after lung transplantation, even at matching workloads, indicating a likely improvement in autonomic modulation.

Quantification of Improvements in Static and Dynamic Ventilatory Measures Following Lung Volume Reduction Surgery for Severe COPD

Rationale: This study quantitatively measured the effects of lung volume reduction surgery (LVRS) on spirometry, static and dynamic lung and chest wall volume subdivision mechanics, and cardiopulmonary exercise measures. Methods: Patients with severe COPD (mean FEV₁ = 23 ± 6% predicted) undergoing LVRS evaluation were recruited. Spirometry, plethysmography and exercise capacity were obtained within 6 months pre-LVRS and again within 12 months post- LVRS. Ventilatory mechanics were quantified using stationary optoelectronic plethysmography (OEP) during spontaneous tidal breathing and during maximum voluntary ventilation (MVV). Statistical significance was set at P< 0.05. Results:Ten consecutive patients met criteria for LVRS (5 females, 5 males, age: 62±6yrs). Post -LVRS (mean follow up 7 months ± 2 months), the group showed significant improvements in dyspnea scores (pre 4±1 versus post 2 ± 2), peak exercise workload (pre 37± 21 watts versus post 50 ± 27watts ), heart rate (pre 109±19 beats per minutes [bpm] versus post 118±19 bpm), duty cycle (pre 30.8 ± 3.8% versus post 38.0 ± 5.7%), and spirometric measurements (forced expiratory volume in 1 second [FEV₁] pre 23 ± 6% versus post 32 ± 13%, total lung capacity / residual lung volume pre 50 ± 8 versus 50 ± 11) . Six to 12 month changes in OEP measurements were observed in an increased percent contribution of the abdomen compartment during tidal breathing (41.2±6.2% versus 44.3±8.9%, P=0.03) and in percent contribution of the pulmonary ribcage compartment during MVV (34.5±10.3 versus 44.9±11.1%, P=0.02). Significant improvements in dynamic hyperinflation during MVV occurred, demonstrated by decreases rather than increases in end expiratory volume (EEV) in the pulmonary ribcage (pre 207.0 ± 288.2 ml versus post -85.0 ± 255.9 ml) and abdominal ribcage compartments (pre 229.1 ± 182.4 ml versus post -17.0 ± 136.2 ml) during the maneuver. Conclusions: Post-LVRS, patients with severe COPD demonstrate significant favorable changes in ventilatory mechanics, during tidal and maximal voluntary breathing. Future work is necessary to determine if these findings are clinically relevant, and extend to other environments such as exercise.

Aerobic fitness and body mass index in individuals with schizophrenia: Implications for neurocognition and daily functioning

Previous reports indicate that among healthy individuals low aerobic fitness (AF) and high body-mass index (BMI) predict poor neurocognition and daily-functioning. It is unknown whether these associations extend to disorders characterized by poor neurocognition, such as schizophrenia. Therefore, we compared AF and BMI in individuals with schizophrenia and non-clinical controls, and then within the schizophrenia group we examined the links between AF, BMI, neurocognition and daily-functioning. Thirty-two individuals with schizophrenia and 64 gender- and age-matched controls completed assessments of AF (indexed by VO2max) and BMI. The former also completed measures of neurocognition, daily-functioning and physical activity. The schizophrenia group displayed significantly lower AF and higher BMI. In the schizophrenia group, AF was significantly correlated with overall neurocognition (r=0.57), along with executive functioning, working memory, social cognition, and processing speed. A hierarchical regression analysis indicated that AF accounted for 22% of the neurocognition variance. Furthermore, AF was significantly correlated with overall daily-functioning (r=0.46). In contrast, BMI displayed significant inverse correlations with neurocognition, but no associations to daily-functioning. AF was significantly correlated physical activity. The authors discuss the potential use of AF-enhancing interventions to improve neurocognitive and daily-functioning in schizophrenia, along with putative neurobiological mechanisms underlying these links, including Brain-Derived Neurotrophic Factor.

Ventilatory efficiency before and after lung volume reduction surgery

BACKGROUND

Lung volume reduction surgery (LVRS) has been shown to improve the clearance of carbon dioxide and minute ventilation (V̇E) in select patients with COPD. One variable often assessed in COPD is ventilatory efficiency (V̇E/V̇CO2 ).

METHODS

We compared 55 LVRS subjects with 25 controls from the National Emphysema Treatment Trial. V̇E/V̇CO2 was calculated from cardiopulmonary exercise testing at baseline and 6-months. We sought to assess V̇E/V̇CO2 changes with LVRS compared with controls who only received standard medical care.

RESULTS

At 6 months, the LVRS group significantly increased peak V̇O2 , work load, V̇E, V̇CO2 , and tidal volume while lowering peak and lowest V̇E/V̇CO2 (improved ventilatory efficiency) and end-tidal carbon dioxide pressure. The control group did not display these changes. The changes were greatest in the LVRS subjects who improved their exercise capacity after surgery (> 10 W).

CONCLUSIONS

The changes were greatest in the LVRS subjects who showed the most functional improvement, indicating an association of improved ventilation with improved functional outcome.

