Resistance Training and Nutritional Supplementation in Older Adults with Sarcopenia after Acute Disease: A Feasibility Study

Resistance exercise and protein supplementation are recognized as effective treatment strategies for age-related sarcopenia; however, there are limited data on their feasibility, tolerability, and safety. The primary outcome of this study was feasibility, evaluated through the 15-item TELOS (Technological, Economics, Legal, Operational, and Scheduling) feasibility components and by recruitment, retention, and consent rates. Tolerability was measured by examining permanent treatment discontinuation, treatment interruption, exercise dose modification, early termination, rescheduling of missed sessions, losses to follow-up, attendance, and nutritional compliance. Safety was evaluated using the parameters provided by the European Medicines Agency, adapted for exercise interventions. Thirty-two subjects were recruited (average age 81.6 [SD 9.3] years). The TELOS components were assessed before the intervention; out of 15 questions relevant for successful implementation, 4 operational needs answers required specific actions to prevent potential barriers. The recruitment rate was 74%. Eleven patients (34.4%) had permanent treatment interruption (retention rate = 65.6%). Patients attended a mean of 23 (SD 12.0) exercise sessions, with a mean of 56 (SD 32.6) nutritional compliances. A total of 21 patients (65.6%) experienced adverse events unrelated to the intervention, while 7 patients (21.9%) presented adverse reactions to strength exercise. The main barriers to feasibility were operational components and recruitment challenges. Although the intervention was generally safe, the high rate of probable adverse effects, unrelated to the intervention but associated with the individual's baseline health condition, may affect adherence to treatment programs of this kind.

Therapeutic approach to dysphagia in post-COVID patients in a rehabilitation unit: a descriptive longitudinal study

BACKGROUND

A high rate of hospitalized patients for COVID-19 had dysphagia, frequently underdiagnosed, and not treated, inducing a prolonged dysphagia with protracted recovery. Specific treatments and protocols have not been well described yet.

AIM

Given the potential benefits of respiratory muscle training (IEMT) and neuromuscular stimulation (NMES) in dysphagia treatment, this study aimed to assess the feasibility of the protocol used for treating dysphagia in patients who experienced prolonged hospitalization for COVID-19.

DESIGN

Observational, descriptive, prospective study.

SETTING

Department of Physical Medicine and Rehabilitation of a tertiary University hospital.

POPULATION

Fifty-eight COVID-19 patients were admitted for intensive rehabilitation (March 2020 to October 2021) were prospectively studied.

METHODS

Dysphagia was diagnosed using videofluoroscopy and treated with a 3-week protocol adapted from neuromuscular stimulation (NMES) in a motor threshold and inspiratory/expiratory muscle strength training (IEMST), five sets of five repetitions three times daily for 3 weeks. Feasibility was assessed with adherence, outcomes achieved, and occurrence of adverse/unexpected events. Respiratory function (peak cough flow, maximal inspiratory/expiratory pressures) and swallow function (Penetration-Aspiration Scale and Bolus Residue Scale measured by videofluoroscopy) were recorded descriptive statistics, Student's t test for numerical data, and Wilcoxon Test for ordinal variables were applied. SPPSS vs28 and STATA version 15.1 (StataCorp, College Station, TX, USA) were used for statistical analysis. P values 0.05 were considered significant.

RESULTS

Dysphagia was highly prevalent in severe COVID-19 patients (86.6%); all respiratory and swallow parameters improved after a 3-week intervention and 12 of 18 patients dependent on tube feeding resumed a normal diet (66.7%; McNemar P=0.03), and 84.09% attended a no restriction diet at discharge. Adherence to treatment was 85%. No significant adverse events were detected.

CONCLUSIONS

We conclude that a structured swallowing-exercise training intervention based on IEMT and NMES is feasible and safe in prolonged hospitalization post-COVID patients.

CLINICAL REHABILITATION IMPACT

To describe rehabilitation protocols used to treat dysphagia in post-COVID patients will help us to optimize the available techniques in each center and to induce a faster recovery avoiding potential complications.

Effects of high-intensity inspiratory muscle training on systemic inflammatory response in cardiac surgery - A randomized clinical trial

PURPOSE

Preoperative inspiratory muscle training reduces the incidence of postoperative pulmonary complications after cardiac surgery, but training protocols vary widely in terms of intensity. Currently, the mechanisms underlying the effectiveness of this practice are not known. The purpose of the present study is to determine whether preoperative high-intensity inspiratory muscle training (HI-IMT) modulates the perioperative systemic inflammatory response in cardiac surgery patients.

METHODS

Participants awaiting surgical aortic valve replacement were randomized to 3 to 6 weeks preoperative home-based HI-IMT or same duration low-intensity inspiratory muscle training (LI-IMT). The primary outcome was the preoperative value of the soluble tumor necrosis factor receptor 1 (sTNFR1). Secondary outcomes assessed perioperative evolution of the cytokines: sTNFR1, Tumor necrosis factor-α, Interleukin (IL)-6, IL-8, IL10, IL1β, and their combined z-score; reflecting post-training and postoperative inflammatory response. Perioperative pulmonary function and postoperative clinical outcomes were collected.

RESULTS

Between February 2018 and March 30, 2019 patients were randomized, to HI-IMT or LI-IMT. There were no differences between the groups in terms of baseline characteristics. The median (IQR) training duration was 34 (28-44) days. After training, the median (IQR) predicted maximal inspiratory pressure was higher in the HI-IMT vs LI-IMT group (119 (96-142%) vs 97 (81-107%); p = .04) Levels of the sTNFR1 cytokine increased during training in the HI-IMT group, pre vs post training (Median (IQR) 1073 (920; 1219) vs 1172 (965; 1368) ng/L; p = .03). The 24-h postoperative global inflammatory score was lower in the HI-IMT than in the LI-IMT group (Median (IQR), -0.37 (-0.62, 0.03) vs -0.10 (-0.17, 0.49), p = .04). Global inflammatory scores were not different at other time points. There were no significant differences between the groups in post-operative pulmonary function and postoperative clinical outcome.

CONCLUSION

High intensity inspiratory muscle training shows immunomodulatory properties. These properties could explain why preoperative inspiratory muscle training can lead to lung protection after cardiac surgery.

Anthropometric measures and physical examination could be used to assess phenotypic GLIM (Global leadership initiative on malnutrition) criteria in heart failure patients

BACKGROUND AND AIMS

The assessment of muscle mass using technology-based methods is less commonly performed when applying the Global Leadership Initiative on Malnutrition (GLIM) criteria due to the lack of skilled clinical nutrition practitioners and/or equipment. Based on the predictive validity of poor health outcomes and feasibility in clinical practice, this study aimed to analyze whether the measurement of calf circumference (CC), mid-upper arm circumference (MAC), and the physical examination could be used as substitutes for muscle mass assessment, as well as handgrip strength (HGS) used as a substitution when applying the GLIM criteria in hospitalized HF patients.

METHODS AND RESULTS

From June 2022 to January 2023, a single-center prospective study including 216 patients was performed. Additionally, covariates were identified by a directed acyclic graph. The multivariate logistic regression analysis was also used to analyze and compare the association between poor health outcomes and malnutrition (based on 5 types of GLIM criteria). Cohen-kappa coefficient and TELOS-feasibility score were calculated. The prevalence of malnutrition ranged from 35.2% to 42.6%, depending on the tool used. After adjusting for covariates, malnutrition assessed using CC, MAC, or physical examination within the GLIM criteria was independently associated with poor clinical outcomes (90-day HF-related readmission or all-cause mortality and prolonged hospital stay) but not with HGS.

CONCLUSION

CC, MAC and results from physical examination but not HGS may serve as a substitutive metric of muscle mass contained in the GLIM criteria to diagnose malnutrition and predict poor clinical outcomes among HF patients.

REGISTRATION NUMBER

This study was registered at Chinese Clinical Trial Registry. (ChiCTR2200057876) on 20 Mar. 2022.

The impacts of exercise interventions on inflammaging markers in overweight/obesity patients with heart failure: A systematic review and meta-analysis of randomized controlled trials

Objectives

The purpose of this meta-analysis was to investigate the association of aerobic, resistance and concurrent exercises vs. control group on inflammaging markers [tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), IL-1-beta, IL-8, and high sensitivity C-reactive protein (hs-CRP)] in overweight or obesity patients with heart failure (HF).

Methods

The databases of Scopus, PubMed, Web of Science and Google Scholar were searched until August 31, 2022 for exercise interventions vs. control group on circulating inflammaging markers in patients with HF. Only randomized controlled trial (RCT) articles were included. Standardized mean difference (SMD) and 95% confidence intervals (95%CIs) were calculated (registration code = CRD42022347164).

