Effects of constant-load exercise and high-intensity interval training on reliever medication consumption and peak expiratory flow in individuals with asthma: a randomised controlled trial

Introduction

The effect of aerobic training on reliever medication consumption (short-acting β2-agonist (SABA)) and peak expiratory flow (PEF) in participants with asthma is poorly known. The comparison between constant-load exercise (CLE) and high-intensity interval training (HIIT) in these outcomes has never been tested. The purpose of the present study was to compare the effects of CLE or HIIT in SABA consumption and PEF improvement during an exercise programme in subjects with asthma.

Methods

Clinically stable participants were randomised into CLE (n=27; 70-85% of the maximal load (Wmax)) or HIIT (n=28; 80-140% Wmax). The programme lasted 12 weeks (two sessions per week, 40 min per session), and the intensity was based on cardiopulmonary exercise testing (CPET). PEF was assessed before and after each exercise session. SABA was used if PEF was <70%. Clinical control (Asthma Control Questionnaire (ACQ)-6), CPET and aerobic fitness were also assessed before and after the intervention.

Results

Both groups were similar at baseline. CLE and HIIT reduced SABA consumption throughout the intervention (p<0.05). Before training, 14 patients required SABA before exercising, but only one needed it after the intervention. Changes in post-exercise PEF were lower in the CLE group than in the HIIT group (1.6±25.3 versus 10.3±13.7%). Both groups improved aerobic fitness (10.1±12.8% versus 5.7±15.6%) and clinical asthma control; however, only the HIIT group achieved a minimal clinically important difference in the ACQ-6 post-intervention (-0.23±1.06 versus -0.52±0.73 Δ score).

Conclusion

CLE and HIIT reduced SABA consumption; however, only HIIT increased PEF and asthma clinical control after the intervention. These results reinforce the importance of exercise training in moderate-to-severe asthma.

The effect of exercise training intervention for patients with abdominal aortic aneurysm on cardiovascular and cardiorespiratory variables: an updated meta-analysis of randomized controlled trials

OBJECTIVE

The purpose of this meta-analysis was to evaluate the effect of exercise training intervention in patients with abdominal aortic aneurysm (AAA).

METHODS

Eight randomized controlled trials (RCTs) that recruited 588 AAA patients were extracted using 4 databases (PubMed, Embase, Wanfang Data, and Cochrane Library). Physiological and biochemistry parameters that included in this study are high-sensitivity C-reactive protein (hs-CRP), respiratory peak oxygen uptake rate (VO2peak), triglyceride (TG), total cholesterol (TC), anaerobic threshold (AT), the diameter of AAA, high density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL), and matrix metalloproteinase-9 (MMP-9). Standard mean difference (SMD) was used to assess the between group effect.

RESULTS

This meta-analysis was synthesized with findings from RCTs and found that hs-CRP (SMD, - 0.56 mg/dL; 95% CI: - 0.90 to 0.22; P = 0.001), VO2peak (SMD, 0.4 mL/kg/min; 95% CI, 0.21 to 0.60; P < 0.001), TG (SMD, - 0.39 mg/dL; 95% CI: - 0.02 to 0.77; P = 0.04), and AT (SMD, 0.75 mL/kg/min; 95% CI, 0.54 to 0.96; P < 0.001) were significantly improved in the exercise groups, while the size of AAA (SMD, - 0.15; 95% CI: - 0.36 to 0.06; P = 0.15), TC (SMD, 0.16 mg/dL; 95% CI: - 0.10 to 0.42; P = 0.23), HDL/LDL ratio (SMD, - 0.06; 95% CI: - 0.32 to 0.20; P = 0.64), HDL (SMD, - 0.09; 95% CI: - 0.39 to 0.20; P = 0.54), LDL (SMD, 0.08; 95% CI: - 0.21 to 0.38; P = 0.59), and MMP-9 (SMD, - 0.23 mg/dL; 95% CI: - 0.53 to 0.06; P = 0.12) did not differ in the exercise groups compared with the controls.

CONCLUSION

Exercise intervention improved some of the CVD risk factors but not all, hs-CRP, VO2peak and AT were significantly improved after exercise intervention, while, changes of MMP-9, the size of AAA, and the overall lipids profile were not. Exercise intervention provides an additional solution for improving cardiorespiratory capacity and health status among AAA patients, and might lead to a delay of AAA progression.

Perioperative Exercise Testing in Pregnant and Non-Pregnant Women of Reproductive Age: A Systematic Review

BACKGROUND

Women have classically been excluded from the development of normal data and reference ranges, with pregnant women experiencing further neglect. The incidence of Caesarean section in pregnant women, and of general operative management in young women (both pregnant and non-pregnant), necessitates the formal development of healthy baseline data in these cohorts to optimise their perioperative management. This systematic review assesses the representation of young women in existing reference ranges for several functional exercise tests in common use to facilitate functional assessment in this cohort.

METHODS

Existing reference range data for the exercise tests the Six Minute Walk Test (6MWT), the Incremental Shuttle Walk Test (ISWT) and Cardiopulmonary Exercise Testing (CPET) in young women of reproductive age were assessed using the MEDLINE (Ovid) database, last searched December 2023. Results were comparatively tabulated but not statistically analysed given underlying variances in data.

RESULTS

The role of exercise testing in the perioperative period as an assessment tool, as well as its safety during pregnancy, was evaluated using 65 studies which met inclusion criteria.

CONCLUSION

There is a significant lack of baseline data regarding these tests in this population, especially amongst the pregnant cohort, which limits the application of exercise testing clinically.

Multimodal Prehabilitation for Patients Undergoing Endovascular Aortic Aneurysm Repair Surgery: A Feasibility Study

BACKGROUND

Elective treatment options for aortic abdominal aneurysms include open repair or the less-invasive endovascular aortic aneurysm repair (EVAR). Recovery from EVAR is generally considered easier and faster than open repair. Despite this, EVAR remains a major procedure, and average return to preoperative quality of life is at least 3 months. The purpose of this study is to determine the safety and feasibility of multimodal prehabilitation, a multidisciplinary preoperative optimization intervention, in patients undergoing EVAR and its impact on perioperative functional capacity and quality of life.

METHODS

Candidates for EVAR with an infra-renal abdominal aortic aneurysm <7.5cm were invited to participate in a 6-week multimodal prehabilitation program that included (1) supervised and home-based exercise, (2) nutritional support, (3) psychosocial support, and (4) smoking cessation. Functional capacity and quality of life were assessed at baseline, before surgery and 6 weeks postoperatively. Recruitment rate, safety, and compliance were also assessed.

RESULTS

A total of 24 patients were included, 17 males (70%) and 7 females (30%). No adverse events occurred during the program. Compliance to each component of the program (median [Q1-Q3]) was 66% [67] for supervised training, 100% [67] for home-based training, and 100% [100] for nutrition. The multimodal prehabilitation program elicited a significant increase in functional capacity and quality of life preoperatively.

CONCLUSION

Multimodal prehabilitation for patients awaiting EVAR is feasible and safe. Multimodal prehabilitation improves both functional capacity and quality of life preoperatively. Further research is needed to assess the impact of multimodal prehabilitation on postoperative quality of life and functional capacity.

CLINICAL IMPACT

Multimodal prehabilitation is safe and feasible in patients awaiting endovascular aneurysm repair. The importance of this finding is that multimodal prehabilitation can be safely delivered preoperatively in patients awaiting EVAR. Although further research is needed, multimodal prehabilitation seems to improve preoperative functional capacity and quality of life. This could have an impact for the future implementation of prehabilitation interventions in order to increase functional reserve and quality of life preoperatively so that this high-risk population can cope better with the surgical stress and return to their normal life faster postoperatively.

Myths and methodologies: Cardiopulmonary exercise testing for surgical risk stratification in patients with an abdominal aortic aneurysm; balancing risk over benefit

The extent to which patients with an abdominal aortic aneurysm (AAA) should exercise remains unclear, given theoretical concerns over the perceived risk of blood pressure-induced rupture, which is often catastrophic. This is especially pertinent during cardiopulmonary exercise testing, when patients are required to perform incremental exercise to symptom-limited exhaustion for the determination of cardiorespiratory fitness. This multimodal metric is being used increasingly as a complementary diagnostic tool to inform risk stratification and subsequent management of patients undergoing AAA surgery. In this review, we bring together a multidisciplinary group of physiologists, exercise scientists, anaesthetists, radiologists and surgeons to challenge the enduring 'myth' that AAA patients should be fearful of and avoid rigorous exercise. On the contrary, by appraising fundamental vascular mechanobiological forces associated with exercise, in conjunction with 'methodological' recommendations for risk mitigation specific to this patient population, we highlight that the benefits conferred by cardiopulmonary exercise testing and exercise training across the continuum of intensity far outweigh the short-term risks posed by potential AAA rupture.

