Barriers and facilitators for physical fitness training in orthopedic geriatric rehabilitation. A qualitative study

PURPOSE

The aim of this explorative, qualitative study is to identify factors that potentially influence the execution of physical fitness training in inpatient orthopedic geriatric rehabilitation (GR), from the perspectives of patients, their relatives and professionals.

MATERIALS AND METHODS

In GR wards of skilled nursing facilities in the Netherlands, semi-structured interviews were held with triads of patients, their relatives and responsible nurses, and focus groups with members of the multidisciplinary teams. Verbatim reports were analyzed according to the framework method.

RESULTS

We found twelve categories of barriers and facilitators related to characteristics of the patients, their family, staff, training program and organization.

CONCLUSIONS

The barriers and facilitators found largely correspond with those found for participation in exercise in related settings, but also show important differences. This overview of barriers and facilitators enables multidisciplinary teams to design improvements at the level of the organization and interventions, as well as at the level of the individual training program, tailoring it to the patient's circumstances and needs. Further research should focus on weighing these barriers and facilitators to develop a feasible guidance for daily practice, as well as testing their effect on the adherence to existing physical fitness training guidelines.

Exercise testing and training in frail older adults with an orthopedic impairment participating in a geriatric rehabilitation program: an international Delphi study

BACKGROUND

Little is known about exercise testing and training in orthopedic geriatric rehabilitation. This study aims to obtain expert-consensus-based recommendations on this matter.

METHODS

Using an online Delphi study we aimed to reach international expert consensus on statements related to testing and training of endurance capacity and muscle strength. Participants needed to have relevant research or clinical expertise. Statements were evaluated and explanatory comments could be provided. After each round anonymous results were presented to participants. Statements could be adjusted or new ones could be formulated if necessary. Consensus was defined as > 75% of participants agreeing.

RESULTS

Thirty experts completed the first round. Twenty-eight (93%) the second and 25 (83%) completed the third round. The majority of experts were physical therapists. Consensus was reached on a total of 34 statements. The statements and comments reflected the need for a pragmatic and tailored approach in this population both for testing and training. For example, for testing endurance capacity, a 6 Minute walk test was promoted and for testing muscle strength, performance in a functional activity was suggested. Ratings of perceived exertion were promoted for monitoring intensity of endurance and muscle strength training in patients without cognitive impairment.

CONCLUSION

In orthopedic GR, endurance and muscle strength testing should be pragmatic and is preferably performed in functional activities. For endurance training existing guidelines of the American College of Sports Medicine can be strived for but adapted as needed and for muscle strength training only lower intensities are agreed upon.

Effectiveness and characteristics of physical fitness training on aerobic fitness in vulnerable older adults: an umbrella review of systematic reviews

OBJECTIVES

To present an overview of effectiveness and training characteristics of physical training on aerobic fitness, compared with alternative or no training, in adults aged over 65 years with various health statuses, providing a basis for guidelines for aerobic training of vulnerable older adults that can be used in geriatric rehabilitation.

DESIGN

An umbrella review of systematic reviews that included both randomised controlled trials and other types of trials.

DATA SOURCES

MEDLINE, Embase, CINAHL and the Cochrane Library were searched on 9 September 2019.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included systematic reviews reporting on physical training interventions that are expected to improve aerobic fitness, presenting results for adults aged 65 years and older, describing at least one of the FITT-characteristics: Frequency, Intensity, Time or Type of exercise, and measuring aerobic fitness at least before and after the intervention.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted the data and assessed the risk of bias. A narrative synthesis was performed.

RESULTS

We included 51 papers on 49 reviews. Positive effect of training on aerobic fitness was reported by 33 reviews, 11 reviews remained inconclusive and 5 reviews reported no effect. Training characteristics varied largely. Frequency: 1-35 sessions/week, Intensity: light-vigorous, Time: <10-120 min/session and Types of exercise: many. The methodological quality was most often low. Subgroup analyses revealed positive effects for all health conditions except for trauma patients. Exercise characteristics from current existing guidelines are widely applicable. For vulnerable older adults, lower intensities and lower frequencies were beneficial. Some health conditions require specific adjustments. Information on adverse events was often lacking, but their occurrence seemed rare.