Results

Forty-six full-text articles (57 intervention arms and 3693 participants) were included. A significant reduction was occurred in inflammaging markers of IL-6 [SMD-0.205(95% CI:-0.332 to -0.078),p = 0.002] and hs-CRP [SMD -0.379 (95% CI:-0.556 to -0.202), p = 0.001] with exercise training in patients with HF. Analysis of subgroup by age, body mass index (BMI), type, intensity, duration of exercise and mean left ventricular ejection fraction (LVEF) revealed that there was a significant reduction in TNF-α for middle-aged (p = 0.031), concurrent training (p = 0.033), high intensity (p = 0.005), and heart failure with reduced ejection fraction (HFrEF) (p = 0.007) compared to the control group. There was a significant reduction in IL-6 for middle-aged (p = 0.006), overweight (p = 0.001), aerobic exercise (p = 0.001), both high and moderate intensities (p = 0.037 and p = 0.034), short-term follow-up (p = 0.001), and heart failure with preserved ejection fraction (HFpEF) (p = 0.001) compared to the control group. There was a significant reduction in hs-CRP for middle-aged (p = 0.004), elderly-aged (p = 0.001), overweight (p = 0.001), aerobic exercise (p = 0.001), concurrent training (p = 0.031), both high and moderate intensities (p = 0.017 and p = 0.001), short-term (p = 0.011), long-term (p = 0.049), and very long-term (p = 0.016) follow-ups, HFrEF (p = 0.003) and heart failure with mildly reduced ejection fraction (HFmrEF) (p = 0.048) compared to the control group.

Conclusions

The results confirmed that aerobic exercise and concurrent training interventions were effective to improve inflammaging markers of TNF-α, IL-6, and hs-CRP. These exercise-related anti-inflammaging responses were observed across ages (middle-aged and elderly-aged), exercise intensities, duration of follow-ups, and mean LVEFs (HFrEF, HFmrEF and HFpEF) in overweight patients with HF.

Impacts of Exercise Interventions on Inflammatory Markers and Vascular Adhesion Molecules in Patients With Heart Failure: A Meta-analysis of RCTs

Background

The aim of this meta-analysis was to investigate the effects of concurrent, aerobic, and resistance exercise on markers of inflammation and vascular adhesion molecules (high-sensitivity C-reactive protein [hs-CRP], interleukin [IL]-6, tumour necrosis factor-alpha [TNF-α], soluble intercellular adhesion molecule-1 [sICAM-1], soluble vascular cell adhesion molecule-1 [sVCAM-1], fibrinogen, IL-1-β, IL-10, IL-18, and E-selectin) in patients with heart failure (HF).

Methods

The PubMed, Scopus, Web of Science, and Google Scholar databases were searched for dates up to August 31, 2022. Randomized controlled trial studies for exercise interventions on circulating inflammatory and vascular adhesion markers in patients with HF were included. Standardized mean difference (SMD) and 95% confidence interval (CI) were calculated.

Results

A total of 45 articles were included. Exercise training significantly reduced hs-CRP (SMD -0.441 [95% CI: -0.642 to -0.240], P = 0.001), IL-6 (SMD -0.158 (95% CI: -0.303 to -0.013], P = 0.032), and sICAM-1 (SMD -0.282 [95% CI: -0.477 to -0.086], P = 0.005) markers. Analysis of subgroups revealed that a significant reduction occurred in hs-CRP level for the following subgroups: middle-aged, elderly, overweight status, aerobic exercise, concurrent training, both high and moderate intensity, and short-term, long-term, and very long-term follow-up, compared to a control group (P < 0.05). A significant reduction occurred in IL-6 and sICAM-1 levels for those in the following subgroups, compared to a control group (P < 0.05): middle-aged, aerobic exercise, moderate-intensity exercise, and short-term follow-up. A reduction in TNF-α level occurred for middle-aged patients, compared to a control-group (P < 0.05).

Conclusions

These exercise-related changes (improved inflammation and vascular adhesion markers) as clinical benefits in general, and for exercise-based cardiac rehabilitation in a more-specific format, improve clinical evolution and survival in patients with HF of different etiologies (registration number = CRD42021271423).

Inspiratory Muscle Training in Nemaline Myopathy

BACKGROUND

Respiratory muscle weakness is a common feature in nemaline myopathy. Inspiratory muscle training (IMT) is an intervention that aims to improve inspiratory muscle strength.

OBJECTIVE

The aim of this controlled before-and-after pilot study was to investigate if IMT improves respiratory muscle strength in patients with nemaline myopathy.

METHODS

Nine patients (7 females; 2 males, age 36.6±20.5 years) with respiratory muscle weakness and different clinical phenotypes and genotypes were included. Patients performed eight weeks of sham IMT followed by eight weeks of active threshold IMT. The patients trained twice a day five days a week for 15 minutes at home. The intensity was constant during the training after a gradual increase to 30% of maximal inspiratory pressure (MIP).

RESULTS

Active IMT significantly improved MIP from 43±15.9 to 47±16.6 cmH2O (p = 0.019). The effect size was 1.22. There was no significant effect of sham IMT. Sniff nasal inspiratory pressure, maximal expiratory pressure, spirometry, and diaphragm thickness and thickening showed no significant improvements.

CONCLUSIONS

This pilot study shows that threshold IMT is feasible in patients with nemaline myopathy and improves inspiratory muscle strength. Our findings provide valuable preliminary data for the design of a larger, more comprehensive trial.

Low Intensity Respiratory Muscle Training in COVID-19 Patients after Invasive Mechanical Ventilation: A Retrospective Case-Series Study

Worldwide, healthcare systems had to respond to an exponential increase in COVID-19 patients with a noteworthy increment in intensive care units (ICU) admissions and invasive mechanical ventilation (IMV). The aim was to determine low intensity respiratory muscle training (RMT) effects in COVID-19 patients upon medical discharge and after an ICU stay with IMV. A retrospective case-series study was performed. Forty COVID-19 patients were enrolled and divided into twenty participants who received IMV during ICU stay (IMV group) and 20 participants who did not receive IMV nor an ICU stay (non-IMV group). Maximal expiratory pressure (PEmax), maximal inspiratory pressure (PImax), COPD assessment test (CAT) and Medical Research Council (MRC) dyspnea scale were collected at baseline and after 12 weeks of low intensity RMT. A greater MRC dyspnea score and lower PImax were shown at baseline in the IMV group versus the non-IMV group (p < 0.01). RMT effects on the total sample improved all outcome measurements (p < 0.05; d = 0.38−0.98). Intragroup comparisons after RMT improved PImax, CAT and MRC scores in the IMV group (p = 0.001; d = 0.94−1.09), but not for PImax in the non-IMV group (p > 0.05). Between-groups comparison after RMT only showed MRC dyspnea improvements (p = 0.020; d = 0.74) in the IMV group versus non-IMV group. Furthermore, PImax decrease was only predicted by the IMV presence (R2 = 0.378). Low intensity RMT may improve respiratory muscle strength, health related quality of life and dyspnea in COVID-19 patients. Especially, low intensity RMT could improve dyspnea level and maybe PImax in COVID-19 patients who received IMV in ICU.

Inspiratory muscle training in patients with heart failure: A systematic review and meta-analysis

Objective

To explore the effect of inspiratory muscle training (IMT) on patients with heart failure and further explore the impact of IMT on patients with heart failure with preserved ejection fraction.

Methods

PubMed, EMBASE, Cochrane Library, CNKI, Wanfang and VIP databases were systematically searched. Randomized controlled trials of inspiratory muscle training in patients with heart failure were included. Revman 5.3 software was used to calculate the weighted mean difference (MD) of the combined effect size. The effects of IMT on the maximum oxygen uptake (peakVO2), maximum inspiratory pressure (PI_max), ventilation efficiency (V_E/VCO₂), six-minute walking distance (6MWD), forced expiratory volume (FEV₁), forced vital capacity (FVC) and quality of life in patients with heart failure were compared and analyzed.

Results

After systematic retrieval and screening, 17 studies were included in this study, and the quality of the included studies was good. The results showed that IMT could increase peakVO2 (MD 2.53; 95% CI 1. 54, 3. 51; P < 0.0001) and PI_max (MD 17.25; 95% CI 13. 75, 20. 75; P < 0.00001); improve the V_E/VCO₂ (MD −4.22; 95% CI −6.78, −1.66; P = 0.001) and significantly improve the quality of life in patients with heart failure (MD −13.34; 95% CI −20.42, −6.26; P = 0.0002). However, the effect of IMT on 6MWD in patients with heart failure was not statistically significant (MD 74.45; 95% CI −12.88,161.79; P = 0.09), and the effect on lung function (FEV₁ and FVC) was also not statistically significant (P = 0.08; P = 0.86). IMT had a more significant positive effect on peakVO2 (MD 2.98; 95% CI 1.63, 4.34; P < 0.0001) and quality of life (MD −14.52; 95% CI −18.53, −10.52; P < 0.00001) in patients with heart failure with preserved ejection fraction. Descriptive analysis suggested that IMT may positively affect dyspnoea in patients with heart failure. In addition, the choice of evaluation scale may affect the evaluation results of quality of life and dyspnoea.