Efficacy of supervised exercise prehabilitation programs to improve major abdominal surgery outcomes: A systematic review and meta-analysis

The optimal package of components for a prehabilitation intervention remains unclear. The aim was to determine the efficacy of supervised exercise prehabilitation programs to enhance patient fitness and improve surgical outcomes. The protocol was preregistered (PROSPERO: CRD42020180693). PubMed, MEDLINE, CINAHL, AMED, CENTRAL, PeDro, ClinicalTrials.gov and the WHO International Clinical Trials Registry were searched. Randomized controlled trials (RCTs) of supervised prehabilitation programs before major abdominal surgery were included. Physical function, cardiorespiratory capacity and surgical outcomes were the primary outcomes measures. Risk of bias was assessed according to the Cochrane Risk of Bias 1.0 tool for RCTs. Data are summarized narratively, and where possible, quantitavely. Meta-analyses results are reported as risk ratios (RR), mean difference of changes between baseline and follow-up time points or mean difference between groups and 95% confidence interval (CI). Twenty RCTs were included in the analysis with a total of 1258 patients. The average 6-min walking distance change was +33 m in the prehabilitation group compared to the usual care (UC) group after prehabilitation (95% CI: [13, 53], P < 0.01). Only in studies with more than one supervised session per week changes in 6-min-walk distance were significantly higher in the prehabilitation group compared to the UC group after prehabiliatation (Mean difference: 47 m, 95% [CI]: [20-75], P < 0.01). The change in peak volume of oxygen uptake during a maximum cardiopulmonary test was +1.47 mL·kg^-1·min^-1 in the prehabilitation group compared to the UC group (95% CI: [0.68, 2.25], P < 0.01). There was no significant difference in the change in oxygen uptake at anaerobic threshold between groups (Mean differences: 0.47, 95% CI: [-0.16, 1.10], P:0.14). Post-operative complications incidence was similar between groups (RR: 0.80, 95% CI: [0.61, 1.05], P:0.11), irrespective of the frequency of supervised session per week (RR: 0.67, 95% CI: [0.43, 1.03], P:0.07). In conclusion, prehabilitation programmes with more than one supervised session per week improved physical function but did not enhance surgical outcomes.

Editor's Choice - The Abdominal Aortic Aneurysm Get Fit Trial: A Randomised Controlled Trial of Exercise to Improve Fitness in Patients with Abdominal Aortic Aneurysm

OBJECTIVE

Ruptured abdominal aortic aneurysm (AAA) carries a mortality rate of up to 80%. Elective repair prevents rupture, but peri-operative mortality remains at 2% - 3%. This mortality rate and long term survival rate are associated with impaired peak oxygen uptake (peak VO₂), oxygen uptake at anaerobic threshold (AT) and ventilatory equivalent for CO₂ (VECO₂) at AT on cardiopulmonary exercise testing (CPET). Improving fitness to optimise these variables could improve peri-operative and long term survival, but the required exercise training suitable for patients with AAA has yet to be established. This randomised controlled trial aimed to evaluate the effectiveness of 24 week, patient directed, community based exercise on CPET measured fitness in AAA surveillance patients.

METHODS

This was a prospective randomised controlled trial in a tertiary UK vascular centre conducted using CONSORT guidelines. Patients on AAA surveillance (n = 56) were randomly assigned to either (1) a 24 week community exercise programme (CEP) with choice of gym or home exercises, or (2) standard clinical care including advice on weight loss and exercise. The primary outcome was change in peak VO₂ at 24 weeks, with secondary outcomes including AT, VECO₂, cardiovascular biomarkers (lipid profile, pro-B-type natriuretic peptide, and high sensitivity C reactive protein, body mass index, and HRQoL. Follow up was at eight, 16, 24, and 36 weeks to evaluate duration of benefit. All analyses were performed on an intention to treat basis.

RESULTS

CEP patients (n = 28) achieved mean (95% confidence interval [CI]) improvements from baseline in peak VO₂ of 1.5 (95% CI 0.5 - 2.5), 2.1 (95% CI 1.1 - 3.2), 2.3 (95% CI 1.2 - 3.3), and 2.2 (95% CI 1.1, 3.3) mL/kg/min at 8, 16, 24, and 36 weeks, respectively. These changes in CEP patients were significantly greater than those seen in control patients at 16 (p = .002), 24 (p = .031), and 36 weeks (p < .001). There were also significant improvements in AT, triglyceride levels, and HRQoL in CEP patients.

CONCLUSION

This CEP significantly improved those CPET parameters associated with impaired peri-operative and long term survival in patients following AAA repair. These improvements were maintained at 12 weeks following the end of the programme.

Is Exercise Blood Pressure Putting the Brake on Exercise Rehabilitation after Acute Type A Aortic Dissection Surgery?

(1) Background: Exercise is recommended to improve physical fitness in patients recovering from acute type A aortic dissection (ATAAD). However, surgery corrects the diseased blood vessels and reduces the risk of ATAAD, but it does not redefine a safe exercise blood pressure (BP) threshold. This review aimed to discuss whether the safe threshold of exercise BP can be upregulated after ATAAD surgery to increase exercise intensity with additional benefits. (2) Data sources: The PubMed databases were searched with the keywords “type A acute aortic dissection surgery”, “exercise”, “BP”, “stress”, and variations of these terms. (3) Study selection: Data from clinical trials, guidelines, and recent reviews were selected for review. (4) Results: Regular exercise can be considered a cardioprotective intervention for aortic dissection patients by attenuating hemodynamic responses at rest and during exercise. Previous studies have mainly focused on moderate-intensity aerobic exercise. In practice, the exercise systolic BP of some patients was higher than 160 mm Hg without adverse events, which indicates that the training intensity may be underestimated for patients after ATAAD surgery. Limited studies suggest a light-to-moderate resistance training for selected patients because it may cause a greater increase in BP. (5) Conclusions: Moderate-intensity continuous aerobic exercise supplemented by low-intensity resistance training is appropriate for cardiac rehabilitation after ATAAD surgery. The BP increase based on the normal exercise BP response, corresponding to the moderate-intensity is relatively safe. For high-risk post-ATAAD patients, considering the overall volume of training, personalizing the exercise regimen to remain within “safe” BP limits, and avoiding excessive fluctuations in BP should be the primary considerations for exercise training.

The physiological and clinical importance of cardiorespiratory fitness in people with abdominal aortic aneurysm

New Findings

What is the topic of this review?

This review focuses on the physiological impact of abdominal aortic aneurysm (AAA) on cardiorespiratory fitness and the negative consequences of low fitness on clinical outcomes in AAA. We also discuss the efficacy of exercise training for improving cardiorespiratory fitness in AAA.

What advances does it highlight?

We demonstrate the negative impact of low fitness on disease progression and clinical outcomes in AAA. We highlight potential mechanistic determinants of low fitness in AAA and present evidence that exercise training can be an effective treatment strategy for improving cardiorespiratory fitness, postoperative mortality and disease progression.

Abstract

An abdominal aortic aneurysm (AAA) is an abnormal enlargement of the aorta, below the level of the renal arteries, where the aorta diameter increases by >50%. As an aneurysm increases in size, there is a progressive increase in the risk of rupture, which ranges from 25 to 40% for aneurysms >5.5 cm in diameter. People with AAA are also at a heightened risk of cardiovascular events and associated mortality. Cardiorespiratory fitness is impaired in people with AAA and is associated with poor (postoperative) clinical outcomes, including increased length of hospital stay and postoperative mortality after open surgical or endovascular AAA repair. Although cardiorespiratory fitness is a well‐recognized prognostic marker of cardiovascular health and mortality, it is not assessed routinely, nor is it included in current clinical practice guidelines for the management of people with AAA. In this review, we discuss the physiological impact of AAA on cardiorespiratory fitness, in addition to the consequences of low cardiorespiratory fitness on clinical outcomes in people with AAA. Finally, we summarize current evidence for the effect of exercise training interventions on cardiorespiratory fitness in people with AAA, including the associated improvements in postoperative mortality, AAA growth and cardiovascular risk. Based on this review, we propose that cardiorespiratory fitness should be considered as part of the routine risk assessment and monitoring of people with AAA and that targeting improvements in cardiorespiratory fitness with exercise training might represent a viable adjunct treatment strategy for reducing postoperative mortality and disease progression.

Prehabilitation for Vascular Surgery Patients: Challenges and Opportunities

Global demand for major surgery is rising as a consequence of a growing, ageing population and clinically applicable approaches to perioperative risk reduction have never been needed more. Prehabilitation aims to optimise aerobic capacity and address modifiable risk factors prior to surgery to improve postoperative outcomes. Given the inherently high-risk nature of vascular surgery and the frequently high-acuity, frail, vascular surgical population, the potential to introduce an intervention into the surgical pathway that may reduce postoperative complications cannot be overlooked. The aim of this article is to examine the current evidence base for prehabilitation in patients awaiting vascular surgery, and to summarise the potential benefits, pitfalls, and practicalities of this emerging perioperative intervention. There is a paucity of high-quality research specifically aimed at prehabilitation for patients undergoing vascular surgery, both peripheral and aortic, making it difficult to draw definitive conclusions upon which to base a change in practice. Currently, evidence is taken from small, often single-centre heterogenous studies that vary significantly from each other, meaning that the optimal exercise regimen for patients awaiting vascular surgery has yet to be defined. Establishing the impact of prehabilitation on outcomes for vascular patients is important as the effectiveness of preoperative exercise training is likely to vary between surgical interventions and patient populations. However, extrapolation from other cohorts is possible and indeed forms the basis of many current prehabilitation programmes. Given the success of prehabilitation in other surgical groups, it has potential to become an important future research target for patients awaiting vascular surgery.