CONCLUSION

Physical fitness training can be effective for vulnerable older adults. Exercise characteristics from current existing guidelines are widely applicable, although lower frequencies and intensities are also beneficial. For some conditions, adjustments are advised.

PROSPERO REGISTRATION NUMBER

CRD42020140575.

Skeletal muscle alterations in patients with acute Covid-19 and post-acute sequelae of Covid-19

Skeletal muscle-related symptoms are common in both acute coronavirus disease (Covid)-19 and post-acute sequelae of Covid-19 (PASC). In this narrative review, we discuss cellular and molecular pathways that are affected and consider these in regard to skeletal muscle involvement in other conditions, such as acute respiratory distress syndrome, critical illness myopathy, and post-viral fatigue syndrome. Patients with severe Covid-19 and PASC suffer from skeletal muscle weakness and exercise intolerance. Histological sections present muscle fibre atrophy, metabolic alterations, and immune cell infiltration. Contributing factors to weakness and fatigue in patients with severe Covid-19 include systemic inflammation, disuse, hypoxaemia, and malnutrition. These factors also contribute to post-intensive care unit (ICU) syndrome and ICU-acquired weakness and likely explain a substantial part of Covid-19-acquired weakness. The skeletal muscle weakness and exercise intolerance associated with PASC are more obscure. Direct severe acute respiratory syndrome coronavirus (SARS-CoV)-2 viral infiltration into skeletal muscle or an aberrant immune system likely contribute. Similarities between skeletal muscle alterations in PASC and chronic fatigue syndrome deserve further study. Both SARS-CoV-2-specific factors and generic consequences of acute disease likely underlie the observed skeletal muscle alterations in both acute Covid-19 and PASC.

Aerobic Exercise Training in Post-Polio Syndrome: Process Evaluation of a Randomized Controlled Trial

Objective

To explore reasons for the lack of efficacy of a high intensity aerobic exercise program in post-polio syndrome (PPS) on cardiorespiratory fitness by evaluating adherence to the training program and effects on muscle function.

Design

A process evaluation using data from an RCT.

Patients

Forty-four severely fatigued individuals with PPS were randomized to exercise therapy (n = 22) or usual care (n = 22).

Methods

Participants in the exercise group were instructed to exercise 3 times weekly for 4 months on a bicycle ergometer (60–70% heart rate reserve).

Results

The attendance rate was high (median 89%). None of the participants trained within the target heart rate range during >75% of the designated time. Instead, participants exercised at lower intensities, though still around the anaerobic threshold (AT) most of the time. Muscle function did not improve in the exercise group.

Conclusion

Our results suggest that severely fatigued individuals with PPS cannot adhere to a high intensity aerobic exercise program on a cycle ergometer. Despite exercise intensities around the AT, lower extremity muscle function nor cardiorespiratory fitness improved. Improving the aerobic capacity in PPS is difficult through exercise primarily focusing on the lower extremities, and may require a more individualized approach, including the use of other large muscle groups instead.

Trial Registration

Netherlands National Trial Register NTR1371

Reliability of contractile properties of the knee extensor muscles in individuals with post-polio syndrome

Objective

To assess the reliability of contractile properties of the knee extensor muscles in 23 individuals with post-polio syndrome (PPS) and 18 age-matched healthy individuals.

Methods

Contractile properties of the knee extensors were assessed from repeated electrically evoked contractions on 2 separate days, with the use of a fixed dynamometer. Reliability was determined for fatigue resistance, rate of torque development (MRTD), and early and late relaxation time (RT50 and RT25), using the intraclass correlation coefficient (ICC) and standard error of measurement (SEM, expressed as % of the mean).

Results

In both groups, reliability for fatigue resistance was good, with high ICCs (>0.90) and small SEM values (PPS: 7.1%, healthy individuals: 7.0%). Reliability for contractile speed indices varied, with the best values found for RT50 (ICCs>0.82, SEM values <2.8%). We found no systematic differences between test and retest occasions, except for RT50 in healthy subjects (p = 0.016).

Conclusions

In PPS and healthy individuals, the reliability of fatigue resistance, as obtained from electrically evoked contractions is high. The reliability of contractile speed is only moderate, except for RT50 in PPS, demonstrating high reliability.