Conclusion

IMT has a significant positive effect on respiratory status in patients with heart failure, but different dyspnoea and quality of life evaluation scales can affect the final evaluation results.

A comparison of the effects of inspiratory muscle strength and endurance training on exercise capacity, respiratory muscle strength and endurance, and quality of life in pacemaker patients with heart failure: A randomized study

BACKGROUND

Studies have widely investigated the effects of inspiratory muscle strength training in patients with heart failure (HF). The effects of inspiratory muscle strength or endurance training on outcomes in patients with pacemakers have not been adequately studied.

OBJECTIVES

The aim was to compare the effects of inspiratory muscle strength and endurance training on exercise capacity, quality of life (QoL), peripheral and respiratory muscle strength, respiratory muscle endurance, pulmonary function, dyspnea, fatigue, and physical activity levels in pacemaker patients with HF.

METHODS

A randomized, controlled, double-blind study was conducted. Fourteen pacemaker patients with HF received inspiratory muscle strength training (IMST) at 50% of maximal inspiratory pressure (MIP), and 18 patients received endurance training (IMET) at 30% of MIP 7 days/8 weeks. Exercise capacity [6 min. walking test (6MWT) and the Incremental Shuttle Walking Test (ISWT)], pulmonary function, respiratory muscle strength [MIP, maximal expiratory pressure (MEP)], endurance, peripheral muscle strength, dyspnea, fatigue, QoL, and physical activity level were evaluated before and after.

RESULTS

Demographic characteristics were similar in IMST (3F/11M, 56.92 ± 7.61y, EF: 25%, ICD/CRT:11/3) and IMET (4F/14M, 56 ± 10.77y, EF: 30%, ICD/CRT:16/2) groups (p > 0.05). Significant improvements were present in MIP, MEP, respiratory muscle endurance, peripheral muscle strength, 6MWT and ISWT walking distances, dyspnea, QoL, physical activity level, fatigue scores within groups (p ≤ 0.05). However, there were no significant differences between the groups (p > 0.05). There were no significant improvements in FEV₁%, FVC%, FEV₁/FVC%, and FEF_25-75 within and between the groups (p > 0.05).

CONCLUSIONS

Inspiratory muscle strength and endurance training similarly improves respiratory and peripheral muscle strength, exercise capacity, QoL, physical activity level, and decreases dyspnea and fatigue and are safe and effective in pacemaker patients with HF.

TRIAL REGISTRATION

www.

CLINICALTRIALS

gov; study number: NCT03501355.

The role of exercise training on cardiovascular peptides in patients with heart failure: A systematic review and meta-analysis

Background

The purpose of this systematic review & meta-analysis was to determine the roles of aerobic, resistance or concurrent exercises vs. control (CON) group on B-type natriuretic peptide (BNP) and N-terminal-pro hormone BNP (NT-proBNP) in patients with heart failure.

Methods

The electronic databases of PubMed, Scopus, Web of Science, and Google Scholar were searched up to May 2022 for aerobic vs. CON, resistance vs. CON, and concurrent vs. CON studies on circulating (serum or plasma) levels of BNP and NT-proBNP in patients with heart failure. Non-randomized or randomized controlled trial studies were included. Standardized mean difference (SMD) and 95% confidence intervals (95% CIs) were calculated. This systematic review & meta-analysis was registered in PROSPERO at the University of York with the registration number [CRD42021271632].

Results

A total of 28 articles (37 intervention arms), 26 aerobic intervention arms, 3 resistance intervention arms, and 8 concurrent intervention arms were included. A total of 2563 participants (exercise groups = 1350 and CON groups = 1213) were included. Exercise training significantly decreased NT-proBNP marker [-0.229 (SMD and 95% CI: 0.386 to -0.071), p = 0.005], irrespective of overweight/obesity status. Analysis of subgroup by type of exercise training revealed that there was a significant reduction in the NT-proBNP marker for aerobic exercise group compared to the CON group [-0.336 (SMD and 95% CI: 0.555 to -0.105), p = 0.004], whereas concurrent exercise did not show significant changes in the NT-proBNP marker [-0.134 (SMD and 95% CI: 0.350 to 0.083), p = 0.227]. In addition, exercise training did not significantly change the BNP marker [-0.122 (SMD and 95% CI: 0.322 to 0.079), p = 0.235].

Conclusions

The results suggested that exercise training, especially aerobic exercise can be improved the NT-proBNP concentrations in patients with HF (irrespective of overweight/obesity status), which may be a sign of positive physiological adaptations to aerobic exercise.

The Retornus-2 study: impact of respiratory muscle training in subacute stroke patients with dysphagia, study protocol of a double-blind randomized controlled trial

Background

Stroke can lead to varying degrees of oropharyngeal dysphagia, respiratory muscle dysfunction and even increase medical complications such as aspiration, malnutrition and death. Recent studies suggest that inspiratory and expiratory respiratory muscle training (IEMT) can improve swallowing efficacy and may reduce aspiration events. The main purpose of this study is to examine whether an 8-week IEMT programme can improve respiratory muscle strength and swallow dysfunction severity in subacute stroke patients with dysphagia.

Methods

Retornus-2 is a two-arm, prospectively registered, randomized controlled study with blinded assessors and the participation of fifty individuals who have suffered a stroke. The intervention group undergoes IEMT training consisting of 5 sets of 10 repetitions, three times a day for 8 weeks. Training loads increase weekly. The control group undergoes a sham-IEMT protocol. The primary outcome examines the efficacy of the IEMT protocol to increase respiratory muscle strength and reduce dysphagia severity. The secondary outcome assesses the longitudinal impact of dysphagia on body composition and nutritional assessment over a 6-month follow-up.

Discussion

IEMT induces an improvement in respiratory muscle strength and might be associated with relevant benefits in dysphagia patterns, as well as a reduction in the number of aspiration events confirmed by videofluoroscopy or fiberoptic endoscopic evaluation of swallowing. The description of the impact of swallowing impairment on nutritional status will help develop new strategies to face this known side-effect.

Trial registration

Clinicaltrials.gov NCT03021252. Registered on 10 January 2017. https://clinicaltrials.gov/ct2/results?cond=retornus+2&term=&cntry=ES&state=&city=&dist=

WHO trial Registration data set: Due to heavy traffic generated by the COVID-19 outbreak, the ICTRP Search Portal does not respond. The portal recommends other registries such as clinicaltrials.gov. Protocol version: RETORNUS 2_ PROTOCOL_2.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05353-y.

Effects of Respiratory Muscle Training on Baroreflex Sensitivity, Respiratory Function, and Serum Oxidative Stress in Acute Cervical Spinal Cord Injury

Background: respiratory complications are a leading cause of morbidity and mortality in individuals with spinal cord injury (SCI). We examined the effects of respiratory muscle training (RMT) in patients with acute cervical SCI. Methods: this prospective trial enrolled 44 adults with acute cervical SCI, of which twenty received RMT and twenty-four did not receive RMT. Respiratory function, cardiovascular autonomic function, and reactive oxidative species (ROS) were compared. The experimental group received 40-min high-intensity home-based RMT 7 days per week for 10 weeks. The control group received a sham intervention for a similar period. The primary outcomes were the effects of RMT on pulmonary and cardiovascular autonomic function, and ROS production in individuals with acute cervical SCI. Results: significant differences between the two groups in cardiovascular autonomic function and the heart rate response to deep breathing (p = 0.017) were found at the 6-month follow-up. After RMT, the maximal inspiratory pressure (p = 0.042) and thiobarbituric acid-reactive substances (TBARS) (p = 0.006) improved significantly, while there was no significant difference in the maximal expiratory pressure. Significant differences between the two groups in tidal volume (p = 0.005) and the rapid shallow breathing index (p = 0.031) were found at 6 months. Notably, the SF-36 (both the physical (PCS) and mental (MCS) component summaries) in the RMT group had decreased significantly at the 6-month follow-up, whereas the clinical scores did not differ significantly (p = 0.333) after RMT therapy. Conclusions: High-intensity home-based RMT can improve pulmonary function and endurance and reduce breathing difficulties in patients with respiratory muscle weakness after injury. It is recommended for rehabilitation after spinal cord injury.