Feasibility of a prehabilitation program before major abdominal surgery: a pilot prospective study

OBJECTIVE

To assess the feasibility of a prehabilitation program and its effects on physical performance and outcomes after major abdominal surgery.

METHODS

In this prospective pilot study, patients underwent prehabilitation involving three training sessions per week for 3 weeks preoperatively. The feasibility of delivering the intervention was assessed based on recruitment and adherence to the program. Its impacts on fitness (oxygen uptake (VO₂)) and physical performance (Timed Up and Go Test, 6-Minute Walk Test) were evaluated.

RESULTS

From May 2017 to January 2020, 980 patients were identified and 44 (4.5%) were invited to participate. The main obstacles to patient recruitment were insufficient time (<3 weeks) prior to scheduled surgery (n = 276, 28%) and screening failure (n = 312, 32%). Of the 44 patients, 24 (55%) declined to participate, and 20 (23%) were included. Of these, six (30%) were not adherent to the program. Among the remaining 14 patients, VO₂ at ventilatory threshold significantly increased from 9.7 to 10.9 mL/min/kg. No significant difference in physical performance was observed before and after prehabilitation.

CONCLUSION

Although prehabilitation seemed to have positive effects on exercise capacity, logistic and patient-related difficulties were encountered. The program is not feasible in its current form for all-comers.

Exercise Training Induces a Shift in Extracellular Redox Status with Alterations in the Pulmonary and Systemic Redox Landscape in Asthma

Redox dysregulation and oxidative stress have been implicated in asthma pathogenesis. Exercise interventions improve symptoms and reduce inflammation in asthma patients, but the underlying mechanisms remain unclear. We hypothesized that a personalised exercise intervention would improve asthma control by reducing lung inflammation through modulation of local and systemic reactive species interactions, thereby increasing antioxidant capacity. We combined deep redox metabolomic profiling with clinical assessment in an exploratory cohort of six female patients with symptomatic asthma and studied their responses to a metabolically targeted exercise intervention over 12 weeks. Plasma antioxidant capacity and circulating nitrite levels increased following the intervention (p = 0.028) and lowered the ratio of reduced to oxidised glutathione (p = 0.029); this was accompanied by improvements in physical fitness (p = 0.046), symptoms scores (p = 0.020), quality of life (p = 0.046), lung function (p = 0.028), airway hyperreactivity (p = 0.043), and eosinophilic inflammation (p = 0.007). Increased physical fitness correlated with improved plasma antioxidant capacity (p = 0.019), peak oxygen uptake and nitrite changes (p = 0.005), the latter also associated with reductions in peripheral blood eosinophil counts (p = 0.038). Thus, increases in “redox resilience” may underpin the clinical benefits of exercise in asthma. An improved understanding of exercise-induced alterations in redox regulation offers opportunities for greater treatment personalisation and identification of new treatment targets.

The physiological impact of high-intensity interval training in octogenarians with comorbidities

BACKGROUND

Declines in cardiorespiratory fitness (CRF) and fat-free mass (FFM) with age are linked to mortality, morbidity and poor quality of life. High-intensity interval training (HIIT) has been shown to improve CRF and FFM in many groups, but its efficacy in the very old, in whom comorbidities are present is undefined. We aimed to assess the efficacy of and physiological/metabolic responses to HIIT, in a cohort of octogenarians with comorbidities (e.g. hypertension and osteoarthritis).

METHODS

Twenty-eight volunteers (18 men, 10 women, 81.2 ± 0.6 years, 27.1 ± 0.6 kg·m^-2 ) with American Society of Anaesthesiology (ASA) Grade 2-3 status each completed 4 weeks (12 sessions) HIIT after a control period of equal duration. Before and after each 4 week period, subjects underwent body composition assessments and cardiopulmonary exercise testing. Quadriceps muscle biopsies (m. vastus lateralis) were taken to quantify anabolic signalling, mitochondrial oxidative phosphorylation, and cumulative muscle protein synthesis (MPS) over 4-weeks.

RESULTS

In comorbid octogenarians, HIIT elicited improvements in CRF (anaerobic threshold: +1.2 ± 0.4 ml·kg^-1 ·min^-1 , P = 0.001). HIIT also augmented total FFM (47.2 ± 1.4 to 47.6 ± 1.3 kg, P = 0.04), while decreasing total fat mass (24.8 ± 1.3 to 24 ± 1.2 kg, P = 0.0002) and body fat percentage (33.1 ± 1.5 to 32.1 ± 1.4%, P = 0.0008). Mechanistically, mitochondrial oxidative phosphorylation capacity increased after HIIT (i.e. citrate synthase activity: 52.4 ± 4 to 67.9 ± 5.1 nmol·min^-1 ·mg^-1 , P = 0.005; membrane protein complexes (C): C-II, 1.4-fold increase, P = 0.002; C-III, 1.2-fold increase, P = 0.03), as did rates of MPS (1.3 ± 0.1 to 1.5 ± 0.1%·day^-1 , P = 0.03). The increase in MPS was supported by up-regulated phosphorylation of anabolic signalling proteins (e.g. AKT, p70S6K, and 4E-BP1; all P < 0.05). There were no changes in any of these parameters during the control period. No adverse events were reported throughout the study.

CONCLUSIONS

The HIIT enhances skeletal muscle mass and CRF in octogenarians with disease, with up-regulation of MPS and mitochondrial capacity likely underlying these improvements. HIIT can be safely delivered to octogenarians with disease and is an effective, time-efficient intervention to improve muscle mass and physical function in a short time frame.

The effects of neoadjuvant chemoradiotherapy and an in-hospital exercise training programme on physical fitness and quality of life in locally advanced rectal cancer patients: a randomised controlled trial (The EMPOWER Trial)

BACKGROUND

The EMPOWER trial aimed to assess the effects of a 9-week exercise prehabilitation programme on physical fitness compared with a usual care control group. Secondary aims were to investigate the effect of (1) the exercise prehabilitation programme on psychological health; and (2) neoadjuvant chemoradiotherapy (NCRT) on physical fitness and psychological health.

METHODS

Between October 2013 and December 2016, adults with locally advanced rectal cancer undergoing standardised NCRT and surgery were recruited to a multi-centre trial. Patients underwent cardiopulmonary exercise testing (CPET) and completed HRQoL questionnaires (EORTC-QLQ-C30 and EQ-5D-5L) pre-NCRT and post-NCRT (week 0/baseline). At week 0, patients were randomised to exercise prehabilitation or usual care (no intervention). CPET and HRQoL questionnaires were assessed at week 0, 3, 6 and 9, whilst semi-structured interviews were assessed at week 0 and week 9. Changes in oxygen uptake at anaerobic threshold (VO2 at AT (ml kg-1 min-1)) between groups were compared using linear mixed modelling.

RESULTS

Thirty-eight patients were recruited, mean age 64 (10.4) years. Of the 38 patients, 33 were randomised: 16 to usual care and 17 to exercise prehabilitation (26 males and 7 females). Exercise prehabilitation significantly improved VO2 at AT at week 9 compared to the usual care. The change from baseline to week 9, when adjusted for baseline, between the randomised groups was + 2.9 ml kg -1 min -1; (95% CI 0.8 to 5.1), p = 0.011.

CONCLUSION

A 9-week exercise prehabilitation programme significantly improved fitness following NCRT. These findings have informed the WesFit trial (NCT03509428) which is investigating the effects of community-based multimodal prehabilitation before cancer surgery.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01914068 . Registered 1 August 2013.

Moderate aerobic exercise prevents matrix degradation and death in a mouse model of aortic dissection and aneurysm

Thoracic aortic aneurysm and dissection (TAAD) is a deadly disease characterized by intimal disruption induced by hemodynamic forces of the circulation. The effect of exercise in patients with TAAD is largely unknown. β-Aminopropionitrile (BAPN) is an irreversible inhibitor of lysyl oxidase that induces TAAD in mice. The objective of this study was to investigate the effect of aerobic exercise on BAPN-induced TAAD. Upon weaning, mice were given either BAPN-containing water or standard drinking water and subjected to either conventional cage activity (BAPN-CONV) or forced treadmill exercise (BAPN-EX) for up to 26 wk. Mortality was 23.5% (20/85) for BAPN-CONV mice versus 0% (0/22) for BAPN-EX mice (hazard ratio 3.8; P = 0.01). BAPN induced significant elastic lamina fragmentation and intimal-medial thickening compared with BAPN-untreated controls, and aneurysms were identified in 50% (5/10) of mice that underwent contrast-enhanced CT scanning. Exercise significantly decreased BAPN-induced wall thickening, calculated circumferential wall tension, and lumen diameter, with 0% (0/5) of BAPN-EX demonstrating chronic aortic aneurysm formation on CT scan. Expression of selected genes relevant to vascular diseases was analyzed by qRT-PCR. Notably, exercise normalized BAPN-induced increases in TGF-β pathway-related genes Cd109, Smad4, and Tgfβr1; inflammation-related genes Vcam1, Bcl2a1, Ccr2, Pparg, Il1r1, Il1r1, Itgb2, and Itgax; and vascular injury- and response-related genes Mmp3, Fn1, and Vwf. Additionally, exercise significantly increased elastin expression in BAPN-treated animals compared with controls. This study suggests that moderate aerobic exercise may be safe and effective in preventing the most devastating outcomes in TAAD.NEW & NOTEWORTHY Moderate aerobic exercise was shown to significantly reduce mortality, extracellular matrix degradation, and thoracic aortic aneurysm and dissection formation associated with lysyl oxidase inhibition in a mouse model. Gene expression suggested a reversal of TGF-β, inflammation, and extracellular matrix remodeling pathway dysregulation, along with augmented elastogenesis with exercise.