Significance

This was the first study to examine the reliability of electrically evoked contractile properties in individuals with PPS. Our results demonstrate its potential to study mechanisms underlying muscle fatigue in PPS and to evaluate changes in contractile properties over time in response to interventions or from natural course.

Recovery of walking ability using a robotic device in subacute stroke patients: a randomized controlled study

PURPOSE

This study investigates the effectiveness of Lokomat + conventional therapy in recovering walking ability in non-ambulatory subacute stroke subjects involved in inpatient rehabilitation.

METHOD

Thirty first-ever stroke patients completed 8 weeks of intervention. One group (n = 16) received Lokomat therapy twice a week, combined with three times 30 min a week of conventional overground therapy. The second group (n = 14) received conventional assisted overground therapy only, during a similar amount of time (3.5 h a week). The intervention was part of the normal rehabilitation program. Primary outcome measure was walking speed. Secondary outcome measures assessed other walking- and mobility-related tests, lower-limb strength and quality of life measures. All outcome measures were assessed before and after the intervention and at wk 24 and wk 36 after start of the intervention.

RESULTS

Patients showed significant (p < 0.05) gains in walking speed, other walking- and mobility related tests, and strength of the paretic knee extensors relative to baseline at all assessments. However, there were no significant differences in improvements in any of the variables between groups at any time during the study.

CONCLUSION

These results indicate that substituting Lokomat therapy for some of conventional therapy is as effective in recovering walking ability in non-ambulatory stroke patients as conventional therapy alone. Implications for Rehabilitation Recovery of walking after stroke is important. Robot-assisted therapy is currently receiving much attention in research and rehabilitation practice as devices such as the Lokomat seem to be promising assistive devices. Technical developments, sub-optimal study designs in literature and new therapy insights warrant new effectiveness studies. RESULTS of a financially and practically feasible study indicate that substituting Lokomat therapy for some of conventional therapy is as effective in recovering walking ability in non-ambulatory stroke patients as compared to conventional overground therapy alone.

Exercise intensity of robot-assisted walking versus overground walking in nonambulatory stroke patients

It has been suggested that aerobic training should be considered in stroke rehabilitation programs to counteract detrimental health effects and decrease cardiovascular risk caused by inactivity. Robot-assisted treadmill exercise (using a Lokomat device) has the potential to increase the duration of walking therapy relative to conventional overground therapy. We investigated whether exercise intensity during Lokomat therapy is adequate to elicit a training effect and how assistance during walking in the Lokomat affects this exercise intensity. Ten patients with stroke (age 54 +/- 9 yr) walked in both the Lokomat and in a hallway. Furthermore, 10 nondisabled subjects (age 43 +/- 14 yr) walked in the Lokomat at various settings and on a treadmill at various speeds. During walking, oxygen consumption and heart rate were monitored. Results showed that for patients with stroke, exercise intensity did not reach recommended levels (30% heart rate reserve) for aerobic training during Lokomat walking. Furthermore, exercise intensity during walking in the Lokomat (9.3 +/- 1.6 mL/min/kg) was lower than during overground walking (10.4 +/- 1.3 mL/min/kg). Also, different settings of the Lokomat only had small effects on exercise intensity in nondisabled subjects.

Robot-assisted walking vs overground walking in stroke patients: an evaluation of muscle activity

OBJECTIVE

There is increasing evidence that robot-assisted treadmill training might be useful for gait rehabilitation after stroke. The aim of this study was to evaluate the muscle activity of stroke patients during robot-assisted walking and overground walking, and of a group of able-bodied subjects during overground walking.

DESIGN

Case-control observational study.

SUBJECTS

Ten stroke subjects and 10 able-bodied control subjects.

METHODS

Electromyography measurements of 7 lower-limb muscles were made in 3 trials: robotic walking, in which stroke subjects walked in a robot-assisted gait orthosis; overground walking for the same group of stroke subjects; and overground walking for control subjects. Trials were compared with respect to electromyography amplitude of selected leg muscles.

RESULTS

Higher muscle activity during overground walking compared with robotic walking was found in several muscles during several phases of the gait cycle. A significant trial × leg interaction revealed smaller differences in muscle activity between the paretic and non-paretic leg during robotic walking compared with overground walking. Furthermore, the muscle activity pattern was not significantly different between control walking and robotic walking, while it was different between control walking and overground walking.

