Preoperative Rehabilitation Is Feasible in the Weeks Prior to Surgery and Significantly Improves Functional Performance

BACKGROUND

Frailty is a multidimensional state of increased vulnerability. Frail patients are at increased risk for poor surgical outcomes. Prior research demonstrates that rehabilitation strategies deployed after surgery improve outcomes by building strength.

OBJECTIVES

Examine the feasibility and impact of a novel, multi-faceted prehabilitation intervention for frail patients before surgery.

DESIGN

Single arm clinical trial.

SETTING

Veterans Affairs hospital.

PARTICIPANTS

Patients preparing for major abdominal, urological, thoracic, or cardiac surgery with frailty identified as a Risk Analysis Index≥30.

INTERVENTION

Prehabilitation started in a supervised setting to establish safety and then transitioned to home-based exercise with weekly telephone coaching by exercise physiologists. Prehabilitation included (a)strength and coordination training; (b)respiratory muscle training (IMT); (c)aerobic conditioning; and (d)nutritional coaching and supplementation. Prehabilitation length was tailored to the 4-6 week time lag typically preceding each participant's normally scheduled surgery.

MEASUREMENTS

Functional performance and patient surveys were assessed at baseline, every other week during prehabilitation, and then 30 and 90 days after surgery. Within-person changes were estimated using linear mixed models.

RESULTS

43 patients completed baseline assessments; 36(84%) completed a median 5(range 3-10) weeks of prehabilitation before surgery; 32(74%) were retained through 90-day follow-up. Baseline function was relatively low. Exercise logs show participants completed 94% of supervised exercise, 78% of prescribed IMT and 74% of home-based exercise. Between baseline and day of surgery, timed-up-and-go decreased 2.3 seconds, gait speed increased 0.1 meters/second, six-minute walk test increased 41.7 meters, and the time to complete 5 chair rises decreased 1.6 seconds(all P≤0.007). Maximum and mean inspiratory and expiratory pressures increased 4.5, 7.3, 14.1 and 13.5 centimeters of water, respectively(all P≤0.041).

CONCLUSIONS

Prehabilitation is feasible before major surgery and achieves clinically meaningful improvements in functional performance that may impact postoperative outcomes and recovery. These data support rationale for a larger trial powered to detect differences in postoperative outcomes.

Cardiopulmonary exercise testing in post-COVID-19 patients: Where does exercise intolerance come from?

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES). Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq).

Background

Post-COVID-19 persistent symptoms and exercise intolerance are poorly understood. Cardiopulmonary exercise testing (CPET) assessment is important to address the sources of the underlying symptoms and limitations.

Purpose

To evaluate the source and magnitude of exercise intolerance in post-COVID-19 subjects via CPET.

Methods

This cohort study assessed subjects with different SARS-CoV-2 illness severities. The propensity score matching method was used to select the control group. Patients with available CPET prior to SARS-CoV-2 infection were compared before and after COVID-19.

Results

288 subjects (144 post-COVID-19 and 144 matched-controls) were assessed. The median age was 43.0 years, and 57% were male, with different illness severity (60.4% mild, 20.8% moderate, 18.8% severe). Residual symptoms were reported in 41% of the sample. CPET was performed 14.4±9.4 weeks after disease onset, with exercise limitations being attributed to the peripheral muscle (91.7%), pulmonary (6.3%), and cardiovascular (2.1%) systems. Lower median percent-predicted peak oxygen consumption was observed in the severe subgroup (72.2%) compared to both mild (98.5%) and control subgroups (91.6%). Peak oxygen consumption (peakVO2), VO2 at the ventilatory thresholds (VO2 at VT), and heart rate differed among illnesses, severities, and controls. Conversely, ventilatory equivalents, oxygen uptake efficiency slope, and peak oxygen pulse were similar (Figure 1). Additional subgroup analysis of 42 subjects with prior CPET revealed changes only on peak treadmill speed in the mild subgroup and additional reductions on peakVO2 and VO2 at VT in the moderate/severe subgroup (Figure 2), while ventilatory equivalents, oxygen uptake efficiency slope, and peak oxygen pulse remained unchanged.

Conclusions

Peripheral muscle fatigue was the most common etiology of exercise limitation in post-COVID-19 patients regardless of the SARS-CoV-2 illness severity. Our data suggest that treatment should emphasize comprehensive rehabilitation programs, including aerobic and muscle strengthening components.

Impact of a new and remote diagnosis of heart disease on exercise behavior in older adults

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Exercise is an important factor in the primary and secondary prevention of heart disease. However, few data are available on predictors of exercise in older adults, especially the impact of a new and remote diagnosis of heart disease (NHDD and RHDD, respectively) on exercise behavior. It is possible that the motivational impact of a NHDD may be more powerful than a RHDD in promoting exercise in older persons.