Impact of pulmonary hypertension on exercise performance in patients with interstitial lung disease undergoing evaluation for lung transplantation

BACKGROUND AND OBJECTIVE

Pulmonary hypertension (PH) is a known complication in patients with interstitial lung disease (ILD). Cardiopulmonary exercise testing (CPET) is an essential tool for the assessment of patients with cardiac and pulmonary diseases due to its prognostic and therapeutic implications. Few studies have evaluated the relationship between CPET response and mean pulmonary artery pressures (mPAP) in ILD. The purpose of the present study was to determine and compare the potential correlations between CPET, 6-min walk test (6MWT), pulmonary function testing (PFT) and PH in patients with ILD being evaluated for lung transplantation.

METHODS

The present study reviewed patients with ILD who received lung transplantations and had CPETs within 2 years before transplantation, right heart catheterizations, PFTs and 6MWTs within 4 months of CPET.

RESULTS

A total of 72 patients with ILD were analysed; 36% had PH. There were significant correlations between mPAP and CPET parameters in patients with PH; but mPAP had no impact on percent of predicted diffusion capacity of the lung for carbon monoxide or 6-min walk distance (6MWD). CPET parameters were able to detect differences between levels of severity of PH through the use of the ratio of minute ventilation to rate of carbon dioxide production (VE/VCO2) and the partial pressure of end-tidal carbon dioxide.

CONCLUSIONS

This is the first study that analyses 6MWD, PFT and CPET in patients with ILD awaiting lung transplantation with and without PH. The present study demonstrates the significant impact of PH on exercise capacity and performance in patients with ILD awaiting lung transplantation.

Comparison of cardiopulmonary exercise testing variables in COPD patients with and without coronary artery disease

BACKGROUND

Coronary artery disease (CAD) is a common concomitant condition and an important cause of morbidity and mortality in patients with chronic obstructive pulmonary disease (COPD). Since COPD and CAD can both independently cause reduced exercise capacity, it is reasonable to hypothesize that the combination of these diseases may compound the abnormalities observed during cardiopulmonary exercise testing (CPET). However, little is known about the impact of CAD on the CPET response in COPD patients. The aim of this study is to compare exercise capacity and gas exchange variables in COPD patients with and without CAD.

METHODS

Fifty-four COPD subjects without CAD (COPDnoCAD) were matched to 54 COPD subjects diagnosed with CAD (COPD/CAD) according to age, gender, body mass index and severity of COPD. All subjects underwent resting pulmonary function and symptom-limited CPET.

RESULTS

Comparing COPDnoCAD patients with COPD/CAD patients revealed that exercise capacity, as measured by % peak oxygen consumption (42 ± 16% vs 53 ± 19%, p = 0.002) and % peak wattage (23 ± 13% vs 32 ± 16%, p = 0.001), was significantly lower in COPD/CAD. Ventilatory response, as measured by VE/VCO2 nadir (36 ± 9 vs 32 ± 5, p = 0.001), was significantly higher in COPD/CAD, with % peak VO2 and VE/VCO2 nadir correlating to % FEV1 and inversely correlating with %DLCO.

CONCLUSION

COPD patients with CAD have significantly impaired CPET responses with lower exercise capacity and impaired gas exchange compared to COPD patients without CAD. These findings may affect the clinical interpretation of CPET data in COPD patients who have concomitant CAD.

Chronotropic incompetence predicts mortality in severe obstructive pulmonary disease

We evaluated the prevalence of chronotropic incompetence (CI), a marker of autonomic dysfunction, and its prognostic value in patients with chronic obstructive pulmonary disease (COPD). We performed a retrospective analysis of 449 patients with severe COPD who underwent a cardiopulmonary exercise test, after excluding patients with lung volume reduction surgery, left ventricular dysfunction and those not in sinus rhythm. CI was defined as percent predicted heart rate reserve (%HRR). Events were defined as death or lung transplant during a median follow-up of 68 months. Median age was 61 years; median percent predicted forced expiratory volume in one second (%FEV1) of 25% and median %HRR of 33%. The hazard ratio for an event in the lowest quartile of %HRR, taking the highest quartile as reference, was of 3.2 (95% confidence interval: 2.1-4.8; p<0.001). In a multivariate regression model, %HRR was an independent predictor of events. In conclusion, CI was an independent and powerful outcome predictor in patients with severe COPD.

Optoelectronic plethysmography compared to spirometry during maximal exercise

The purpose of this study was to compare simultaneous measurements of tidal volume (Vt) by optoelectronic plethysmography (OEP) and spirometry during a maximal cycling exercise test to quantify possible differences between methods. Vt measured simultaneously by OEP and spirometry was collected during a maximal exercise test in thirty healthy participants. The two methods were compared by linear regression and Bland-Altman analysis at submaximal and maximal exercise. The average difference between the two methods and the mean percentage discrepancy were calculated. Submaximal exercise (SM) and maximal exercise (M) Vt measured by OEP and spirometry had very good correlation, SM R=0.963 (p<0.001), M R=0.982 (p<0.001) and high degree of common variance, SM R(2)=0.928, M R(2)=0.983. Bland-Altman analysis demonstrated that during SM, OEP could measure exercise Vt as much as 0.134 L above and -0.025 L below that of spirometry. OEP could measure exercise Vt as much as 0.188 L above and -0.017 L below that of spirometry. The discrepancy between measurements was -2.0 ± 7.2% at SM and -2.4 ± 3.9% at M. In conclusion, Vt measurements at during exercise by OEP and spirometry are closely correlated and the difference between measurements was insignificant.