Feasibility, tolerability, and effects of exercise-based prehabilitation after neoadjuvant therapy in esophagogastric cancer patients undergoing surgery: an interventional pilot study

Patients requiring surgery for locally advanced esophagogastric cancer often require neoadjuvant therapy (NAT), which may have a detrimental impact on cardiorespiratory reserve. The aims of this study were to investigate the feasibility and tolerability of a 5-week preoperative high-intensity interval training program after NAT, and to assess the potential effects of the training protocol on exercise capacity, muscle function, and health-related quality of life (HRQL). We prospectively studied consecutive patients with resectable locally advanced esophageal and gastric cancer in whom NAT was planned (chemo- or chemoradiotherapy). Feasibility was assessed with the TELOS (Technological, Economics, Legal, Operational, and Scheduling) components, and data on exercise tolerability (attendance and occurrence of adverse or unexpected events). Exercise capacity was assessed with peak oxygen uptake (VO2peak) in a cardiopulmonary exercise test at baseline, post-NAT, and following completion of a high-intensity interval exercise training (25 sessions). Changes in muscle strength and HRQL were also assessed. Of 33 recruited subjects (mean age 65 years), 17 received chemoradiotherapy and 16 chemotherapy. All the TELOS components were addressed before starting the intervention; from a total of 17 questions considered as relevant for a successful implementation, seven required specific actions to prevent potential concerns. Patients attended a mean of 19.4 (6.4) exercise sessions. The predefined level of attendance (≥15 sessions of scheduled sessions) was achieved in 27 out of 33 (81.8%) patients. Workload progression was adequate in 24 patients (72.7%). No major adverse events occurred. VO2peak decreased significantly between baseline and post-NAT (19.3 vs. 15.5 mL/Kg/min, P < 0.05). Exercise led to a significant improvement of VO2peak (15.5 vs. 19.6 mL/kg/min, P < 0.05). Exercise training was associated with clinically relevant improvements in some domains of HRQL, with the social and role function increasing by 10.5 and 11.6 points, respectively, and appetite loss and fatigue declining by 16 and 10.5, respectively. We conclude that a structured exercise training intervention is feasible and safe following NAT in patients with esophagogastric cancer, and it has positive effects to restore exercise capacity to baseline levels within 5 weeks with some improvements in HRQL.

Unraveling the Role of Respiratory Muscle Metaboloreceptors under Inspiratory Training in Patients with Heart Failure

Exercise intolerance may be considered a hallmark in patients who suffer from heart failure (HF) syndrome. Currently, there is enough scientific evidence regarding functional and structural deterioration of skeletal musculature in these patients. It is worth noting that muscle weakness appears first in the respiratory muscles and then in the musculature of the limbs, which may be considered one of the main causes of exercise intolerance. Functional deterioration and associated atrophy of these respiratory muscles are related to an increased muscle metaboreflex leading to sympathetic–adrenal system hyperactivity and increased pulmonary ventilation. This issue contributes to increased dyspnea and/or fatigue and decreased aerobic function. Consequently, respiratory muscle weakness produces exercise limitations in these patients. In the present review, the key role that respiratory muscle metaboloreceptors play in exercise intolerance is accurately addressed in patients who suffer from HF. In conclusion, currently available scientific evidence seems to affirm that excessive metaboreflex activity of respiratory musculature under HF is the main cause of exercise intolerance and sympathetic–adrenal system hyperactivity. Inspiratory muscle training seems to be a useful personalized medicine intervention to reduce respiratory muscle metaboreflex in order to increase patients’ exercise tolerance under HF condition.

The Safety and Efficacy of Inspiratory Muscle Training for Patients With Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention: Study Protocol for a Randomized Controlled Trial

Background: Uncommonly high rates of pneumonia in patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI) have been observed during recent years. Inspiratory muscle training (IMT) could reduce pneumonia in patients undergoing coronary artery bypass grafting and other cardiac surgeries. The relationship between IMT and AMI is unknown. Here, we describe the feasibility and potential benefit of IMT in patients at high risk for pneumonia with AMI who have undergone primary PCI.

Methods: Our study is a prospective, randomized, controlled, single-center clinical trial. A total of 60 participants will be randomized into an IMT group and control group with 30 participants in each group. Participants in the IMT group will undergo training for 15 min per session, twice a day, from 12 to 24 h after primary PCI, until 30 days post-randomization; usual care will be provided for the control group. The primary endpoint is the change in inspiratory muscle strength, the secondary endpoint included feasibility, pneumonia, major adverse cardiovascular events, length of stay, pulmonary function tests measure, and quality of life.

Discussion: Our study is designed to evaluate the feasibility of IMT and its effectiveness in improving inspiratory muscle strength in participants with AMI who have undergone primary PCI.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT04491760.

Inspiratory Muscle Training in Patients With Heart Failure: What Is New? Systematic Review and Meta-Analysis

OBJECTIVE

The benefits of inspiratory muscle training (IMT) have already been demonstrated in patients with heart failure (HF), but the best mode of training and which patients benefit from this intervention are not clear. The purpose of this study was to review the effects of IMT on respiratory muscle strength, functional capacity, pulmonary function, quality of life, and dyspnea in patients with HF; IMT isolated or combined with another intervention (combined IMT), the presence of inspiratory muscle weakness, training load, and intervention time were considered.

METHODS

The search included the databases MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Physiotherapy Evidence Database, and LILACS database through September 2019. The review included randomized studies that assessed IMT in isolation or combined with another intervention-in comparison with a control group, a placebo, or another intervention-in patients with HF. Fourteen studies were included, 13 for meta-analysis (10 for isolated IMT and 3 for combined IMT).

RESULTS

Isolated IMT demonstrated an increase in maximal inspiratory pressure (MIP) (25.12 cm H2O; 95% CI = 15.29 - 34.95), 6-Minute Walk Test (81.18 m; 95% CI = 9.73 - 152.63), maximum oxygen consumption (12 weeks: 3.75 mL/kg/min; 95% CI = 2.98 to 4.51), and quality of life (-20.68; 95% CI = -29.03 to -12.32). The presence of inspiratory muscle weakness, higher loads, and longer intervention times resulted in greater increases in MIP. IMT combined with another intervention demonstrated an increase only in MIP.

CONCLUSIONS

Isolated IMT resulted in an increase in inspiratory muscle strength, functional capacity, and quality of life. IMT combined with another intervention resulted only in a small increase in inspiratory strength. Isolated IMT with higher loads can be considered an adjuvant intervention, especially for those who do not adhere to conventional rehabilitation and who have respiratory muscle weakness.

IMPACT

A systematic review was necessary to review the effects of IMT on respiratory muscle strength, lung function, functional capacity, quality of life, and dyspnea in patients with HF. Various clinical issues important for a better training prescription were considered; these included whether the performance of the training IMT as a form of isolated training benefits patients with HF, whether the combination of IMT with another intervention has additional effects, whether any patient with HF can benefit from IMT (alone or combined with another intervention), and whether only patients who already have respiratory muscle weakness benefit. Also important was establishing which training load provides the best result and the best intervention time, so that health care can be provided more efficiently.

LAY SUMMARY

For people with heart failure, IMT by itself, without being combined with other exercise, can improve ease of breathing, increase the amount of distance that they can walk, and improve quality of life. Inspiratory training with higher loads might be helpful for those with respiratory muscle weakness who are unable to do conventional exercise.

Prediction of 5-year mortality risk by malnutrition according to the GLIM format using seven pragmatic approaches to define the criterion of loss of muscle mass

OBJECTIVES

To assess the association between baseline malnutrition according to the GLIM format, using seven pragmatic approaches to define the criterion of loss of muscle mass, with mortality in the SarcoPhAge (Sarcopenia and Physical Impairment with advancing Age) study during a 5-year follow-up. Secondarily, to calculate diagnostic performance indicators, concordance, and feasibility of these 7 pragmatic approaches compared to the original GLIM criteria.

METHODS

Post-hoc analysis of the SarcoPhAge cohort, which included 534 community-dwelling volunteers ≥65-year-old, followed-up from 2013 to 2019. Baseline malnutrition was defined by GLIM criteria and 7 approaches: 1) Omission of a reduced muscle mass as a criterion; 2) Substitution for handgrip strength, 3) Calf-circumference, 4) Mid-arm circumference, 5) Goodman's grid, 6) Ishii's score chart, and 7) Yu's formula. The association between malnutrition (according to GLIM criteria and the 7 approaches) and mortality was assessed by Cox-regressions. Sensitivity, Specificity, Positive (PPV), Negative (NPV) predictive values, area under the curve (AUC), Cohen-kappa coefficient, and TELOS-feasibility score were calculated.

RESULTS

Data to calculate GLIM criteria were available for 373 subjects (73.07 ± 5.96 years, 56% women). Prevalence of malnutrition with GLIM criteria was 24.4% (ranged from 13.9% to 20.9% with the 7 approaches). GLIM criteria showed a HR = 3.38 (1.89-6.09) to predict mortality during the 5-year follow-up, which ranged from HR = 2.72 (1.51-4.91) to 3.94 (2.14-7.24) with the 7 approaches. All 7 approaches were feasible (TELOS ≥ 3), showed sensitivity ≥ 65%, specificity ≥ 95.4%, PPV ≥ 85%, NPV ≥ 88%, AUC ≥ 0.7 and had almost-perfect/strong concordance (k ≥ 0.7) with the original GLIM criteria.