A pilot study of aquatic prehabilitation in adults with knee osteoarthritis undergoing total knee arthroplasty - short term outcome

BACKGROUND

Knee osteoarthritis (KOA) is increasingly more prevalent and significant number of patients require knee arthroplasty. Although knee arthroplasty is generally successful, it takes months to recover physical function. Preoperative physical function is known to predict postoperative outcomes and exercise can improve preoperative physical function. However, patients with KOA have difficulty exercise on land due to pain and stiffness, while water exercise can be better tolerated. We hypothesized that preoperative water exercise to improve preoperative physical function will improve postoperative outcomes after total knee arthroplasty (TKA).

METHODS

We enrolled 43 participants who were scheduled for elective TKA in 4-8 weeks and scored at or below 50th percentile in mobility assessment tool-sf (MAT-sf). All enrolled participants were assessed on 1) clinical osteoarthritis symptom severity using Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), 2) physical function using Short Physical Performance Battery (SPPB), 3) self-reported mobility using Mobility Assessment Tool-short form (MAT-sf), 4) depression using Geriatric Depression Scale-short form (GDS-sf), 5) cognitive function using Montreal Cognitive Assessment (MoCA). Blood samples for high-sensitivity-C-reactive protein (hs-CRP), tumor necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6) were stored at - 80 °C then all samples were analyzed together. All the enrolled participants were randomly assigned to the aquatic exercise intervention (AEI) or usual care group. Sixty minute sessions of AEI was conducted three times a week for 4-8 weeks. Participants in both groups were evaluated within 1 week before their scheduled surgery, as well as 4 weeks after the surgery.

RESULTS

The mean age was 67.1 (±6.2), 44% were female, 74% were White. There is no statistically significant difference in combined outcome of any complication, unscheduled ER visit, and disposition to nursing home or rehab facility by AEI. However, AEI was associated with more favorable outcomes: WOMAC scores (p < 0.01), chair-stand (p = 0.019), MAT-sf as well as improved depression (p = 0.043) and cognition (p = 0.008).

CONCLUSION

4-8 weeks of aquatic exercise intervention resulted in improved functional outcomes as well as improved depression and cognition in elderly patients undergoing TKA. A larger study is warranted to explore the role of water exercise in clinical and functional outcomes of TKA.

Effect of continuous positive airway pressure on maximal exercise capacity in patients with obstructive sleep apnea: a systematic review and meta-analysis

STUDY OBJECTIVES

Exercise capacity is impaired in obstructive sleep apnea (OSA). There are conflicting reports on the effect of continuous positive airway pressure (CPAP) on maximal exercise capacity. The objective of this review was to determine if there is a change in exercise capacity and anaerobic threshold following CPAP treatment in OSA patients.

METHODS

We conducted a systematic review and meta-analyses to summarize the changes in peak rate of oxygen uptake (V̇O₂ peak) or maximum rate of oxygen uptake (V̇O2 max) and anaerobic threshold (AT) during cardiopulmonary exercise testing following CPAP intervention in patients with OSA. A systematic literature review was conducted to identify published literature on markers of V̇O₂ peak, V̇O₂ max, and AT pre- vs post-CPAP using a web-based literature search of PubMed/MEDLINE, Embase, CINAHL, and Cochrane review (CENTRAL) databases. Two independent reviewers screened the articles for data extraction and analysis.

RESULTS

The total search of all the databases returned 470 relevant citations. Following application of eligibility criteria, 6 studies were included in the final meta-analysis for V̇O₂ peak, 2 studies for V̇O₂ max, and five studies for AT. The meta-analysis showed a mean net difference in V̇O₂ peak between pre- and post-CPAP of 2.69 mL·kg^-1·min^-1, P = .02, favoring treatment with CPAP. There was no difference in V̇O₂ max or AT with CPAP treatment (mean net difference 0.66 mL·kg^-1·min^-1 [P = .78] and -144.98 mL·min^-1 [P = .20] respectively).

CONCLUSIONS

There is a paucity of high-quality studies investigating the effect of CPAP on exercise capacity. Our meta-analysis shows that V̇O₂ peak increases following CPAP treatment in patients with OSA, but we did not observe any change in V̇O₂ max or AT. Our findings should be considered preliminary and we recommend further randomized controlled trials to confirm our findings and to clarify the peak and maximum rates of oxygen uptake adaptations with CPAP therapy.

Prehabilitation

In this article, we review the evidence underpinning the broader prehabilitation concept and the target behavioural and lifestyle risk factors including their perioperative impact and evidence for prehabilitation intervention. We also identify principles for delivering prehabilitation in practice, alongside lessons for the perioperative setting from well-established allied interventions; cardiac and pulmonary rehabilitation.

Cardiopulmonary exercise testing in severe osteoarthritis: a crossover comparison of four exercise modalities

Cardiopulmonary exercise testing is performed increasingly for cardiorespiratory fitness assessment and pre-operative risk stratification. Lower limb osteoarthritis is a common comorbidity in surgical patients, meaning traditional cycle ergometry-based cardiopulmonary exercise testing is difficult. The purpose of this study was to compare cardiopulmonary exercise testing variables and subjective responses in four different exercise modalities. In this crossover study, 15 patients with osteoarthritis scheduled for total hip or knee arthroplasty (mean (SD) age 68 (7) years; body mass index 31.4 (4.1) kg.m^-2 ) completed cardiopulmonary exercise testing on a treadmill, elliptical cross-trainer, cycle and arm ergometer. Mean (SD) peak oxygen consumption was 20-30% greater on the lower limb modalities (treadmill 21.5 (4.6) (p < 0.001); elliptical cross-trainer (21.2 (4.1) (p < 0.001); and cycle ergometer (19.4 (4.2) ml.min^-1 .kg^-1 (p = 0.001), respectively) than on the arm ergometer (15.7 (3.7) ml.min^-1 .kg^-1 ). Anaerobic threshold was 25-50% greater on the lower limb modalities (treadmill 13.5 (3.1) (p < 0.001); elliptical cross-trainer 14.6 (3.0) (p < 0.001); and cycle ergometer 10.7 (2.9) (p = 0.003)) compared with the arm ergometer (8.4 (1.7) ml.min^-1 .kg^-1 ). The median (95%CI) difference between pre-exercise and peak-exercise pain scores was greater for tests on the treadmill (2.0 (0.0-5.0) (p = 0.001); elliptical cross-trainer (3.0 (2.0-4.0) (p = 0.001); and cycle ergometer (3.0 (1.0-5.0) (p = 0.001)), compared with the arm ergometer (0.0 (0.0-1.0) (p = 0.406)). Despite greater peak exercise pain, cardiopulmonary exercise testing modalities utilising the lower limbs affected by osteoarthritis elicited higher peak oxygen consumption and anaerobic threshold values compared with arm ergometry.

The "Minimum Clinically Important Difference" in Frequently Reported Objective Physical Function Tests After a 12-Week Renal Rehabilitation Exercise Intervention in Nondialysis Chronic Kidney Disease

OBJECTIVE

Chronic kidney disease patients are characterized by impaired physical function. The goal of exercise-based interventions is an improvement in functional performance. However, improvements are often determined by "statistically significant" changes. We investigated the "minimum clinically important difference," "the smallest change that is important to the patient," for commonly reported physical function tests.

DESIGN

Nondialysis chronic kidney disease patients completed 12-wks of a combined aerobic (plus resistance training). The incremental shuttle walking test, sit-to-stand 5 and 60, estimated 1-repetition maximum for the knee extensors, and VO2peak were assessed. After the intervention, patients rated their perceived change in health. Both anchor- and distribution-based minimum clinically important difference approaches were calculated.

RESULTS

The minimum clinically important difference was calculated as follows: incremental shuttle walking test, +45 m; sit-to-stand 5, -4.2 secs; VO2peak, +1.5 ml/kg per min. Because of comparable increases in "anchor" groups, no minimum clinically important difference was estimated for the sit-to-stand 60 or estimated 1-repetition maximum.

CONCLUSIONS

We have established the minimum clinically important difference in chronic kidney disease for common tests of physical function. These values represent the minimum change required for patients to perceive noticeable and beneficial change to their health. These scores will help interpret changes after exercise interventions where these tests are used. These minimum clinically important differences can be used to power future studies to detect clinically important changes.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Define the "minimum clinically important difference"; (2) Distinguish between concepts of minimum clinically important difference, "minimal detectable change,", and "statistically significant change"; and (3) Interpret other study findings and their own results in the context of the minimum clinically important difference rather than statistically significant changes.

LEVEL

Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Preoperative behavioural intervention to reduce drinking before elective orthopaedic surgery: the PRE-OP BIRDS feasibility RCT

BACKGROUND

Heavy alcohol consumption is associated with an increased risk of postoperative complications and extended hospital stay. Alcohol consumption therefore represents a modifiable risk factor for surgical outcomes. Brief behavioural interventions have been shown to be effective in reducing alcohol consumption among increased risk and risky drinkers in other health-care settings and may offer a method of addressing preoperative alcohol consumption.

