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

BACKGROUND: Frailty is a multidimensional state of increased vulnerability. Frail patients are at increased risk for poor surgical outcomes. Prior research demonstrates that rehabilitation strategies deployed after surgery improve outcomes by building strength. OBJECTIVES: Examine the feasibility and impact of a novel, multi-faceted prehabilitation intervention for frail patients before surgery. DESIGN: Single arm clinical trial. SETTING: Veterans Affairs hospital. PARTICIPANTS: Patients preparing for major abdominal, urological, thoracic, or cardiac surgery with frailty identified as a Risk Analysis Index≥30. INTERVENTION: Prehabilitation started in a supervised setting to establish safety and then transitioned to home-based exercise with weekly telephone coaching by exercise physiologists. Prehabilitation included (a)strength and coordination training; (b)respiratory muscle training (IMT); (c)aerobic conditioning; and (d)nutritional coaching and supplementation. Prehabilitation length was tailored to the 4-6 week time lag typically preceding each participant's normally scheduled surgery. MEASUREMENTS: Functional performance and patient surveys were assessed at baseline, every other week during prehabilitation, and then 30 and 90 days after surgery. Within-person changes were estimated using linear mixed models. RESULTS: 43 patients completed baseline assessments; 36(84%) completed a median 5(range 3-10) weeks of prehabilitation before surgery; 32(74%) were retained through 90-day follow-up. Baseline function was relatively low. Exercise logs show participants completed 94% of supervised exercise, 78% of prescribed IMT and 74% of home-based exercise. Between baseline and day of surgery, timed-up-and-go decreased 2.3 seconds, gait speed increased 0.1 meters/second, six-minute walk test increased 41.7 meters, and the time to complete 5 chair rises decreased 1.6 seconds(all P≤0.007). Maximum and mean inspiratory and expiratory pressures increased 4.5, 7.3, 14.1 and 13.5 centimeters of water, respectively(all P≤0.041). CONCLUSIONS: Prehabilitation is feasible before major surgery and achieves clinically meaningful improvements in functional performance that may impact postoperative outcomes and recovery. These data support rationale for a larger trial powered to detect differences in postoperative outcomes.

Prolonged heart rate recovery time after 6-minute walk test is an independent risk factor for cardiac events in heart failure: a prospective cohort study

OBJECTIVES: To determine whether the time for peak exercise heart rate to return to resting heart rate after the 6-minute walk test (6MWT) can predict cardiac events in patients with heart failure (HF) within 2 years. DESIGN: Prospective cohort study. SETTING: HF outpatient facility at a tertiary teaching hospital. PARTICIPANTS: Seventy-six patients with HF, New York Heart Association functional classification II and III, and left ventricular ejection fraction <50% MAIN OUTCOME MEASURES: Patients used a heart rate monitor to measure the time for peak exercise heart rate to return to resting heart rate after the 6MWT. Data were analysed using Polar Pro-Trainer 5 software (Kempele, Finland). Patients were followed for >2 years for cardiac events (hospitalisations and death). RESULTS: Thirty-four patients had cardiac events during the 2-year follow-up period. There was a significant difference in time to return to resting heart rate between the groups with and without cardiac events {with 3.6 [standard deviation (SD) A] vs without 2.8 (SD B) minutes; mean difference C; 95% confidence interval (CI) of the difference D to E; P=0.003}. No significant differences between patients with and without cardiac events were found for mean walking distance, mean heart rate recovery at 1 minute and mean heart rate recovery at 2 minutes. The receiver operating curve discriminated between patients with and without cardiac events (área under the curve 0.71, 95% CI 0.61 to 0.81; P< 0.001). Using logistic regression analysis, prolonged time to return to resting heart rate (≥3 minutes) independently increased the risk for cardiac events 6.9-fold (95% CI 2.34 to 20.12; P< 0.001). The Kaplan­Meier curve showed more cardiac events in patients with prolonged time to return to resting heart rate (P=0.028). CONCLUSIONS: Prolonged time to return to resting heart rate (≥3 minutes) after the 6MWT was an independent predictor of cardiac events in patients with HF.

Prolonged heart rate recovery time after 6-minute walk test is an independent risk factor for cardiac events in heart failure: A prospective cohort study.

OBJECTIVES: To determine whether the time for peak exercise heart rate to return to resting heart rate after the 6-minute walk test (6MWT) can predict cardiac events in patients with heart failure (HF) within 2 years. DESIGN: Prospective cohort study. SETTING: HF outpatient facility at a tertiary teaching hospital. PARTICIPANTS: Seventy-six patients with HF, New York Heart Association functional classification II and III, and left ventricular ejection fraction <50%. MAIN OUTCOME MEASURES: Patients used a heart rate monitor to measure the time for peak exercise heart rate to return to resting heart rate after the 6MWT. Data were analysed using Polar Pro-Trainer 5 software (Kempele, Finland). Patients were followed for >2 years for cardiac events (hospitalisations and death). RESULTS: Thirty-four patients had cardiac events during the 2-year follow-up period. However, there was a significant difference in the time to return to resting heart rate between the groups with and without cardiac events {with 3.6 (SD 1.1) vs without 2.8 (SD 1.1) minutes; mean difference of 0.79 (95% confidence interval (CI) of the difference 0.28 to 1.28; P=0.003}. No significant differences between patients with and without cardiac events were found for mean walking distance, mean heart rate recovery at 1minute and mean heart rate recovery at 2minutes. The receiver operating curve discriminated between patients with and without cardiac events (área under the curve 0.71, 95% CI 0.61 to 0.81; P<0.001). Using logistic regression analysis, prolonged time to return to resting heart rate (≥3minutes) independently increased the risk for cardiac events 6.9-fold (95% CI 2.34 to 20.12; P<0.001). The Kaplan-Meier curve showed more cardiac events in patients with prolonged time to return to resting heart rate (P=0.028). CONCLUSIONS: Prolonged time to return to resting heart rate (≥3minutes) after the 6MWT was an independent predictor of cardiac events in patients with HF.