Purpose

The purpose of this study was to examine predictors of exercise in older adults using the Health and Retirement Survey (HRS), a prospective, nationally representative household survey examining retirement and health among older persons in the United States that is repeated every two years. We hypothesized that older persons with a NHDD and RHDD will be more likely to exercise.

Methods

Data from respondents who were age 55 or older in 1998 were grouped using three waves of the HRS (1998, 2000, and 2002) which provided three distinct person-wave observations for each respondent, yielding 38,634 respondent person-wave observations (9,629 with RHDD and 1,689 with NHDD) with a mean age of 70±9 years (55% female). Logistic regression models were developed to examine the predictors of exercise while controlling for a variety of demographic and health related variables.

Results

A NHDD was the strongest positive predictor (odds ratio=1.195, p<0.01; 95% CI=1.054-1.355) while a RHDD was not a significant predictor of exercise in older adults (odds ratio=1.034, p=0.31; 95% CI=.969-1.105). No significant difference in demographic, co-morbid conditions, or perceived health was observed between older adults with a NHDD and RHDD.

Conclusions

A NHDD was a strong positive predictor of exercise in older adults. A RHDD was not a significant predictor of exercise, suggesting that the motivation impact of a heart disease diagnosis lessens over time and secondary prevention efforts such as cardiac rehabilitation continue to be of importance. Long-term programming for maintenance of exercise in older persons with a RHDD appears to be particularly important and requires further investigation.

Heart rate recovery is improved after locomotor training in persons with incomplete spinal cord injury: implications for health and prevention

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Heart rate recovery after exercise provides meaningful information about physical fitness and prognosis in both health and disease. A more rapid decrease in heart rate after exercise has been associated with higher levels of fitness as well as better health and survival. In fact, heart rate recovery (HRR) ≤ 12 beats at one minute after maximal and sub-maximal exercise is a significant prognostic index of poorer health and survival. However, little research has examined HRR in persons with spinal cord injury (SCI) despite the need for a responsive measure of fitness and health in this population.

Purpose

The purpose of this study was to examine HRR before and after locomotor training (LT) in persons with SCI.

Methods

Twenty-nine subjects with incomplete SCI performed LT 5 days per week for 12 weeks using one of four training approaches: treadmill-based training with manual assistance (TMM), treadmill-based training with stimulation (TMS), over-ground training with stimulation (OGS), and treadmill-based training with robotic assistance (TMR). Before and after 12 weeks of LT the HRR was measured one minute after 2-3 minutes of walking at each subject’s maximal capacity. Heart rate data was captured via a recording band placed on each subjects’ chest that transmitted wireless signals to a data collection system which recorded heart rate data continuously.

Results

The peak HR during maximal walking of the cohort before and after LT was 75 ±15% and 71 ±14% of the age-predicted maximal HR, respectively. Fifteen of the 29 subjects (52%) had an abnormal HRR (≤ 12 beats) at baseline; following LT, HRR was improved in 11/15 (73%) of these subjects. In addition, 50% of subjects with a normal baseline HRR improved HRR after LT. There was no significant difference in HRR among training approaches at baseline or after LT.

Conclusions

Twelve weeks of LT was associated with an improvement in HRR in almost three-quarters of the subjects with an abnormal HRR at baseline, and HRR improved in one-half of the subjects with a normal HRR at baseline. These findings suggest that HRR may be of value for tracking fitness and prognosis in persons with SCI. Further investigation of HRR in subjects with SCI is warranted.

Exercise training in heart failure: inpatient and outpatient considerations

Exercise training has become increasingly important in the treatment of heart failure patients. It has long been known that the exercise tolerance of a patient with heart failure is related to his or her morbidity and mortality. Recently, it has been proved that exercise training improves cardiorespiratory function, functional status, and psychosocial status of heart failure patients. It is unknown whether these improvements will improve morbidity and mortality but quality of life appears to be enhanced. Subtle improvements in these areas may lead to a more satisfying and productive life for many heart failure patients. However, further investigation of the specific effects of such improvements is needed.

Inspiratory muscle training in patients with chronic heart failure awaiting cardiac transplantation: results of a pilot clinical trial

BACKGROUND AND PURPOSE

Persons with chronic heart failure (HF) have poor ventilatory muscle strength, and this weakness is associated with dyspnea. The purpose of this study was to examine the effects of inspiratory muscle training (IMT) on ventilatory muscle strength and dyspnea in patients with chronic HF.