CONCLUSION

Despite lower muscle activity, robot-assisted treadmill training may elicit a more symmetrical pattern of leg muscle activity, which approaches that of able-bodied individuals.

High-density surface EMG study on the time course of central nervous and peripheral neuromuscular changes during 8weeks of bed rest with or without resistive vibration exercise

The aim of the present study was to assess the time course and the origin of adaptations in neuromuscular function as a consequence of prolonged bed rest with or without countermeasure. Twenty healthy males volunteered to participate in the present study and were randomly assigned to either an inactive control group (Ctrl) or to a resistive vibration exercise (RVE) group. Prior to, and seven times during bed rest, we recorded high-density surface electromyogram (sEMG) signals from the vastus lateralis muscle during isometric knee extension exercise at a range of contraction intensities (5-100% of maximal voluntary isometric torque). The high-density sEMG signals were analyzed for amplitude (root mean square, RMS), frequency content (median frequency, F(med)) and muscle fiber conduction velocity (MFCV) in an attempt to describe bed rest-induced changes in neural activation properties at the levels of the motor control and muscle fibers. Without countermeasures, bed rest resulted in a significant progressive decline in maximal isometric knee extension strength, whereas RMS remained unaltered throughout the bed rest period. In line with observed muscle atrophy, both F(med) and MFCV declined during bed rest. RVE training during bed rest resulted in maintained maximal isometric knee extension strength, and a strong increase ( approximately 30%) in maximal EMG amplitude, from 10 days of bed rest on. Exclusion of other factors led to the conclusion that the RVE training increased motor unit firing rates as a consequence of an increased excitability of motor neurons. An increased firing rate might have been essential under training sessions, but it did not affect isometric voluntary torque capacity.

Characteristics of fast voluntary and electrically evoked isometric knee extensions during 56 days of bed rest with and without exercise countermeasure

The contractile characteristics of fast voluntary and electrically evoked unilateral isometric knee extensions were followed in 16 healthy men during 56 days of horizontal bed rest and assessed at bed rest days 4, 7, 10, 17, 24, 38 and 56. Subjects were randomized to either an inactive control group (Ctrl, n = 8) or a resistive vibration exercise countermeasure group (RVE, n = 8). No changes were observed in neural activation, indicated by the amplitude of the surface electromyogram, or the initial rate of voluntary torque development in either group during bed rest. In contrast, for Ctrl, the force oscillation amplitude at 10 Hz stimulation increased by 48% (P < 0.01), the time to reach peak torque at 300 Hz stimulation decreased by 7% (P < 0.01), and the half relaxation time at 150 Hz stimulation tended to be slightly reduced by 3% (P = 0.056) after 56 days of bed rest. No changes were observed for RVE. Torque production at 10 Hz stimulation relative to maximal (150 Hz) stimulation was increased after bed rest for both Ctrl (15%; P < 0.05) and RVE (41%; P < 0.05). In conclusion, bed rest without exercise countermeasure resulted in intrinsic speed properties of a faster knee extensor group, which may have partly contributed to the preserved ability to perform fast voluntary contractions. The changes in intrinsic contractile properties were prevented by resistive vibration exercise, and voluntary motor performance remained unaltered for RVE subjects as well.

Knee extensor fatigability after bedrest for 8 weeks with and without countermeasure

We analyzed the effects of gravitational unloading on muscular fatigability and the effectiveness of resistive vibration exercise to counteract these changes. Changes in knee extensor fatigability as a consequence of 8 weeks of horizontal bedrest with or without daily resistive vibration exercise were evaluated in 17 healthy male volunteers. Bedrest increased fatigability (% decrease in maximal voluntary isometric torque per minute exercise) from -7.2 +/- 0.5 to -10.2 +/- 1.0%/min (P < 0.05), which was accompanied by a decline (of 52.0 +/- 3.7%, P < 0.05) in muscle blood flow. Daily resistive vibration exercise training during bedrest prevented increases in fatigability (from -10.8 +/- 1.8 to -8.4 +/- 1.6%/min, P < 0.05), and mitigated the reduction in blood flow (decline of 26.1 +/- 5.1%, P < 0.05). Daily resistive exercise may thus be suggested as an effective countermeasure during spaceflight and illness-related prolonged bedrest to combat the detrimental changes in muscle endurance that result from gravitational unloading.