Exercise training in heart failure: inpatient and outpatient considerations.

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

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

BACKGROUND AND PURPOSE: Persons with chronic heart failure (HF) have poor ventilatory muscle strength, and this weakness is associated with dyspnea. The purpose of this study was to examine the effects of inspiratory muscle training (IMT) on ventilatory muscle strength and dyspnea in patients with chronic HF. SUBJECTS: Fourteen patients (mean age [+/-SD] = 52 +/- 8.5 years) with end-stage cardiomyopathy and chronic HF (mean left ventricular ejection fraction = 23% +/- 13% and New York Heart Association class = 3.6 +/- 0.6) participated in the study. METHODS: Inspiratory muscle training was performed at 20% of maximal inspiratory pressure (MIP) for 5 to 15 minutes, three times a day, for 8 weeks. Dyspnea was evaluated at rest and during exercise. RESULTS: Both MIP and maximal expiratory pressure (MEP) were greater after 2 weeks of IMT (51 +/- 21 to 63 +/- 23 cm H2O and 85 +/- 22 to 96 +/- 19 cm H2O, representing 24% and 13% improvement). Dyspnea scores at rest and during exercise decreased after 2 weeks (2.0 +/- 0.7 to 1.3 +/- 0.5 and 3.6 +/- 0.5 to 2.6 +/- 0.6, representing 29% and 28% improvement) and plateaued throughout the remainder of IMT. Baseline MEP was related to the percentage of change in MEP after IMT (r = -.72), and several measures of pulmonary function were related to the degree of improvement in dyspnea after IMT (r = -.57 to -.82) and in MIP after IMT (r = .71). CONCLUSION AND DISCUSSION: Improvements in MIP, MEP, and dyspnea were found after 2 weeks of IMT. Greater pulmonary function was associated with greater improvement in dyspnea and ventilatory muscle strength after IMT. These improvements may decrease the dependency and impairment associated with chronic HF.

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

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

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

BACKGROUND: The 6-min walk test (6'WT) is a simple measure of functional capacity and predicts survival in patients with moderate heart failure (HF). METHODS: To assess the role of the 6'WT in the evaluation of patients with advanced HF, 45 patients (age 49 +/- 8 years, mean +/- SD; New York Heart Association class 3.3 +/- 0.6; left ventricular ejection fraction 0.20 +/- 0.06; right ventricular ejection fraction 0.31 +/- 0.11) underwent symptom-limited cardiopulmonary exercise testing and the 6'WT during cardiac transplant evaluation. RESULTS: Mean 6'WT distance ambulated was 310 +/- 100 m and peak oxygen uptake (peak Vo2) was 12.2 +/- 4.5 mL/kg/min. There was a significant correlation between 6'WT distance ambulated and peak Vo2 (r = 0.64, p < 0.001). Multivariate analysis of patient characteristics, resting hemodynamics, and 6'WT results identified the distance ambulated during the 6'WT as the strongest predictor of peak Vo2 (p < 0.001). 6'WT distance ambulated less than 300 m predicted an increased likelihood of death or pretransplant hospital admission for continuous inotropic or mechanical support within 6 months (p = 0.04), but did not predict long-term overall or event-free survival with a mean follow-up of 62 weeks. Peak Vo2 was the best predictor of long-term overall and event-free survival. CONCLUSIONS: In patients with advanced HF evaluated for cardiac transplantation, distance ambulated during the 6'WT predicts (1) peak Vo2 and (2) short-term event-free survival.

Heart failure.

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

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

BACKGROUND: As early perioperative survival with left ventricular assist device support improves, additional emphasis must be placed on patient rehabilitation. Especially as mean left ventricular assist device support times exceed 100 days, it is essential for health professionals to mobilize patients to prevent the incidence of the deleterious effects of bedrest. The timing of optimal functional performance and the safety of rehabilitation has not been described. METHODS: We retrospectively studied patients surviving left ventricular assist device implantation (34 of 41 patients; 27 men, 7 women; age 51 +/- 11 years). Physical therapy consisted of progressive mobilization leading to treadmill exercise or cycling. All patients exercised in the "pump on full" mode with flows >or= 3.0 L/min. RESULTS: Twenty of thirty-four patients initiated ambulation at 7 to 10 days with independent ambulation by 14 days in 55% of the group. Treadmill exercise was tolerated by 82% of the patients, begun at postoperative day 21 by eighteen patients. The greatest improvement in exercise performance was seen by 6 to 8 weeks (20 to 30 minutes at 3.17 +/- 0.79 metabolic equivalents). Maximal functional capacity achieved was influenced by medical complications. A total of 1878 treatment sessions lasting 1390 hours was performed. Only four minor incidents occurred representing 2.9 incidents/1000 patient hours; all involved a transient decrease in pump flow. None of these events resulted in an increase in morbidity or mortality. CONCLUSIONS: Progressive mobilization in patients with left ventricular assist device is safe. Patients return to independence in activities of daily living and tolerate prolonged workloads of up to 5 metabolic equivalents. There is rapid improvement in functional capacity until 6 weeks after operation. Delay in transplantation until this time may optimize postoperative recovery.

Pulmonary medications.

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