CONCLUSIONS

GLIM criteria and the 7 approaches predicted three-to four-fold mortality, all ensured an accurate diagnosis, and were feasible in clinical settings.

Inspiratory Muscle Training in Patients with Heart Failure

Background: Prior systematic reviews and meta-analysis addressed that inspiratory muscle training (IMT) improved inspiratory muscle weakness, cardiorespiratory fitness and quality of life similar to conventional exercise training as a first alternative in deconditioned patients with heart failure (HF) lead to a better adaptation to posterior exercise training. The heterogeneity and variability in a wide range of new studies about this topic led to the necessity of an updated and comprehensive narrative review. The present review aimed to analyze and update the most relevant studies about IMT in patients who suffer from HF. Methods: A narrative review was carried out about IMT in HF patients including 26 experimental studies divided into 21 clinical trials and 5 quasi-experimental studies identified through database searching in PubMed, Cochrane and PEDro. Results: There is enough evidence to state that IMT produces improvements in functional capacity of patients with HF. Nevertheless, there is not enough evidence to support that IMT could improve cardiovascular parameters, blood biomarkers or quality of life in these patients. Conclusions: Thus, IMT may be recommended to improve functional capacity in patients who suffer from HF; nevertheless, more evidence is needed regarding cardiovascular parameters, biomarkers and quality of life. Furthermore, mortality or HF hospitalization was not evaluated and most studies were not longer than 3 months. According to IMT protocols and study designs heterogeneity and mid-term follow-up, further investigations through high-quality long-term randomized clinical trials should be performed to achieve systematic reviews and meta-analysis to support strong evidence for IMT in HF patients.

Oxidative and inflammatory effects of pulmonary rehabilitation in patients with bronchiectasis. A prospective, randomized study

Introduction

Background: systemic inflammation and oxidative stress are important factors in the pathogenesis of bronchiectasis. Pulmonary rehabilitation (PR) is recommended for bronchiectasis, but there is no data about its effect on the inflammatory and REDOX status of these patients. Aims: to investigate the effect of PR in non-cystic-fibrosis bronchiectasis (NCFB) patients, and to compare it with the effect of PR plus a hyperproteic oral nutritional supplement (PRS) enriched with beta-hydroxy-beta-methylbutyrate (HMB) on serum inflammatory and oxidative biomarkers. Materials and methods: this was an open randomized, controlled trial. Thirty individuals (65 years old or younger with a body mass index over 18.5, older than 65 years with a body mass index over 20) were recruited from September 2013 to September 2014, and randomly assigned to receive PR or PRS. Total neutrophils, and inflammatory and oxidative biomarker levels were measured at baseline, and then at 3 and 6 months. Results: in the PRS group neutrophil levels were decreased from baseline at 6 months. A significantly different fold change was found between the PR and PRS groups. In the PR group, IL-6 and adiponectin were increased by the end of the study while TNFα levels were decreased from baseline at 6 months. REDOX biomarkers remained stable throughout the study except for 8-isoprostane levels, which were increased from baseline at 6 months in both groups of patients. Conclusions: a PR program induced a pro-oxidative effect accompanied by changes in circulating inflammatory cytokine levels in NCFB patients. Our results would also suggest a possible beneficial effect of the HMB enriched supplement on neutrophil level regulation in these patients. The information provided in this study could be useful for choosing the right therapeutic approach in the management of bronchiectasis.

Physical Therapist Clinical Practice Guideline for the Management of Individuals With Heart Failure

The American Physical Therapy Association (APTA), in conjunction with the Cardiovascular and Pulmonary Section of APTA, have commissioned the development of this clinical practice guideline to assist physical therapists in their clinical decision making when managing patients with heart failure. Physical therapists treat patients with varying degrees of impairments and limitations in activity and participation associated with heart failure pathology across the continuum of care. This document will guide physical therapist practice in the examination and treatment of patients with a known diagnosis of heart failure. The development of this clinical practice guideline followed a structured process and resulted in 9 key action statements to guide physical therapist practice. The level and quality of available evidence were graded based on specific criteria to determine the strength of each action statement. Clinical algorithms were developed to guide the physical therapist in appropriate clinical decision making. Physical therapists are encouraged to work collaboratively with other members of the health care team in implementing these action statements to improve the activity, participation, and quality of life in individuals with heart failure and reduce the incidence of heart failure-related re-admissions.

The effect of inspiratory muscle training on fatigue and dyspnea in patients with heart failure: A randomized, controlled trial

AIM

Fatigue and dyspnea are debilitating symptoms in patients with heart failure (HF). The purpose of this study was to evaluate the effects of inspiratory muscle training (IMT) on dyspnea, fatigue and the New York Heart Association (NYHA) functional classification in patients with HF.

METHODS

In this prospective, randomized, controlled trial, 84 patients with HF (NYHA classes II-III/IV) with a mean age of 56.62 ± 9.56 years were randomly assigned to a 6-week IMT (n = 42) or a sham IMT (n = 42) program. The IMT was performed at 40% of the maximal inspiratory pressure (MIP) in the IMT group and at 10% in the sham group. The main outcomes were assessed at baseline and after the intervention and included dyspnea severity scale (Modified Medical Research Council [MMRC], Fatigue Severity Scale [FSS] and the NYHA functional classification (based on the presenting symptoms).

RESULTS

The between-group analysis showed significant improvements in dyspnea, fatigue and the NYHA functional classification in the IMT group compared to the sham group (P < .05). The within-group analysis showed significant improvements in dyspnea (from 2.63 ± 0.79 to 1.38 ± 0.66, P < .001), fatigue (from 43.36 ± 8.5 to 28.95 ± 9.11, P < .001) and the NYHA functional classification (from 2.73 ± 0.5 to 2.1 ± 0.6, P = .001) in the IMT group, while fatigue and dyspnea increased significantly in the sham group.

CONCLUSIONS

The 6-week home-based IMT was found to be an effective and safe tool for reducing dyspnea and fatigue and improving the NYHA functional classification.

Effects of prophylactic swallowing exercises on dysphagia and quality of life in patients with head and neck cancer receiving (chemo) radiotherapy: the Redyor study, a protocol for a randomized clinical trial

BACKGROUND

Radiation-induced dysphagia is common in patients with head and neck cancer (HNC). Available evidence suggests that exercise therapy prior to oncological treatment could potentially improve deglutition and quality of life; however, a randomized clinical trial is needed to confirm this observation.

METHODS/DESIGN

The Redyor study is a single-blind randomized clinical trial designed to compare the effect of prophylactic oropharyngeal exercises on quality of life and dysphagia of 52 patients with HNC referred to the Radiotherapy Department. The intervention will consist of respiratory muscle training (3 times/day, 5 days/week, 21 weeks) added to the standard swallow therapy. All patients will perform the same exercise intervention, but at different times: before chemoradiotherapy (CRT; early intervention group) or immediately after completing CRT (late intervention group). The main outcome will be change in dysphagia severity assessed with the Penetration-Aspiration Scale in videofluoroscopy study; quality of life will be assessed with the EORTC-QLQ-C30 and its Head and Neck Cancer Module (QLQ-H&N35) at 3, 6, and 12 months after completing CRT.

DISCUSSION

This ongoing clinical trial, registered in 2016, is based on the hypothesis that undergoing a pre-radiotherapy rehabilitation (pre-habilitation) program will have greater benefits (less decrease in quality of life, less delay in swallowing parameters, and less severe dysphagia) compared to post-CRT rehabilitation. The main objective is to assess dysphagia severity in HNC patients; and secondly, to evaluate changes in dysphagia-related quality of life, and to determine the correlation between a clinical variable and instrumental parameters during this period.

TRIAL REGISTRATION

NCT0209009911 .

Effects of prophylactic swallowing exercises on dysphagia and quality of life in patients with head and neck cancer receiving (chemo) radiotherapy: the Redyor study, a protocol for a randomized clinical trial

BACKGROUND

Radiation-induced dysphagia is common in patients with head and neck cancer (HNC). Available evidence suggests that exercise therapy prior to oncological treatment could potentially improve deglutition and quality of life; however, a randomized clinical trial is needed to confirm this observation.

METHODS/DESIGN

The Redyor study is a single-blind randomized clinical trial designed to compare the effect of prophylactic oropharyngeal exercises on quality of life and dysphagia of 52 patients with HNC referred to the Radiotherapy Department. The intervention will consist of respiratory muscle training (3 times/day, 5 days/week, 21 weeks) added to the standard swallow therapy. All patients will perform the same exercise intervention, but at different times: before chemoradiotherapy (CRT; early intervention group) or immediately after completing CRT (late intervention group). The main outcome will be change in dysphagia severity assessed with the Penetration-Aspiration Scale in videofluoroscopy study; quality of life will be assessed with the EORTC-QLQ-C30 and its Head and Neck Cancer Module (QLQ-H&N35) at 3, 6, and 12 months after completing CRT.