OBJECTIVES

To investigate the feasibility of introducing a screening process to assess adult preoperative drinking levels and to deliver a brief behavioural intervention adapted for the target population group. To conduct a two-arm (brief behavioural intervention plus standard preoperative care vs. standard preoperative care alone), multicentre, pilot randomised controlled trial to assess the feasibility of proceeding to a definitive trial. To conduct focus groups and a national web-based survey to establish current treatment as usual for alcohol screening and intervention in preoperative assessment.

DESIGN

A single-centre, qualitative, feasibility study was followed by a multicentre, two-arm (brief behavioural intervention vs. treatment as usual), individually randomised controlled pilot trial with an embedded qualitative process evaluation. Focus groups and a quantitative survey were employed to characterise treatment as usual in preoperative assessment.

SETTING

The feasibility study took place at a secondary care hospital in the north-east of England. The pilot trial was conducted at three large secondary care centres in the north-east of England.

PARTICIPANTS

Nine health-care professionals and 15 patients (mean age 70.5 years, 86.7% male) participated in the feasibility study. Eleven health-care professionals and 68 patients (mean age 66.2 years, 80.9% male) participated in the pilot randomised trial. An additional 19 health-care professionals were recruited to one of three focus groups, while 62 completed an electronic survey to characterise treatment as usual.

INTERVENTIONS

The brief behavioural intervention comprised two sessions. The first session, delivered face to face in the preoperative assessment clinic, involved 5 minutes of structured brief advice followed by 15-20 minutes of behaviour change counselling, including goal-setting, problem-solving and identifying sources of social support. The second session, an optional booster, took place approximately 1 week before surgery and offered the opportunity to assess progress and boost self-efficacy.

MAIN OUTCOME MEASURES

Feasibility was assessed using rates of eligibility, recruitment and retention. The progression criteria for a definitive trial were recruitment of ≥ 40% of eligible patients and retention of ≥ 70% at 6-month follow-up. Acceptability was assessed using themes identified in qualitative data.

RESULTS

The initial recruitment of eligible patients was low but improved with the optimisation of recruitment processes. The recruitment of eligible participants to the pilot trial (34%) fell short of the progression criteria but was mitigated by very high retention (96%) at the 6-month follow-up. Multimethod analyses identified the methods as acceptable to the patients and professionals involved and offers recommendations of ways to further improve recruitment.

CONCLUSIONS

The evidence supports the feasibility of a definitive trial to assess the effectiveness of brief behavioural intervention in reducing preoperative alcohol consumption and for secondary outcomes of surgical complications if recommendations for further improvements are adopted.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN36257982.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 12. See the National Institute for Health Research Journals Library website for further project information.

Compliance, adherence and effectiveness of a community-based pre-operative exercise programme: a pilot study

BACKGROUND

Pre-operative exercise training improves HR components of fitness and HRQoL following hospital-based programmes.

OBJECTIVE

To assess compliance and adherence of a pragmatic community-based preoperative exercise programme and its effect on health-related (HR) components of fitness and health-related quality of life (HRQoL).

METHODS

Thirty-two surgical oncological participants (15 prostate cancer and 17 colorectal cancer (CRC)) were recruited and assessed to measure HR components of fitness (strength and functional exercise capacity) and HRQoL. An exercise programme was prescribed in the time available prior to surgery with repeat assessments pre-operatively.

RESULTS

Twenty-four participants (14 prostate cancer and 10 CRC) completed the full study (75% compliance). Exercise training was delivered over a median interquartile range (IQR) of 4 (3-4) weeks and 2 (1-3) weeks for the prostate cancer and CRC participants, with > 80% adherence. From baseline to post-exercise intervention, there were significant improvements in lower body strength in the prostate cancer group (p = 0.045), the CRC group (p = 0.001), and in both groups overall (p = .001). Additionally, there were statistically significant improvements in HRQoL: global health status for CRC group (p = 0.025) and for both groups overall (p = 0.023); emotional health subscale for the prostate cancer group (p = 0.048) and for both groups overall (p = 0.027); nausea/vomiting/pain subscale for the CRC group (p = 0.005) and for both groups overall (p = 0.030); and for health scale status for the prostate cancer group (p = 0.019) and for both groups overall (p = 0.006).

CONCLUSION

This community-based pre-operative exercise programme showed acceptable compliance and adherence rates, and significantly increased upper and lower body strength and HRQoL. Pre-operative exercise training should be considered as early as possible in the surgical-oncology pathway and respected within patient scheduling.

Exercise Training Improves Ventilatory Efficiency in Patients With a Small Abdominal Aortic Aneurysm: A RANDOMIZED CONTROLLED STUDY

PURPOSE

To investigate the effects of exercise training on ventilatory efficiency and physiological responses to submaximal exercise in subjects with small abdominal aortic aneurysm (AAA).

METHODS

Sixty-five male patients (72.3 ± 7.0 years) were randomized to exercise training (n = 33) or usual care group (n = 32). Exercise subjects participated in a training groups for 3 mo. Cardiopulmonary exercise testing was performed before and after the study period and peak (Equation is included in full-text article.)O2, the ventilatory threshold (VT), the oxygen uptake efficiency slope (OUES), and the (Equation is included in full-text article.)E2/(Equation is included in full-text article.)CO2 slope were identified. Baseline work rates at VT were matched to examine cardiopulmonary responses after training.

RESULTS

Significant interactions indicating improvements before and after training in the exercise group were noted for time (P < .01), (Equation is included in full-text article.)O2 (P < .01), and work rate (P < .01) at the VT. At peak effort, significant interactions were noted for time (P < .01) and work rate (P < .01), while borderline significance was noted for absolute (P = .07) and relative (P = .04) (Equation is included in full-text article.)O2. Significant interactions were observed for the OUES both when using all exercise data (P = .04) and when calculated up to the VT (P < .01). For the (Equation is included in full-text article.)E2/(Equation is included in full-text article.)CO2 slope, significance was noted only when calculated up to the VT (P = .04). After training, heart rate, (Equation is included in full-text article.)E, (Equation is included in full-text article.)O2 and respiratory exchange ratio were significantly attenuated for the same baseline work rate only in the exercise group (all P < .01).

CONCLUSIONS

Exercise training improves ventilatory efficiency in patients with small AAA. In addition, patients who exercised exhibited less demanding cardiorespiratory responses to submaximal effort.

Comprehensive Cardiac Rehabilitation as a Therapeutic Strategy for Abdominal Aortic Aneurysm

Abdominal aortic aneurysms (AAA) are referred to as “time bombs”. The only way to prevent AAA rupture is elective repair beforehand using surgical replacement or an endovascular procedure. Non-surgical strategies to prevent AAA expansion are under intense investigation. At each AAA stage, that is, occurrence, expansion, and rupture, the mechanisms and risk factors are different, as discussed in this review. Based on the mechanism and risk factors for AAA expansion, the most effective strategy against AAA expansion need to be identified, but so far none has. Exercise is known to be essential for preventing atherosclerosis related to the coexistence of AAA and CAD, but some doctors are hesitant to prescribe exercise programs to AAA patients given that BP elevation during exercise can cause AAA expansion or rupture. In our retrospective study and prospective study on the safety and effectiveness of exercise for AAA patients, the protective role of mild-moderate exercise against expansion of small AAA was clearly shown. The stability of AAA on exercise might be related to reduced inflammatory activity in the aortic wall, stabilized elevation in BP during exercise, increased aortic blood flow, upregulation of transforming growth factor-β1, moderated BMI and/or fat, or improved endothelial function. Until a revolutionary drug emerges that can regress AAA, cardiac rehabilitation remains the best strategy for preventing AAA expansion and rupture.

Aortic and Systemic Arterial Stiffness Responses to Acute Exercise in Patients With Small Abdominal Aortic Aneurysms

OBJECTIVE/BACKGROUND

Elevated arterial stiffness is a characteristic of abdominal aortic aneurysm (AAA), and is associated with AAA growth and cardiovascular mortality. A bout of exercise transiently reduces aortic and systemic arterial stiffness in healthy adults. Whether the same response occurs in patients with AAA is unknown. The effect of moderate- and higher intensity exercise on arterial stiffness was assessed in patients with AAA and healthy adults.

METHODS

Twenty-two men with small diameter AAAs (36 ± 5 mm; mean age 74 ± 6 years) and 22 healthy adults (mean age 72 ± 5 years) were included. Aortic stiffness was measured using carotid to femoral pulse wave velocity (PWV), and systemic arterial stiffness was estimated from the wave reflection magnitude (RM) and augmentation index (Alx75). Measurements were performed at rest and during 90 min of recovery following three separate test sessions in a randomised order: (i) moderate intensity continuous exercise; (ii) higher intensity interval exercise; or (iii) seated rest.

RESULTS

At rest, PWV was higher in patients with AAA than in healthy adults (p < .001), while AIx75 and RM were similar between groups. No differences were observed between AAA patients and healthy adults in post-exercise aortic and systemic arterial stiffness after either exercise protocol. When assessed as the change from baseline (delta, Δ), post-exercise ΔAIx75 was not different to the seated rest protocol. Conversely, post-exercise ΔPWV and ΔRM were both lower at all time points than seated rest (p < .001). ΔPWV was lower immediately after higher intensity than after moderate intensity exercise (p = .015).