SUBJECTS

Fourteen patients (mean age [+/-SD] = 52 +/- 8.5 years) with end-stage cardiomyopathy and chronic HF (mean left ventricular ejection fraction = 23% +/- 13% and New York Heart Association class = 3.6 +/- 0.6) participated in the study.

METHODS

Inspiratory muscle training was performed at 20% of maximal inspiratory pressure (MIP) for 5 to 15 minutes, three times a day, for 8 weeks. Dyspnea was evaluated at rest and during exercise.

RESULTS

Both MIP and maximal expiratory pressure (MEP) were greater after 2 weeks of IMT (51 +/- 21 to 63 +/- 23 cm H2O and 85 +/- 22 to 96 +/- 19 cm H2O, representing 24% and 13% improvement). Dyspnea scores at rest and during exercise decreased after 2 weeks (2.0 +/- 0.7 to 1.3 +/- 0.5 and 3.6 +/- 0.5 to 2.6 +/- 0.6, representing 29% and 28% improvement) and plateaued throughout the remainder of IMT. Baseline MEP was related to the percentage of change in MEP after IMT (r = -.72), and several measures of pulmonary function were related to the degree of improvement in dyspnea after IMT (r = -.57 to -.82) and in MIP after IMT (r = .71).

CONCLUSION AND DISCUSSION

Improvements in MIP, MEP, and dyspnea were found after 2 weeks of IMT. Greater pulmonary function was associated with greater improvement in dyspnea and ventilatory muscle strength after IMT. These improvements may decrease the dependency and impairment associated with chronic HF.

Preoperative and postoperative conditioning for lung transplantation and volume-reduction surgery

This article summarizes the importance of preoperative and postoperative conditioning for lung transplantation and volume reduction surgery. Assessment of exercise tolerance and functional status and identification of the primary limitations to exercise conditioning will enhance preoperative and postoperative exercise conditioning. Exercise conditioning can be implemented in a pyramidal manner with emphasis on the most needed and appropriate mode of exercise and the manipulation of exercise frequency, duration, and intensity. Several important adjuncts to exercise conditioning can improve exercise conditioning efforts before and after lung transplantation and volume reduction surgery, including ventilatory muscle training, optimal use of supplemental oxygen and pulmonary medications, and different methods to prescribe aerobic exercise.

The six-minute walk test predicts peak oxygen uptake and survival in patients with advanced heart failure

BACKGROUND

The 6-min walk test (6'WT) is a simple measure of functional capacity and predicts survival in patients with moderate heart failure (HF).

METHODS

To assess the role of the 6'WT in the evaluation of patients with advanced HF, 45 patients (age 49 +/- 8 years, mean +/- SD; New York Heart Association class 3.3 +/- 0.6; left ventricular ejection fraction 0.20 +/- 0.06; right ventricular ejection fraction 0.31 +/- 0.11) underwent symptom-limited cardiopulmonary exercise testing and the 6'WT during cardiac transplant evaluation.

RESULTS

Mean 6'WT distance ambulated was 310 +/- 100 m and peak oxygen uptake (peak Vo2) was 12.2 +/- 4.5 mL/kg/min. There was a significant correlation between 6'WT distance ambulated and peak Vo2 (r = 0.64, p < 0.001). Multivariate analysis of patient characteristics, resting hemodynamics, and 6'WT results identified the distance ambulated during the 6'WT as the strongest predictor of peak Vo2 (p < 0.001). 6'WT distance ambulated less than 300 m predicted an increased likelihood of death or pretransplant hospital admission for continuous inotropic or mechanical support within 6 months (p = 0.04), but did not predict long-term overall or event-free survival with a mean follow-up of 62 weeks. Peak Vo2 was the best predictor of long-term overall and event-free survival.

CONCLUSIONS

In patients with advanced HF evaluated for cardiac transplantation, distance ambulated during the 6'WT predicts (1) peak Vo2 and (2) short-term event-free survival.

Heart failure

Congestive heart failure (CHF) affects more than 2 million Americans and requires greater than 900,000 hospitalizations each year. The incidence of CHF is increasing because of the increasing age of the American population and the use of newer medications and technologies that have increased survival at the expense of increased morbidity. Physical therapists are treating many patients who have varying degrees of CHF. Recent research has demonstrated the importance of exercise conditioning in patients with CHF. This article will review the pathophysiology, compensatory mechanisms, and signs and symptoms of CHF as well as provide a discussion of physical therapy in the treatment of patients with CHF.

Early progressive mobilization of patients with left ventricular assist devices is safe and optimizes recovery before heart transplantation

BACKGROUND

As early perioperative survival with left ventricular assist device support improves, additional emphasis must be placed on patient rehabilitation. Especially as mean left ventricular assist device support times exceed 100 days, it is essential for health professionals to mobilize patients to prevent the incidence of the deleterious effects of bedrest. The timing of optimal functional performance and the safety of rehabilitation has not been described.