DISCUSSION

This ongoing clinical trial, registered in 2016, is based on the hypothesis that undergoing a pre-radiotherapy rehabilitation (pre-habilitation) program will have greater benefits (less decrease in quality of life, less delay in swallowing parameters, and less severe dysphagia) compared to post-CRT rehabilitation. The main objective is to assess dysphagia severity in HNC patients; and secondly, to evaluate changes in dysphagia-related quality of life, and to determine the correlation between a clinical variable and instrumental parameters during this period.

TRIAL REGISTRATION

NCT0209009911 .

Moderate-to-high intensity inspiratory muscle training improves the effects of combined training on exercise capacity in patients after coronary artery bypass graft surgery: A randomized clinical trial

BACKGROUND

The effects of adding moderate-to-high intensity inspiratory muscle training (IMT) to short-term aerobic and resistance exercise (combined training [CT]), after coronary artery bypass grafting (CABG) are not established. This study aimed to determine the effects of moderate-to-high intensity IMT + CT on exercise capacity, respiratory muscle strength, inspiratory muscle endurance, quality of life (QoL), and laboratory biomarkers in patients after CABG who were participants of a phase II cardiac rehabilitation program.

METHODS

Twenty-four patients were randomly assigned to either the IMT + CT group (n = 12), who performed moderate-to-high intensity IMT with CT or the sham-IMT + CT group (n = 12). Patients completed two sessions per week for 12 weeks. Each patient underwent a cardiopulmonary exercise test, six-minute walk test (6MWT), respiratory muscle strength and endurance evaluation, QoL questionnaire, and serum advanced oxidation protein products, ferric reducing antioxidant power [FRAP], nitrate/nitrate, and high-sensitivity C-reactive protein, before and after the 12-week intervention.

RESULTS

The IMT + CT group showed significantly greater improvements in peak oxygen uptake (1.3 mL∙kg^-1∙min^-1; 95% confidence interval [95% CI], 0.5 to 2.2), distance covered during the 6MWT (78.8 m; 95% CI, 28.1 to 129.5), maximal inspiratory pressure (23.0 cmH₂O; 95% CI, 9.3 to 36.7), QoL (-15.1 points; 95% CI, -26.9 to -3.3), and FRAP (83.7 μmol/L; 95% CI, 20.2 to 147.1) compared to the sham-IMT + CT group as a result of the intervention.

CONCLUSIONS

Short-term moderate-to-high intensity IMT with CT provided additional benefits in exercise capacity, inspiratory muscle strength, QoL, and antioxidant profile in patients after CABG. Trial Registration clinicaltrials.gov Identifier: NCT02885077.

High-Intensity Respiratory Muscle Training Improves Strength and Dyspnea Poststroke: A Double-Blind Randomized Trial

OBJECTIVE

To examine whether high-intensity home-based respiratory muscle training, that is, with higher loads, delivered more frequently and for longer duration, than previously applied, would increase the strength and endurance of the respiratory muscles, reduce dyspnea and respiratory complications, and improve walking capacity post-stroke.

DESIGN

Randomized trial with concealed allocation, blinded participants and assessors, and intention-to-treat analysis.

SETTING

Community-dwelling patients.

PARTICIPANTS

Patients with stroke, who had respiratory muscle weakness (N=38).

INTERVENTIONS

The experimental group received 40-minute high-intensity home-based respiratory muscle training, 7 days per week, for 8 weeks, progressed weekly. The control group received a sham intervention of similar dose.

MAIN OUTCOME MEASURES

Primary outcome was inspiratory muscle strength (via maximal inspiratory pressure), whereas secondary outcomes were expiratory muscle strength (maximal expiratory pressure), inspiratory muscle endurance, dyspnea (Medical Research Council score), respiratory complications (hospitalizations), and walking capacity (6-minute walk test). Outcomes were measured at baseline, after intervention, and 1 month beyond intervention.

RESULTS

Compared to the control, the experimental group increased inspiratory (27cmH₂O; 95% confidence interval [95% CI], 15 to 40) and expiratory (42cmH₂O; 95% CI, 25 to 59) strength, inspiratory endurance (33 breaths; 95% CI, 20 to 47), and reduced dyspnea (-1.3 out of 5.0; 95% CI, -2.1 to -0.6), and the benefits were maintained at 1 month beyond training. There was no significant between-group difference for walking capacity or respiratory complications.

CONCLUSION

High-intensity home-based respiratory muscle training was effective in increasing strength and endurance of the respiratory muscles and reducing dyspnea for people with respiratory muscle weakness post-stroke, and the magnitude of the effect was higher, than that previously reported in studies, which applied standard protocols.

Effects of High-Intensity Inspiratory Muscle Training Associated with Aerobic Exercise in Patients Undergoing CABG: Randomized Clinical Trial

OBJECTIVE

Evaluate the interaction between high-intensity inspiratory muscle training (IMT) and aerobic exercise on physical capacity, respiratory muscle strength, peripheral muscle strength, and quality of life of patients who underwent coronary artery bypass grafting (CABG).

METHODS

Twenty-four patients underwent CABG were randomized into two groups. During 36 sessions, one group received IMT associated with aerobic exercise and the other group received only aerobic exercise. Primary outcome was the distance in the six-minute walk distance (6MWD) test. Secondary outcomes included respiratory muscle strength, peripheral muscle strength, and quality of life. Measures were taken at the baseline, at the 12th session, the 24th session, and 36th session.

RESULTS

Baseline characteristics were similar between the groups. There was no statistically significant difference between the two groups in any outcome [6MWD - P=0.935; peak oxygen consumption (PeakVO2) - P=0.853; maximal inspiratory pressure (MIP) - P=0.243; maximal expiratory pressure (MEP) - P=0.268; sitting-rising test (SRT) - P=0.212], but there was interaction in MIP (P=0.000) and all outcomes improved in the two groups (6MWD - P=0.000; PeakVO2 - P=0.000; MIP - P=0.000; MEP - P=0.000; SRT - P=0.000).

CONCLUSION

There was an improvement of all outcomes in both groups, but IMT was not able to provide additional benefits. The use of this combination should be used with caution to not generate higher costs in the rehabilitation process of these patients.

Yoga and breathing technique training in patients with heart failure and preserved ejection fraction: study protocol for a randomized clinical trial

Background

Current therapies for heart failure (HF) are followed by strategies to improve quality of life and exercise tolerance, besides reducing morbidity and mortality. Some HF patients present changes in the musculoskeletal system and inspiratory muscle weakness, which may be restored by inspiratory muscle training, thus increasing respiratory muscle strength and endurance, maximal oxygen uptake (VO₂), functional capacity, respiratory responses to exercise, and quality of life. Yoga therapies have been shown to improve quality of life, inflammatory markers, and peak VO₂ mostly in HF patients with a reduced ejection fraction. However, the effect of different yoga breathing techniques in patients showing HF with a preserved ejection fraction (HFpEF) remain to be assessed.

Methods/design

A PROBE (prospective randomized open blinded end-point) parallel-group trial will be conducted at two specialized HF clinics. Adult patients previously diagnosed with HFpEF will be included. After signing informed consent and performing a pre-test intervention, patients will be randomized into three groups and provided with either (1) active yoga breathing techniques; (2) passive yoga breathing techniques (pranayama); or and (3) control (standard pharmacological treatment). Follow-up will last 8 weeks (16 sessions). The post-intervention tests will be performed at the end of the intervention period for analysis of outcomes. Interventions will occur continuously according to patients’ enrollment. The main outcome is respiratory muscular resistance. A total of 33 enrolled patients are expected. The present protocol followed the SPIRIT guidelines and fulfilled the SPIRIT checklist.

Discussion

This trial is probably the first to assess the effects of a non-pharmacological intervention, namely yoga and specific breathing techniques, to improve cardiorespiratory function, autonomic system, and quality of life in patients with HFpEF.

Trial registration

REBEC Identifier: RBR-64mbnx (August 19, 2012).

Clinical Trials Register: NCT03028168. Registered on 16 January 2017).

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2802-5) contains supplementary material, which is available to authorized users.

Effect of exercise therapy on established and emerging circulating biomarkers in patients with heart failure: a systematic review and meta-analysis

Background

Biomarkers are important in the diagnosis, risk stratification and management of patients with heart failure (HF). The established biomarkers of myocardial stretch, brain natriuretic peptide (BNP) and amino (N) portion of BNP (NT-proBNP) have been extensively studied, and early analyses have demonstrated response to exercise training. Several other biomarkers have been identified over the last decade and may provide valuable and complementary information which may guide treatment strategies, including exercise therapy.

Methods

A systematic search of PubMed, EMBASE and Cochrane Trials Register to 31 October 2017 was conducted for exercise-based rehabilitation trials in HF. Randomised and controlled trials that reported biomarkers, BNP, NT-proBNP, soluble ST2, galectin-3, mid-regional atrial natriuretic peptide, mid-regional adrenomedullin and copeptin, were included.