CONCLUSION

High resting aortic stiffness in patients with AAA is not exacerbated after exercise. There was a similar post-exercise attenuation in arterial stiffness between patients with AAA and healthy adults compared with seated rest. This effect was most pronounced following higher intensity interval exercise, suggesting that this form of exercise may be a safe and effective adjunctive therapy for patients with small AAAs.

The potential of cardiac rehabilitation as a method of suppressing abdominal aortic aneurysm expansion: a pilot study

This study is a prospective evaluation of the effectiveness of cardiac rehabilitation (CR) in terms of clinical outcomes for small abdominal aortic aneurysms (AAA) that were previously reported in a retrospective cohort study. We conducted a prospective non-randomized trial on patients with small AAA (N = 40; mean age 75.0 ± 6.6 years). Patients were enrolled into one of two groups, rehabilitation (CR) or non-rehabilitation (non-CR) group. Only CR group participated in a supervised-CR program including bicycle ergometer for 150 days. The AAA expansion rate and the risk of AAA repair were compared between two groups. We also researched the relationship between AAA expansion rate and body composition, blood IL-6 and TGFβ1 levels. The CR (N = 15) and non-CR groups (N = 25) were comparable in terms their baseline data. The CR group had a significantly smaller change in the maximal AAA size (- 1.3 ± 2.4 mm/years) compared to the non-CR group (2.0 ± 3.6 mm/years) (p < 0.01). The IL-6, and TGFβ1 levels were unrelated to the changes in AAA size. There was mild positive correlation between the change in systolic blood pressure from rest to exercise and the AAA expansion rate (p = 0.06). The risk of AAA repair after 12 months was lower in the CR group compared to the non-CR group (0% vs. 28%, respectively). CR in patients with small AAA significantly suppressed AAA expansion and resulted in a lowered risk of AAA repair.Clinical trial Trial name: The study of the profitability and protective effect of cardiac rehabilitation on abdominal aortic aneurysm. Number: UMIN000028237. UTL: https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R0000323.

Pre-operative respiratory optimisation: an expert review

Postoperative pulmonary complications are common and cause increased mortality and hospital stay. Smoking and respiratory diseases including asthma, chronic obstructive pulmonary disease and obstructive sleep apnoea are associated with developing postoperative pulmonary complications. Independent risk factors for such complications also include low pre-operative oxygen saturation, or a recent respiratory infection. Postponing surgery in patients who have respiratory infections or inadequately treated respiratory disease, until these can be fully treated, should, therefore, reduce postoperative pulmonary complications. There is evidence from several studies that pre-operative smoking cessation reduces such complications, with no agreed duration at which the benefits become significant; the longer the abstinence, the greater the benefit. Intensive smoking cessation programmes are more effective, and there are long-term benefits, as many patients become permanent non-smokers following their surgery. Supervised exercise programmes normally last 6-8 weeks, and although they reduce overall complications, the evidence of benefit for postoperative pulmonary complications is mixed. High-intensity interval training can improve fitness in just 2 weeks, and so may be more useful for surgical patients. Specific respiratory pre-operative interventions, such as deep breathing exercises and incentive spirometry, can help when used as components of a package of respiratory care. Pre-operative inspiratory muscle training programmes that involve inspiration against a predetermined respiratory load may also reduce some postoperative pulmonary complications. Pre-operative exercise programmes are recommended for patients having major surgery, or in those where pre-operative testing has shown low levels of cardiorespiratory fitness; interval training or respiratory interventions are more feasible as these reduce complications after a shorter pre-operative intervention.

A systematic review of the impact of preoperative exercise for patients with abdominal aortic aneurysm

BACKGROUND

Abdominal aortic aneurysm (AAA) surgery carries significant risk of morbidity and mortality. Preoperative exercise may improve the physical fitness capacity of patients with AAA as well as postoperative outcomes.

METHODS

A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. An electronic search was performed on MEDLINE, Embase, and Cochrane Library for relevant studies. A methodologic assessment of included studies was conducted using the Physiotherapy Evidence Database (PEDro) scale.

RESULTS

Seven studies (six randomized controlled trials and one retrospective cohort study) were included. The overall quality of studies was assessed to range from fair to good. Three studies included AAA patients without indication for surgery, whereas four other studies included AAA patients awaiting surgical repair. One study implemented an inspiratory muscle training program; five studies implemented a continuous moderate-intensity exercise regimen; one study implemented a high-intensity interval training program. Overall compliance with the exercise regimen was high (94% in those not waiting for surgery; 75.8% to 82.3% in those waiting for surgery). In patients not awaiting surgery, preoperative exercise may improve physical fitness parameters including ventilatory threshold (P = .016 at 12 weeks; P = .09 at 12 months) and anaerobic threshold (10% increase; P = .007) but not peak oxygen consumption (P = .183 at 12 weeks; P = .29 at 12 months). In patients awaiting surgery, one study demonstrated a statistically significant improvement in peak oxygen consumption (difference, 1.6 mL/kg/min; P = .004) and anaerobic threshold (difference, 1.9 mL/kg/min; P = .012) for patients who exercised. In terms of postoperative outcomes, exercise may reduce the risk of cardiac, renal, and respiratory complications, although only in those who undergo open surgery. Only patients who underwent endovascular repair had a shorter length of hospital stay when preoperative exercise was conducted.

CONCLUSIONS

Despite the encouraging evidence of preoperative exercise for AAA patients, it remains premature to recommend it as a preoperative intervention. Given the heterogeneity of reported outcomes, future studies should consider conducting well-designed randomized controlled trials with standardized reporting outcomes and definitions.

Meta-analysis of randomized controlled trials on safety and efficacy of exercise training in patients with abdominal aortic aneurysm

OBJECTIVE

Low exercise capacity preoperatively leads to increased postoperative complications, perioperative mortality, length of stay, and inpatient costs among patients going through elective abdominal aortic aneurysm (AAA) surgery. Therefore, exercise training may be extremely important for reducing perioperative adverse events in AAA patients. This paper aimed to perform a meta-analysis of randomized controlled trials to evaluate the safety of exercise training and its effects on exercise capacity in AAA patients.

METHODS

We searched for randomized controlled trials published up to December 2017 that compared exercise training vs usual care without exercise training in AAA patients. The primary outcome was safety, specifically the occurrence of cardiovascular adverse events during the study. Secondary outcomes were changes in AAA diameter, inflammation markers, and exercise capacity based on peak oxygen consumption (peak V˙o₂) and anaerobic threshold (AT).

RESULTS

We identified 341 trials, and after an assessment of relevance, 7 trials with a combined total of 489 participants were analyzed. There were a total of two cardiovascular adverse events during the exercise test and training, and the cardiovascular event rate and its 95% confidence interval (CI) were 0.8% and 0.2% to 3.1%. Exercise training did not tend to increase AAA diameter, and it also tended to decrease high-sensitivity C-reactive protein level in patients with AAA. All studies that evaluated the changes in AAA diameter or high-sensitivity C-reactive protein level involved patients with AAA diameter <55 mm at baseline; there was no study involving participants with AAA diameter ≥55 mm at baseline. Exercise training significantly increased peak V˙o₂ (pooled mean difference, 1.67 mL/kg/min; 95% CI, 0.69-2.65; P < .001) and AT (pooled mean difference, 1.98 mL/kg/min; 95% CI, 0.77-3.19; P < .001) in AAA patients. The result of meta-regression suggested that the effects of exercise training on peak V˙o₂ and AT were not modulated by the exercise duration.

CONCLUSIONS

Our analyses suggested that exercise training among AAA patients is generally safe, although future research should be carried out to further clarify the safety among patients with large AAAs. Exercise training improved peak V˙o₂ and AT in AAA patients. More data are required to identify the optimal exercise duration for improving exercise capacity in patients with AAA.

Preoperative Behavioural Intervention versus standard care to Reduce Drinking before elective orthopaedic Surgery (PRE-OP BIRDS): protocol for a multicentre pilot randomised controlled trial

Background

Evidence suggests that increased preoperative alcohol consumption increases the risk of postoperative complications; therefore, a reduction or cessation in alcohol intake before surgery may reduce perioperative risk. Preoperative assessment presents an opportunity to intervene to optimise patients for surgery. This multicentre, two-arm, parallel group, individually randomised controlled trial will investigate whether a definitive trial of a brief behavioural intervention aimed at reducing preoperative alcohol consumption is feasible and acceptable to healthcare professionals responsible for its delivery and the preoperative elective orthopaedic patient population.

Methods

Screening will be conducted by trained healthcare professionals at three hospitals in the North East of England. Eligible patients (those aged 18 or over, listed for elective hip or knee arthroplasty surgery and scoring 5 or more or reporting consumption of six or more units on a single occasion at least weekly on the alcohol screening tool) who enrol in the trial will be randomised on a one-to-one non-blinded basis to either treatment as usual or brief behavioural intervention delivered in the pre-assessment clinic. Patients will be followed up 1–2 days pre-surgery, 1–5 days post-surgery (as an in-patient), 6 weeks post-surgery, and 6 months post intervention. Feasibility will be assessed through rates of screening, eligibility, recruitment, and retention to 6-month follow-up. An embedded qualitative study will explore the acceptability of study methods to patients and staff.