The effect of lung volume reduction surgery on chronotropic incompetence

BACKGROUND

Chronotropic incompetence (CI) is a marker of poor prognosis in patients with COPD. Treatments that improve pulmonary function and exercise capacity may affect CI. Objectives are to evaluate CI before and after lung volume reduction surgery (LVRS) and determine if changes in CI are associated with changes in pulmonary function and exercise capacity.

METHODS

We performed a retrospective review of 75 patients who underwent LVRS and who had complete cardiopulmonary exercise testing and concurrent pulmonary function tests two months before and about 6 months after surgery. Additionally we evaluated 28 control patients that were randomized to medical treatment as part of the National Emphysema Treatment Trial at our center. We studied CI using the percent of predicted heart rate reserve=(heart rate peak-heart rate rest)/((208-0.7×age)-heart rate rest)×100, before and after surgery and compared it to the control group.

RESULTS

Mean percent of predicted heart rate reserve improved from 41% to 50% (p-value <0.001) after LVRS, while the control group did not change. The mean forced vital capacity and expiratory volume in 1s, peak oxygen consumption, carbon dioxide production, ventilation, tidal volume and maximal workload all improved in the surgery group, while the controls did not improve.

CONCLUSIONS

CI improves after LVRS in a population of patients with COPD. CI improvements are associated with the increases in pulmonary function and exercise capacity. This improvement is seen in a domain of known cardiopulmonary impairment prior to surgery that improves as a positive response to the therapy of LVRS.

The Acute Effects of Acupuncture Upon Autonomic Balance in Healthy Subjects

Restoration of the sympathovagal (S/V) balance, involving a lowering of sympathetic and/or an augmentation of vagal modulation or a combination of both is associated with improvements in cardiovascular morbidity and mortality. To determine whether acupuncture exerts a favorable influence upon resting blood pressure and sympathovagal balance, a single-blind cross-over investigation was used to study the acute effects of acupuncture on S/V balance in normal healthy subjects. The ANOVA revealed a significant lowering of the sympathovagal balance (LF:HF) during rest for the acupuncture treatment from pre (4 ± 2 nu) to post (2.2 ± 1.8 nu)(p < 0.05). No such change was seen during sham treatment. The ANOVA revealed significant differences in systolic blood pressures during rest (114 ± 4 vs. 108 ± 3 mmHg) for the acupuncture treatment (p < 0.05). No significance was found during the sham treatment. The ANOVA failed to reveal any significant improvements in sympathovagal balance during the sustained isometric contraction. The clinical significance of these findings appears to suggest that acupuncture treatment might be beneficial in lowering blood pressure at rest. Furthermore, the lowering of the blood pressure might be in part due to a lowering of the sympathovagal balance. These findings are of importance since acupuncture treatments are non-pharmacological and have no known detrimental side-effects. This investigation employed healthy volunteers, yet acupuncture has been found to have more potent effects in animal models of hypertension and or in the presence of an autonomic imbalance.

Sildenafil for chronic obstructive pulmonary disease: a randomized crossover trial

RATIONALE

Pulmonary hypertension with exercise is common in chronic obstructive pulmonary disease (COPD) and may contribute to exercise limitation in this disease. We aimed to determine the effects of treatment with sildenafil on exercise capacity in patients with COPD and emphysema.

METHODS

We performed a randomized, double-blind, placebo-controlled 2-period crossover trial of sildenafil thrice daily in ten adults with COPD and emphysema on CT scan without pulmonary hypertension. We randomized study participants to 4 weeks of sildenafil (or placebo) followed by a 1-week washout and then 4 weeks of placebo (or sildenafil). The 2 primary outcomes were the 6-minute walk distance and oxygen consumption at peak exercise.

RESULTS

Sildenafil had no effect on 6-minute walk distance (placebo-corrected difference = -7.8 m, 95% confidence interval, -23.2 to 7.5 m, p = 0.35) or oxygen consumption at peak exercise (placebo-corrected difference = -0.1 ml/kg/min, 95% confidence interval -2.1 to 1.8 ml/kg/min, p = 0.89). Sildenafil increased the alveolar-arterial oxygen gradient (p = 0.02), worsened symptoms (p = 0.04), and decreased quality-of-life (p = 0.03). Adverse events were more frequent while receiving sildenafil (p = 0.005).

CONCLUSIONS

Routine sildenafil administration did not have a beneficial effect on exercise capacity in patients with COPD and emphysema without pulmonary hypertension. Sildenafil significantly worsened gas exchange at rest and quality of life. (clinicaltrials.gov NCT00104637).