Results

Forty-three studies were included in the systematic review, with 27 studies suitable for meta-analyses. Data pooling was only possible for NT-proBNP and BNP. Meta-analyses of conventional training studies demonstrated a statistically significant improvement in NT-proBNP (pmol/L); mean difference (MD) −32.80 (95% CI −56.19 to −9.42), p=0.006 and in BNP (pmol/L); MD −17.17 (95% CI −29.56 to −4.78), p=0.007. Pooled data of non-conventional training failed to demonstrate any statistically significant improvements.

Conclusion

Pooled data indicated a favourable effect of conventional exercise therapy on the established biomarkers, NT-proBNP and BNP; however, this was in contrast to a number of studies that could not be pooled. Limited evidence exists as to the effect of exercise training on emerging biomarkers.

The ‘aerobic/resistance/inspiratory muscle training hypothesis in heart failure’

Evidence from large multicentre exercise intervention trials in heart failure patients, investigating both moderate continuous aerobic training and high intensity interval training, indicates that the ‘crème de la crème’ exercise programme for this population remains to be found. The ‘aerobic/resistance/inspiratory (ARIS) muscle training hypothesis in heart failure’ is introduced, suggesting that combined ARIS muscle training may result in maximal exercise pathophysiological and functional benefits in heart failure patients. The hypothesis is based on the decoding of the ‘skeletal muscle hypothesis in heart failure’ and on revision of experimental evidence to date showing that exercise and functional intolerance in heart failure patients are associated not only with reduced muscle endurance, indication for aerobic training (AT), but also with reduced muscle strength and decreased inspiratory muscle function contributing to weakness, dyspnoea, fatigue and low aerobic capacity, forming the grounds for the addition of both resistance training (RT) and inspiratory muscle training (IMT) to AT. The hypothesis will be tested by comparing all potential exercise combinations, ARIS, AT/RT, AT/IMT, AT, evaluating both functional and cardiac indices in a large sample of heart failure patients of New York Heart Association class II–III and left ventricular ejection fraction ≤35% ad hoc by the multicentre randomized clinical trial, Aerobic Resistance, InSpiratory Training OutcomeS in Heart Failure (ARISTOS-HF trial).

Can diaphragmatic breathing modify chest wall volumes during inspiratory loaded breathing in patients with heart failure?

BACKGROUND

Some inspiratory muscle training protocols for patients with heart failure report the request of diaphragmatic breathing during inspiratory loaded breathing. However, it is unclear whether this condition modifies the chest wall volumes.

OBJECTIVE

The primary purpose was to evaluate chest wall volumes during inspiratory loaded breathing as well as during inspiratory loaded breathing associated with diaphragmatic breathing in patients with heart failure.

METHODS

Sixteen men with heart failure functional class I to III, aged 50(SD=7) years were evaluated. Volumes of the pulmonary rib cage, abdominal rib cage and abdomen, as well as other breathing pattern variables, were assessed by optoelectronic plethysmography during quiet breathing, inspiratory loaded breathing, and inspiratory loaded breathing associated with diaphragmatic breathing.

RESULTS

Chest wall tidal volume significantly increased from quiet breathing 0.53(SD=0.14)L to inspiratory loaded breathing 1.33(SD=0.48)L and to inspiratory loaded breathing associated with diaphragmatic breathing 1.36(SD=0.48)L. A significant volume variation was observed on the three compartments (p<0.05 for all). During inspiratory loaded breathing associated with diaphragmatic breathing, patients showed increased abdominal volume compared to quiet breathing [0.28(SD=0.05) to 0.83(SD=0.47)L, p<0.001]; as well as from inspiratory loaded breathing [0.63(SD=0.23) to 0.83(SD=0.47)L, p=0.044]. No significant changes were observed between the two inspiratory loaded breathing conditions on the percentages of the contribution of each chest wall compartment for the tidal volume, respiratory rate, minute ventilation, and duty cycle.

CONCLUSION

When inspiratory loaded breathing was associated with diaphragmatic breathing, a higher volume in the abdominal compartment was obtained without significant changes in other breathing pattern variables.

Diaphragm abnormalities in heart failure and aging: mechanisms and integration of cardiovascular and respiratory pathophysiology

Inspiratory function is essential for alveolar ventilation and expulsive behaviors that promote airway clearance (e.g., coughing and sneezing). Current evidence demonstrates that inspiratory dysfunction occurs during healthy aging and is accentuated by chronic heart failure (CHF). This inspiratory dysfunction contributes to key aspects of CHF and aging cardiovascular and pulmonary pathophysiology including: (1) impaired airway clearance and predisposition to pneumonia; (2) inability to sustain ventilation during physical activity; (3) shallow breathing pattern that limits alveolar ventilation and gas exchange; and (4) sympathetic activation that causes cardiac arrhythmias and tissue vasoconstriction. The diaphragm is the primary inspiratory muscle; hence, its neuromuscular integrity is a main determinant of the adequacy of inspiratory function. Mechanistic work within animal and cellular models has revealed specific factors that may be responsible for diaphragm neuromuscular abnormalities in CHF and aging. These include phrenic nerve and neuromuscular junction alterations as well as intrinsic myocyte abnormalities, such as changes in the quantity and quality of contractile proteins, accelerated fiber atrophy, and shifts in fiber type distribution. CHF, aging, or CHF in the presence of aging disturbs the dynamics of circulating factors (e.g., cytokines and angiotensin II) and cell signaling involving sphingolipids, reactive oxygen species, and proteolytic pathways, thus leading to the previously listed abnormalities. Exercise-based rehabilitation combined with pharmacological therapies targeting the pathways reviewed herein hold promise to treat diaphragm abnormalities and inspiratory muscle dysfunction in CHF and aging.

Effects of inspiratory muscle training in chronic heart failure patients: A systematic review and meta-analysis

OBJECTIVE

The aim of this study was to evaluate the effects of inspiratory muscle training (IMT) in chronic heart failure (CHF) patients.

DESIGN

We searched MEDLINE, EMBASE, Cochrane Library, CINHAL, and CBMdisc to collect controlled trials on the application of inspiratory muscle training in CHF patients from the establishment of these databases to November 2016. Two reviewers independently screened literature according to the inclusion and exclusion criteria, extracted data, and assessed the quality of literature. Meta-analysis was conducted by software RevMan5.3.

RESULTS

Eight studies involving 302 patients were identified. Meta-analysis indicated that IMT significantly improved PI_max , V_E /VCO₂ slope and dyspnea (weighted mean difference [WMD] = 16.52, 95% CI: 13.87-19.17, P < .01; WMD = -5.78, 95% CI: -7.72 to -3.85, P < .01; SMD = -0.95, 95% CI: -1.5 to -0.39, P < .01), and descriptive results showed that long-term IMT (≥6 weeks) can improve the quality of life of CHF patients, and patients in IMT group also have a significant improvement in 6-minute walking distance test (6-MWD).

CONCLUSION

IMT can improve pulmonary function, exercise tolerance, and quality of life of CHF patients and relieve the symptom of dyspnea.

Effect of high-intensity home-based respiratory muscle training on strength of respiratory muscles following a stroke: a protocol for a randomized controlled trial

BACKGROUND

Respiratory muscle training has shown to increase strength of the respiratory muscles following a stroke. However, low duration and/or intensity of training may be responsible for the small effect size seen and/or absence of carry-over effects to an activity, e.g., walking. Therefore, an investigation of the effects of long-duration, high-intensity respiratory muscle training is warranted.

OBJECTIVE

This proposed protocol for a randomized clinical trial will examine the efficacy of high-intensity respiratory muscle training to increase strength and improve activity following a stroke.

METHODS

This study will be a two-arm, prospectively registered, randomized controlled trial, with blinded assessors. Thirty-eight individuals who have suffered a stroke will participate. The experimental group will undertake a 40-min of respiratory muscle training program, seven days/week, for eight weeks in their homes. Training loads will be increased weekly. The control group will undertake a sham respiratory muscle training program with equivalent duration and scheduling of training. The primary outcome will be the strength of the inspiratory muscles, measured as maximal inspiratory pressure. Secondary outcomes will include expiratory muscle strength, inspiratory muscle endurance, dyspnea, respiratory complications, and walking capacity. Outcomes will be collected by a researcher blinded to group allocation at baseline (Week 0), after intervention (Week 8), and one month beyond intervention (Week 12).

CONCLUSION

High-intensity respiratory muscle training may have the potential to optimize the strength of the respiratory muscles following a stroke. If benefits are carried over to activity, the findings may have broader implications, since walking capacity has been shown to predict physical activity and community participation on this population.