METHODS

We retrospectively studied patients surviving left ventricular assist device implantation (34 of 41 patients; 27 men, 7 women; age 51 +/- 11 years). Physical therapy consisted of progressive mobilization leading to treadmill exercise or cycling. All patients exercised in the "pump on full" mode with flows >or= 3.0 L/min.

RESULTS

Twenty of thirty-four patients initiated ambulation at 7 to 10 days with independent ambulation by 14 days in 55% of the group. Treadmill exercise was tolerated by 82% of the patients, begun at postoperative day 21 by eighteen patients. The greatest improvement in exercise performance was seen by 6 to 8 weeks (20 to 30 minutes at 3.17 +/- 0.79 metabolic equivalents). Maximal functional capacity achieved was influenced by medical complications. A total of 1878 treatment sessions lasting 1390 hours was performed. Only four minor incidents occurred representing 2.9 incidents/1000 patient hours; all involved a transient decrease in pump flow. None of these events resulted in an increase in morbidity or mortality.

CONCLUSIONS

Progressive mobilization in patients with left ventricular assist device is safe. Patients return to independence in activities of daily living and tolerate prolonged workloads of up to 5 metabolic equivalents. There is rapid improvement in functional capacity until 6 weeks after operation. Delay in transplantation until this time may optimize postoperative recovery.

The relationship of the 6-min walk test to maximal oxygen consumption in transplant candidates with end-stage lung disease

STUDY OBJECTIVE

To assess the relationship of distance ambulated during the 6-min walk test (6'WT) to maximal oxygen consumption (VO2 max).

DESIGN

Multivariate analysis of patient characteristics to VO2 max.

SETTING

Pre-lung transplant evaluation.

PATIENTS

60 patients (22 men, 38 women; mean age, 44 years) with end-stage lung disease (mean FEV1 and forced vital capacity of 0.97 and 1.93, respectively).

MEASUREMENTS AND RESULTS

The 6'WT was performed on a level hallway surface, and VO2 max was obtained during maximal cycle ergometry exercise testing with respiratory gas analysis. Multivariate analysis of patient characteristics (age, sex, weight, FEV1, FVC, diffusing capacity for carbon monoxide (DCO), 6'WT distance ambulated, number of rests per 6'WT, and the maximal heart rate, blood pressure, rate-pressure product, respiratory rate, oxygen saturation, rating of perceived exertion, and amount of supplemental oxygen used during the 6'WT) was performed on two groups of 30 patients each (group A or B) who were randomly assigned to either group by a process of random selection using a computer-generated random numbers program. Distance ambulated was the strongest independent predictor of VO2 max (r = 0.73; p < 0.0001) in both groups, and adding age, weight, and pulmonary function test results (FVC, FEV1, and DCO) to the regression equation increased the correlation coefficient to 0.83. Because of the significant correlation of distance ambulated during the 6'WT to VO2 max, the prediction equation obtained from the multivariate analysis of group A, VO2 max = 0.006 x distance (feet) +3.38, was used to estimate the VO2 max of the group B patients. No significant difference was observed between the estimated (x +/- SD = 8.9 +/- 2.4 mL/kg/min) and observed (x +/- SD = 9.4 +/- 3.8 mL/kg/min) VO2 max (mean difference, 0.5 mL/kg/min; SD of the difference = 2.88).

CONCLUSIONS

The distance ambulated during a 6'WT can predict VO2 max in patients with end-stage lung disease. The addition of several patient characteristics can increase the ability to predict VO2 max and account for more of the variability. Such information is valuable when assessing patient response to therapeutic intervention if respiratory gas analysis is unavailable or impractical.

Pulmonary medications

Many of the patients seen by physical therapists have primary or secondary diagnoses for which cardiovascular- or pulmonary-active medications may be prescribed. There is a need, therefore, for physical therapists to understand the pharmacologic treatment of such patients. This article discusses medications commonly used in the treatment of pulmonary disorders. These medications are typically divided into the following categories: bronchodilators, anti-inflammatory agents, decongestants, antihistamines, antitussives, mucokinetics, respiratory stimulants and depressants, and paralyzing and antimicrobial agents. Regardless of which group a particular medication belongs to, the rationale for its prescription centers on promoting bronchodilation or relieving bronchoconstriction, facilitating the removal of secretions from the lungs, improving alveolar ventilation or oxygenation, or optimizing the breathing pattern. The relative importance of each of these goals depends on the specific disease process involved and the resultant respiratory problem(s).