Discussion

This pilot randomised controlled trial will establish the feasibility and acceptability of trial procedures reducing uncertainties ahead of a definitive randomised controlled trial to establish the effectiveness of brief behavioural intervention to reduce alcohol consumption in the preoperative period and the potential impact on perioperative complications.

Trial registration

Reference number ISRCTN36257982

The cardiopulmonary exercise test grey zone; optimising fitness stratification by application of critical difference

BACKGROUND

Cardiorespiratory fitness can inform patient care, although to what extent natural variation in CRF influences clinical practice remains to be established. We calculated natural variation for cardiopulmonary exercise test (CPET) metrics, which may have implications for fitness stratification.

METHODS

In a two-armed experiment, critical difference comprising analytical imprecision and biological variation was calculated for cardiorespiratory fitness and thus defined the magnitude of change required to claim a clinically meaningful change. This metric was retrospectively applied to 213 patients scheduled for colorectal surgery. These patients underwent CPET and the potential for misclassification of fitness was calculated. We created a model with boundaries inclusive of natural variation [critical difference applied to oxygen uptake at anaerobic threshold (V˙O2-AT): 11 ml O2 kg-1 min-1, peak oxygen uptake (V˙O2 peak): 16 ml O2 kg-1 min-1, and ventilatory equivalent for carbon dioxide at AT (V̇E/V̇CO2-AT): 36].

RESULTS

The critical difference for V˙O2-AT, V˙O2 peak, and V˙E/V˙CO2-AT was 19%, 13%, and 10%, respectively, resulting in false negative and false positive rates of up to 28% and 32% for unfit patients. Our model identified boundaries for unfit and fit patients: AT <9.2 and ≥13.6 ml O2 kg-1 min-1, V˙O2 peak <14.2 and ≥18.3 ml kg-1 min-1, V˙E/V˙CO2-AT ≥40.1 and <32.7, between which an area of indeterminate-fitness was established. With natural variation considered, up to 60% of patients presented with indeterminate-fitness.

CONCLUSIONS

These findings support a reappraisal of current clinical interpretation of cardiorespiratory fitness highlighting the potential for incorrect fitness stratification when natural variation is not accounted for.

Cardiac Rehabilitation Protects Against the Expansion of Abdominal Aortic Aneurysm

Background

Virtually no reports on the effects of exercise in patients with a small abdominal aortic aneurysm (AAA) exist.

Methods and Results

We conducted a retrospective cohort study on 1515 patients with a small AAA before surgery at 2 high‐volume hospitals in Tokyo, Japan, from April 2004 to September 2015. A carefully modified cardiac rehabilitation program without excessive blood pressure elevation during exercise was prescribed to 50 patients with an AAA. Using propensity score matching, mortality and clinical outcomes, including AAA expansion rate, were compared between 2 groups: rehabilitation group and nonrehabilitation group. The background characteristics of the rehabilitation group (n=49) and the nonrehabilitation group (n=163) were almost identical. The risk for AAA repair was much lower in the rehabilitation group after matching (before matching: hazard ratio, 0.43; 95% confidence interval, 0.25–0.72; P=0.001; and after matching: hazard ratio, 0.19; 95% confidence interval, 0.07–0.50; P<0.001). AAA expansion rate was slower in the rehabilitation group (before matching: rehabilitation versus nonrehabilitation group, 2.3±3.7 versus 3.8±3.4 mm/y [P=0.008]; after matching: rehabilitation versus nonrehabilitation group, 2.1±3.0 versus 4.5±4.0 mm/y [P<0.001]). Elevation of blood pressure during exercise was positively correlated with AAA expansion rate after the rehabilitation program (r=0.569, P<0.001).

Conclusions

Cardiac rehabilitation protects against the expansion of small AAAs and mitigates the risk associated with AAA repair, possibly because of the decreased elevation of blood pressure during exercise.

Clinical Trial Registration

URL: upload.umin.ac.jp. Unique identifier: UMIN000028237.

Randomized feasibility trial of high-intensity interval training before elective abdominal aortic aneurysm repair

Background

This study assessed the feasibility of a preoperative high-intensity interval training (HIT) programme in patients awaiting elective abdominal aortic aneurysm repair.

Methods

In this feasibility trial, participants were allocated by minimization to preoperative HIT or usual care. Patients in the HIT group were offered three exercise sessions per week for 4 weeks, and weekly maintenance sessions if surgery was delayed. Feasibility and acceptability outcomes were: rates of screening, eligibility, recruitment, retention, outcome completion, adverse events and adherence to exercise. Data on exercise enjoyment (Physical Activity Enjoyment Scale, PACES), cardiorespiratory fitness (anaerobic threshold and peak oxygen uptake), quality of life, postoperative morbidity and mortality, duration of hospital stay and healthcare utilization were also collected.

Results

Twenty-seven patients were allocated to HIT and 26 to usual care (controls). Screening, eligibility, recruitment, retention and outcome completion rates were 100 per cent (556 of 556), 43·2 per cent (240 of 556), 22·1 per cent (53 of 240), 91 per cent (48 of 53) and 79–92 per cent respectively. The overall exercise session attendance rate was 75·8 per cent (276 of 364), and the mean(s.d.) PACES score after the programme was 98(19) (‘enjoyable’); however, the intensity of exercise was generally lower than intended. The mean anaerobic threshold after exercise training (adjusted for baseline score and minimization variables) was 11·7 ml per kg per min in the exercise group and 11·4 ml per kg per min in controls (difference 0·3 (95 per cent c.i. –0·4 to 1·1) ml per kg per min). There were trivial-to-small differences in postoperative clinical and patient-reported outcomes between the exercise and control groups.

Conclusion

Despite the intensity of exercise being generally lower than intended, the findings support the feasibility and acceptability of both preoperative HIT and the trial procedures. A definitive trial is warranted. Registration number: ISRCTN09433624 (https://www.isrctn.com/).

Effects of acute exercise on endothelial function in patients with abdominal aortic aneurysm

Endothelial dysfunction is observed in patients with abdominal aortic aneurysm (AAA), who have increased risk of cardiovascular events and mortality. This study aimed to assess the acute effects of moderate- and higher-intensity exercise on endothelial function, as assessed by flow-mediated dilation (FMD), in AAA patients (74 ± 6 yr old, n = 22) and healthy adults (72 ± 5 yr old, n = 22). Participants undertook three randomized visits, including moderate-intensity continuous exercise [40% peak power output (PPO)], higher-intensity interval exercise (70% PPO), and a no-exercise control. Brachial artery FMD was assessed at baseline and at 10 and 60 min after each condition. Baseline FMD was lower [by 1.10% (95% confidence interval: 0.72-.81), P = 0.044] in AAA patients than in healthy adults. There were no group differences in FMD responses after each condition ( P = 0.397). FMD did not change after no-exercise control but increased by 1.21% (95% confidence interval: 0.69-1.73, P < 0.001) 10 min after moderate-intensity continuous exercise in both groups and returned to baseline after 60 min. Conversely, FMD decreased by 0.93% (95% confidence interval: 0.41-1.44, P < 0.001) 10 min after higher-intensity interval exercise in both groups and remained decreased after 60 min. We found that the acute response of endothelial function to exercise is intensity-dependent and similar between AAA patients and healthy adults. Our findings provide evidence that regular exercise may improve vascular function in AAA patients, as it does in healthy adults. Improved FMD after moderate-intensity exercise may provide short-term benefit. Whether the decrease in FMD after higher-intensity exercise represents an additional risk and/or a greater stimulus for vascular adaptation remains to be elucidated. NEW & NOTEWORTHY Abdominal aortic aneurysm patients have vascular dysfunction. We observed a short-term increase in vascular function after moderate-intensity exercise. Conversely, higher-intensity exercise induced a prolonged reduction in vascular function, which may be associated with both short-term increases in cardiovascular risk and signaling for longer-term vascular adaptation in abdominal aortic aneurysm patients.

Patients Awaiting Surgical Repair for Large Abdominal Aortic Aneurysms Can Exercise at Moderate to Hard Intensities with a Low Risk of Adverse Events

Purpose: Intervention fidelity refers to the extent an experimental manipulation has been implemented as intended. Our aim was to evaluate the fidelity of high-intensity interval training (HIT) in patients awaiting repair of large abdominal aortic aneurysms.

Methods: Following a baseline cardiopulmonary exercise test, 27 participants performed a hospital-based, supervised HIT intervention in the 4 weeks preceding surgery. The intervention was performed thrice weekly on a cycle ergometer and involved either 8 × 2-min intervals, each interspersed by 2-min recovery periods, or 4 × 4-min intervals interspersed with 4-min recovery periods. When surgery was delayed, participants undertook one maintenance HIT session per week until surgery. Session one power output was set to baseline anaerobic threshold power output and then increased on subsequent sessions until ratings of perceived exertion (RPE; Borg CR-10) for the legs (RPE-L) and sense of breathlessness/ chest (RPE-C) were hard (5) to very hard (7) at the end of each interval. For safety, power output was maintained or reduced if systolic blood pressure exceeded 180 mm Hg or heart rate exceeded 95% of maximum.