Respiratory muscle strength training and neuromuscular electrical stimulation in subacute dysphagic stroke patients: a randomized controlled trial

OBJECTIVE

To evaluate the effectiveness of inspiratory/expiratory muscle training (IEMT) and neuromuscular electrical stimulation (NMES) to improve dysphagia in stroke.

DESIGN

Prospective, single-blind, randomized-controlled trial.

SETTING

Tertiary public hospital.

SUBJECTS

Sixty-two patients with dysphagia were randomly assigned to standard swallow therapy (SST) (Group I, controls, n=21), SST+ IEMT (Group II, n=21) or SST+ sham IEMT+ NMES (Group III, n=20).

INTERVENTIONS

All patients followed a 3-week standard multidisciplinary rehabilitation program of SST and speech therapy. The SST+IEMT group's muscle training consisted of 5 sets/10 repetitions, twice-daily, 5 days/week. Group III's sham IEMT required no effort; NMES consisted of 40-minute sessions, 5 days/week, at 80Hz.

MAIN OUTCOMES

Dysphagia severity, assessed by Penetration-Aspiration Scale, and respiratory muscle strength (maximal inspiratory and expiratory pressures) at the end of intervention and 3-month follow-up.

RESULTS

Maximal respiratory pressures were most improved in Group II: treatment effect was 12.9 (95% confidence interval 4.5-21.2) and 19.3 (95% confidence interval 8.5-30.3) for maximal inspiratory and expiratory pressures, respectively. Swallowing security signs were improved in Groups II and III at the end of intervention. No differences in Penetration-Aspiration Scale or respiratory complications were detected between the 3 groups at 3-month follow-up.

CONCLUSION

Adding IEMT to SST was an effective, feasible, and safe approach that improved respiratory muscle strength. Both IEMT and NMES were associated with improvement in pharyngeal swallowing security signs at the end of the intervention, but the effect did not persist at 3-month follow-up and no differences in respiratory complications were detected between treatment groups and controls.

A Home-Based Diaphragmatic Breathing Retraining in Rural Patients With Heart Failure

Dyspnea limits physical activity and functional status in heart failure patients. This feasibility study examined effects of a diaphragmatic breathing retraining (DBR) intervention delivered over 8 weeks with follow-up at 5 months. The intervention group (n = 18) was trained at baseline and received four telephone calls. An attention control group (n = 18) received four telephone calls with general health information. Results from linear mixed model analysis with effect sizes (η(2)) showed dyspnea improved in both groups, with little difference between groups. Compared with attention alone, the intervention increased physical activity (calories expended; η(2) = .015) and functional status (η(2) = .013) across the 5-month follow-up and increased activity counts at 8 weeks (η(2) = .070). This intervention was feasible and demonstrated promising effects on activity and function but not by reducing dyspnea. Patients may have increased physical activity because of instructions to use DBR during activities of daily living. Further exploration of the intervention's underlying physiological effect is needed.

Breathing exercises and inspiratory muscle training in heart failure

Breathing exercises (BE) and inspiratory muscle training (IMT) have been demonstrated to improve ventilation and ventilation-to-perfusion matching, and to improve exercise, functional performance, and many pathophysiologic manifestations of heart failure (HF). This article provides an extensive review of BE and IMT in patients with HF and identifies several key areas in need of further investigation, including the role of expiratory muscle training, IMT targeted at various locations of inspiration (early, mid, or late inspiration), and alteration of the ratio of inspiratory time to total breath time, all of which have substantial potential to improve many pathophysiologic manifestations of HF.

Inspiratory and expiratory muscle training in subacute stroke: A randomized clinical trial

OBJECTIVE

To assess the effectiveness, feasibility, and safety of short-term inspiratory and expiratory muscle training (IEMT) in subacute stroke patients.

METHODS

Within 2 weeks of stroke onset, 109 patients with a first ischemic stroke event were randomly assigned to the IEMT (n = 56) or sham IEMT (n = 53) study group. The IEMT consisted of 5 sets of 10 repetitions, twice a day, 5 days per week for 3 weeks, at a training workload equivalent to 30% of maximal respiratory pressures. Patients and researchers assessing outcome variables were blinded to the assigned study group. The main outcome was respiratory muscle strength assessed by maximal inspiratory and expiratory pressures (PImax, PEmax). Respiratory complications at 6 months were also recorded.

RESULTS

Both groups improved respiratory muscle strength during the study. IEMT was associated with significantly improved %PImax and %PEmax: effect size d = 0.74 (95% confidence interval [CI] 0.28-1.20) and d = 0.56 (95% CI 0.11-1.02), respectively. No significant training effect was observed for peripheral muscle strength. Respiratory complications at 6 months occurred more frequently in the sham group (8 vs 2, p = 0.042), with an absolute risk reduction of 14%. The number needed to treat to prevent one lung infection event over a follow-up of 6 months was 7. No major adverse events or side effects were observed.

CONCLUSION

IEMT induces significant improvement in inspiratory and expiratory muscle strength and could potentially offer an additional therapeutic tool aimed to reduce respiratory complications at 6 months in stroke patients.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that short-term training may have the potential to improve respiratory muscle strength in patients with subacute stroke.

The striated muscles in pulmonary arterial hypertension: adaptations beyond the right ventricle

Pulmonary arterial hypertension (PAH) is a fatal lung disease characterised by progressive remodelling of the small pulmonary vessels. The daily-life activities of patients with PAH are severely limited by exertional fatigue and dyspnoea. Typically, these symptoms have been explained by right heart failure. However, an increasing number of studies reveal that the impact of the PAH reaches further than the pulmonary circulation. Striated muscles other than the right ventricle are affected in PAH, such as the left ventricle, the diaphragm and peripheral skeletal muscles. Alterations in these striated muscles are associated with exercise intolerance and reduced quality of life. In this Back to Basics article on striated muscle function in PAH, we provide insight into the pathophysiological mechanisms causing muscle dysfunction in PAH and discuss potential new therapeutic strategies to restore muscle dysfunction.

Improving functional capacity in heart failure: the need for a multifaceted approach

PURPOSE OF REVIEW

Functional capacity is a broad term that describes a person's ability to perform the daily activities that require physical exertion. Patients diagnosed with heart failure, regardless of cause, demonstrate a compromised functional capacity. The ability to perform aerobic activities is a central, but not complete, determinant of functional capacity. Muscular strength and endurance are other important elements of functional capacity. It is well established that patients with heart failure demonstrate attenuated muscular strength and endurance as a consequence of their disease process. Typically, a heart failure patient's ability to perform daily activities that are either aerobic or resistive in nature is compromised and contributes to the decline in functional capacity.

RECENT FINDINGS

There is an abundance of literature demonstrating that exercise training improves aerobic capacity and muscular strength and endurance in those with heart failure. These training benefits translate to an improvement in functional capacity and an enhanced ability to perform activities of daily living. There are several approaches to exercise training in the heart failure population, each of which has implications for the degree to which functional capacity can be improved.

SUMMARY

This review summarizes the current body of literature related to exercise training as a means of optimizing functional capacity in patients with heart failure.

Combined aerobic/inspiratory muscle training vs. aerobic training in patients with chronic heart failure: The Vent-HeFT trial: a European prospective multicentre randomized trial

AIMS

Vent-HeFT is a multicentre randomized trial designed to investigate the potential additive benefits of inspiratory muscle training (IMT) on aerobic training (AT) in patients with chronic heart failure (CHF).

METHODS AND RESULTS

Forty-three CHF patients with a mean age of 58 ± 12 years, peak oxygen consumption (peak VO2 ) 17.9 ± 5 mL/kg/min, and LVEF 29.5 ± 5% were randomized to an AT/IMT group (n = 21) or to an AT/SHAM group (n = 22) in a 12-week exercise programme. AT involved 45 min of ergometer training at 70-80% of maximum heart rate, three times a week for both groups. In the AT/IMT group, IMT was performed at 60% of sustained maximal inspiratory pressure (SPImax ) while in the AT/SHAM group it was performed at 10% of SPImax , using a computer biofeedback trainer for 30 min, three times a week. At baseline and at 3 months, patients were evaluated for exercise capacity, lung function, inspiratory muscle strength (PImax ) and work capacity (SPImax ), quality of life (QoL), LVEF and LV diameter, dyspnoea, C-reactive protein (CRP), and NT-proBNP. IMT resulted in a significantly higher benefit in SPImax (P = 0.02), QoL (P = 0.002), dyspnoea (P = 0.004), CRP (P = 0.03), and NT-proBNP (P = 0.004). In both AT/IMT and AT/SHAM groups PImax (P < 0.001, P = 0.02), peak VO2 (P = 0.008, P = 0.04), and LVEF (P = 0.005, P = 0.002) improved significantly; however, without an additional benefit for either of the groups.

CONCLUSION

This randomized multicentre study demonstrates that IMT combined with aerobic training provides additional benefits in functional and serum biomarkers in patients with moderate CHF. These findings advocate for application of IMT in cardiac rehabilitation programmes.