Muscle slowness in a family with nemaline myopathy

All patients of a large family with nemaline myopathy complained of slowness in movement. We confirmed this clinical complaint physiologically by showing lower contractile speed in quadriceps muscle. Electrically evoked contractions of the quadriceps muscle elicited a lower rate of relaxation and a tendency for slower torque generation. Here, we demonstrate for the first time slow muscle characteristics as a physiological correlate for the clinical complaint of slowness.

Strength, size and activation of knee extensors followed during 8 weeks of horizontal bed rest and the influence of a countermeasure

Changes in the quadriceps femoris muscle with respect to anatomical cross sectional area (CSA), neural activation level and muscle strength were determined in 18 healthy men subjected to 8 weeks of horizontal bed rest (BR) with (n = 9) and without (n = 9) resistive vibration exercise (RVE). CSA of the knee extensor muscle group was measured with magnetic resonance imaging every 2 weeks during bed rest. In the control subjects (Ctrl), quadriceps femoris CSA decreased linearly over the 8 weeks of bed rest to -14.1 +/- 5.2% (P < 0.05). This reduction was significantly (P < 0.001) mitigated by the exercise paradigm (-3.5 +/- 4.2%; P < 0.05). Prior to and seven times during bed rest, maximal unilateral voluntary torque (MVT) values of the right leg were measured together with neural activation levels by means of a superimposed stimulation technique. For Ctrl, MVT decreased also linearly over time to -16.8 +/- 7.4% after 8 weeks of bed rest (P < 0.01), whereas the exercise paradigm fully maintained MVT during bed rest. In contrast to previous reports, the maximal voluntary activation remained unaltered for both groups throughout the study. For Ctrl, the absence of deterioration of the activation level might have been related to the repeated testing of muscle function during the bed rest. This notion was supported by the observation that for a subset of Ctrl subjects (n = 5) the MVT of the left leg, which was not tested during BR, was reduced by 20.5 +/- 10.1%, (P < 0.01) which was for those five subjects significantly (P < 0.05) more than the 11.1 +/- 9.2% (P < 0.01) reduction for the right, regularly tested leg.

Effects of stimulation pattern on electrical stimulation-induced leg cycling performance

Electrical stimulation-induced leg cycling (ES-LC) is beneficial for individuals with spinal cord injury (SCI), but cycling performance is often limited because of rapid fatigue of the stimulated muscles. This study evaluated whether a stimulation pattern with a catchlike-inducing pulse train increased force production and hence cycling performance. Five men with SCI performed ES-LC using different stimulation patterns: (1) the standard pattern with ramp modulation, (2) a pattern with no ramp modulation, (3) a pattern with no ramp modulation but with an initial doublet, and (4) a pattern with a middle doublet. None of the experimental patterns resulted in significantly improved cycling performance compared with the standard pattern. However, during the first 3 min of cycling, the current amplitude was significantly higher with the standard stimulation, suggesting that stimulation with no ramp modulation produces more force at the same submaximal current amplitude. The results do not indicate that stimulation with catchlike-inducing trains with the current parameter settings improves ES-LC performance.

Increased vascular resistance in paralyzed legs after spinal cord injury is reversible by training

The purpose of the present study was to determine the effect of a spinal cord injury (SCI) on resting vascular resistance in paralyzed legs in humans. To accomplish this goal, we measured blood pressure and resting flow above and below the lesion (by using venous occlusion plethysmography) in 11 patients with SCI and in 10 healthy controls (C). Relative vascular resistance was calculated as mean arterial pressure in millimeters of mercury divided by the arterial blood flow in milliliters per minute per 100 milliliters of tissue. Arterial blood flow in the sympathetically deprived and paralyzed legs of SCI was significantly lower than leg blood flow in C. Because mean arterial pressure showed no differences between both groups, leg vascular resistance in SCI was significantly higher than in C. Within the SCI group, arterial blood flow was significantly higher and vascular resistance significantly lower in the arms than in the legs. To distinguish between the effect of loss of central neural control vs. deconditioning, a group of nine SCI patients was trained for 6 wk and showed a 30% increase in leg blood flow with unchanged blood pressure levels, indicating a marked reduction in vascular resistance. In conclusion, vascular resistance is increased in the paralyzed legs of individuals with SCI and is reversible by training.