Results: Overall session attendance across the 4-week HIT intervention was 74%. Seventeen participants met our compliance criteria of ≥75% of intervention sessions and all maintenance sessions. When compared to non-compliance, compliant participants had higher fitness, performed more HIT sessions and were able to exercise at higher exercise intensities with a lower proportion of exercise safety breaches. In the 17 compliant participants, the proportion of repetitions meeting the HIT criterion was 30% (RPE-L) and 16% (RPE-C). Mean repetition intensity was 4.1 ± 2.0 Arbitrary Units [AU] (RPE-L) and 3.5 ± 1.9 AU (RPE-C) with a within-subject variability of ±1.4 AU and ±1.6 AU, respectively. We observed higher RPE scores (~0.5 AU) following 2-min intervals when compared to 4-min intervals and exercise power output increased 23% across the 4-week HIT intervention. One participant experienced an adverse event but were still able to complete their remaining exercise sessions.

Conclusions: Despite an inconsistent and lower than prescribed intensity, it is possible to exercise this high-risk patient population at moderate to hard intensities with a low risk of adverse events.

Clinical Trial Registration:http://www.isrctn.com/, registration number ISRCTN09433624.

Peri-operative renal dysfunction: prevention and management

Postoperative increases in serum creatinine concentration, by amounts historically viewed as trivial, are associated with increased morbidity and mortality. Acute kidney injury is common, affecting one in five patients admitted with acute medical disease and up to four in five patients admitted to intensive care, of whom one in two have had operations. This review is focused principally on the identification of patients at risk of acute kidney injury and the prevention of injury. In the main, there are no interventions that directly treat the damaged kidney. The management of acute kidney injury is based on correction of dehydration, hypotension, and urinary tract obstruction, stopping nephrotoxic drugs, giving antibiotics for bacterial infection, and commencing renal replacement therapy if necessary.

Randomized clinical trial of prehabilitation before planned liver resection

BACKGROUND

Patients with low fitness as assessed by cardiopulmonary exercise testing (CPET) have higher mortality and morbidity after surgery. Preoperative exercise intervention, or prehabilitation, has been suggested as a method to improve CPET values and outcomes. This trial sought to assess the capacity of a 4-week supervised exercise programme to improve fitness before liver resection for colorectal liver metastasis.

METHODS

This was a randomized clinical trial assessing the effect of a 4-week (12 sessions) high-intensity cycle, interval training programme in patients undergoing elective liver resection for colorectal liver metastases. The primary endpoint was oxygen uptake at the anaerobic threshold. Secondary endpoints included other CPET values and preoperative quality of life (QoL) assessed using the SF-36®.

RESULTS

Thirty-eight patients were randomized (20 to prehabilitation, 18 to standard care), and 35 (25 men and 10 women) completed both preoperative assessments and were analysed. The median age was 62 (i.q.r. 54-69) years, and there were no differences in baseline characteristics between the two groups. Prehabilitation led to improvements in preoperative oxygen uptake at anaerobic threshold (+1·5 (95 per cent c.i. 0·2 to 2·9) ml per kg per min) and peak exercise (+2·0 (0·0 to 4·0) ml per kg per min). The oxygen pulse (oxygen uptake per heart beat) at the anaerobic threshold improved (+0·9 (0·0 to 1·8) ml/beat), and a higher peak work rate (+13 (4 to 22) W) was achieved. This was associated with improved preoperative QoL, with the overall SF-36® score increasing by 11 (95 per cent c.i. 1 to 21) (P = 0·028) and the overall SF-36® mental health score by 11 (1 to 22) (P = 0·037).

CONCLUSION

A 4-week prehabilitation programme can deliver improvements in CPET scores and QoL before liver resection. This may impact on perioperative outcome.

REGISTRATION NUMBER

NCT01523353 (https://clinicaltrials.gov).

The effects of neoadjuvant chemoradiotherapy and an in-hospital exercise training programme on physical fitness and quality of life in locally advanced rectal cancer patients (The EMPOWER Trial): study protocol for a randomised controlled trial

BACKGROUND

The standard treatment pathway for locally advanced rectal cancer is neoadjuvant chemoradiotherapy (CRT) followed by surgery. Neoadjuvant CRT has been shown to decrease physical fitness, and this decrease is associated with increased post-operative morbidity. Exercise training can stimulate skeletal muscle adaptations such as increased mitochondrial content and improved oxygen uptake capacity, both of which are contributors to physical fitness. The aims of the EMPOWER trial are to assess the effects of neoadjuvant CRT and an in-hospital exercise training programme on physical fitness, health-related quality of life (HRQoL), and physical activity levels, as well as post-operative morbidity and cancer staging.

METHODS/DESIGN

The EMPOWER Trial is a randomised controlled trial with a planned recruitment of 46 patients with locally advanced rectal cancer and who are undergoing neoadjuvant CRT and surgery. Following completion of the neoadjuvant CRT (week 0) prior to surgery, patients are randomised to an in-hospital exercise training programme (aerobic interval training for 6 to 9 weeks) or a usual care control group (usual care and no formal exercise training). The primary endpoint is oxygen uptake at lactate threshold ([Formula: see text] at [Formula: see text]) measured using cardiopulmonary exercise testing assessed over several time points throughout the study. Secondary endpoints include HRQoL, assessed using semi-structured interviews and questionnaires, and physical activity levels assessed using activity monitors. Exploratory endpoints include post-operative morbidity, assessed using the Post-Operative Morbidity Survey (POMS), and cancer staging, assessed by using magnetic resonance tumour regression grading.

DISCUSSION

The EMPOWER trial is the first randomised controlled trial comparing an in-hospital exercise training group with a usual care control group in patients with locally advanced rectal cancer. This trial will allow us to determine whether exercise training following neoadjuvant CRT can improve physical fitness and activity levels, as well as other important clinical outcome measures such as HRQoL and post-operative morbidity. These results will aid the design of a large, multi-centre trial to determine whether an increase in physical fitness improves clinically relevant post-operative outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01914068 (received: 7 June 2013).

SPONSOR

University Hospital Southampton NHS Foundation Trust.

Progressive resistance training in Parkinson's disease: a systematic review and meta-analysis

OBJECTIVES

To investigate if there is evidence on effectiveness of progressive resistance training in rehabilitation of Parkinson disease.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Central, Medline, Embase, Cinahl, Web of Science, Pedro until May 2014. Randomised controlled or controlled clinical trials. The methodological quality of studies was assessed according to the Cochrane Collaboration's domain-based evaluation framework.

DATA SYNTHESIS

random effects meta-analysis with test for heterogeneity using the I² and pooled estimate as the raw mean difference.

PARTICIPANTS

Adults with primary/idiopathic Parkinson's disease of any severity, excluding other concurrent neurological condition.

INTERVENTIONS

Progressive resistance training defined as training consisting of a small number of repetitions until fatigue, allowing sufficient rest between exercises for recovery, and increasing the resistance as the ability to generate force improves.

COMPARISON

Progressive resistance training versus no treatment, placebo or other treatment in randomised controlled or controlled clinical trials.

PRIMARY AND SECONDARY OUTCOME MEASURES

Any outcome.

RESULTS

Of 516 records, 12 were considered relevant. Nine of them had low risk of bias. All studies were randomised controlled trials conducted on small samples with none or 1 month follow-up after the end of intervention. Of them, six were included in quantitative analysis. Pooled effect sizes of meta-analyses on fast and comfortable walking speed, the 6 min walking test, Timed Up and Go test and maximal oxygen consumption were below the level of minimal clinical significance.

CONCLUSIONS

There is so far no evidence on the superiority of progressive resistance training compared with other physical training to support the use of this technique in rehabilitation of Parkinson's disease.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO 2014:CRD42014009844.

Enhanced recovery pathways lead to an improvement in postoperative outcomes following esophagectomy: systematic review and pooled analysis

The aim of this systematic review and pooled analysis is to determine the effect of enhanced recovery programs (ERP) on clinical outcome measures following esophagectomy. Medline, Embase, trial registries, conference proceedings, and reference lists were searched for trials comparing clinical outcome from esophagectomy followed by a conventional pathway with esophagectomy followed by an ERP. Primary outcomes were the incidence of postoperative mortality, anastomotic leak and pulmonary complications, and secondary outcomes were length of hospital stay and the incidence of 30-day readmission. Nine studies were included comprising 1240 patients, 661 patients underwent esophagectomy followed conventional pathway, and 579 patients underwent ERP. Utilization of ERP was associated with a reduction in the incidence of anastomotic leak (12.2-8.3%; pooled odds ratios = 0.61; 95% confidence interval = 0.39 to 0.96; P = 0.03) and pulmonary complications (29.1-19.6%; pooled odds ratios = 0.52; 95% confidence interval = 0.36 to 0.77; P = 0.001) and length of hospital stay, and no significant change in postoperative mortality or readmission rate. There was significant variation in the design of enhanced recovery protocols, surgical approach, and utilization of neoadjuvant therapies between the studies that are important confounding variables to be considered. This study suggests a benefit to the utilization of ERP following esophagectomy. The pathways provide a template for all medical personnel interacting with these patients in order to provide incremental changes in all aspects of clinical care that translates into global improvements seen in postoperative outcomes.