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

PURPOSE: The aim of this explorative, qualitative study is to identify factors that potentially influence the execution of physical fitness training in inpatient orthopedic geriatric rehabilitation (GR), from the perspectives of patients, their relatives and professionals. MATERIALS AND METHODS: In GR wards of skilled nursing facilities in the Netherlands, semi-structured interviews were held with triads of patients, their relatives and responsible nurses, and focus groups with members of the multidisciplinary teams. Verbatim reports were analyzed according to the framework method. RESULTS: We found twelve categories of barriers and facilitators related to characteristics of the patients, their family, staff, training program and organization. CONCLUSIONS: The barriers and facilitators found largely correspond with those found for participation in exercise in related settings, but also show important differences. This overview of barriers and facilitators enables multidisciplinary teams to design improvements at the level of the organization and interventions, as well as at the level of the individual training program, tailoring it to the patient's circumstances and needs. Further research should focus on weighing these barriers and facilitators to develop a feasible guidance for daily practice, as well as testing their effect on the adherence to existing physical fitness training guidelines.

Physical fitness training is important in reaching functional goals in orthopedic geriatric rehabilitation.Practicing outside of therapy can be stimulated by clarity about expectations, proper training equipment and tailored stimulation/assistance.Training volume and intensity should meet the guidelines, but be tailored to the patient.Characteristics of the program, staff and organization need to be considered as they impact the physical fitness training.

Metabolic load during morning care and active bed exercises in critically ill patients: An explorative study.

BACKGROUND: To avoid overexertion in critically ill patients, information on the physical demand, i.e., metabolic load, of daily care and active exercises is warranted. OBJECTIVE: The objective of this study was toassess the metabolic load during morning care activities and active bed exercises in mechanically ventilated critically ill patients. METHODS: This study incorporated an explorative observational study executed in a university hospital intensive care unit. Oxygen consumption (VO2) was measured in mechanically ventilated (≥48 h) critically ill patients during rest, routine morning care, and active bed exercises. We aimed to describe and compare VO2 in terms of absolute VO2 (mL) defined as the VO2 attributable to the activity and relative VO2 in mL per kilogram bodyweight, per minute (mL/kg/min). Additional outcomes achieved during the activity were perceived exertion, respiratory variables, and the highest VO2 values. Changes in VO2 and activity duration were tested using paired tests. RESULTS: Twenty-one patients were included with a mean (standard deviation) age of 59 y (12). Median (interquartile range [IQR]) durations of morning care and active bed exercises were 26 min (21-29) and 7 min (5-12), respectively. Absolute VO2 of morning care was significantly higher than that of active bed exercises (p = 0,009). Median (IQR) relative VO2 was 2.9 (2.6-3.8) mL/kg/min during rest; 3.1 (2.8-3.7) mL/kg/min during morning care; and 3.2 (2.7-4) mL/kg/min during active bed exercises. The highest VO2 value was 4.9 (4.2-5.7) mL/kg/min during morning care and 3.7 (3.2-5.3) mL/kg/min during active bed exercises. Median (IQR) perceived exertion on the 6-20 Borg scale was 12 (10.3-14.5) during morning care (n = 8) and 13.5 (11-15) during active bed exercises (n = 6). CONCLUSION: Absolute VO2 in mechanically ventilated patients may be higher during morning care than during active bed exercises due to the longer duration of the activity. Intensive care unit clinicians should be aware that daily-care activities may cause intervals of high metabolic load and high ratings of perceived exertion.

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

BACKGROUND: Little is known about exercise testing and training in orthopedic geriatric rehabilitation. This study aims to obtain expert-consensus-based recommendations on this matter. METHODS: Using an online Delphi study we aimed to reach international expert consensus on statements related to testing and training of endurance capacity and muscle strength. Participants needed to have relevant research or clinical expertise. Statements were evaluated and explanatory comments could be provided. After each round anonymous results were presented to participants. Statements could be adjusted or new ones could be formulated if necessary. Consensus was defined as > 75% of participants agreeing. RESULTS: Thirty experts completed the first round. Twenty-eight (93%) the second and 25 (83%) completed the third round. The majority of experts were physical therapists. Consensus was reached on a total of 34 statements. The statements and comments reflected the need for a pragmatic and tailored approach in this population both for testing and training. For example, for testing endurance capacity, a 6 Minute walk test was promoted and for testing muscle strength, performance in a functional activity was suggested. Ratings of perceived exertion were promoted for monitoring intensity of endurance and muscle strength training in patients without cognitive impairment. CONCLUSION: In orthopedic GR, endurance and muscle strength testing should be pragmatic and is preferably performed in functional activities. For endurance training existing guidelines of the American College of Sports Medicine can be strived for but adapted as needed and for muscle strength training only lower intensities are agreed upon.

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

OBJECTIVES: To present an overview of effectiveness and training characteristics of physical training on aerobic fitness, compared with alternative or no training, in adults aged over 65 years with various health statuses, providing a basis for guidelines for aerobic training of vulnerable older adults that can be used in geriatric rehabilitation. DESIGN: An umbrella review of systematic reviews that included both randomised controlled trials and other types of trials. DATA SOURCES: MEDLINE, Embase, CINAHL and the Cochrane Library were searched on 9 September 2019. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: We included systematic reviews reporting on physical training interventions that are expected to improve aerobic fitness, presenting results for adults aged 65 years and older, describing at least one of the FITT-characteristics: Frequency, Intensity, Time or Type of exercise, and measuring aerobic fitness at least before and after the intervention. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers extracted the data and assessed the risk of bias. A narrative synthesis was performed. RESULTS: We included 51 papers on 49 reviews. Positive effect of training on aerobic fitness was reported by 33 reviews, 11 reviews remained inconclusive and 5 reviews reported no effect. Training characteristics varied largely. Frequency: 1-35 sessions/week, Intensity: light-vigorous, Time: <10-120 min/session and Types of exercise: many. The methodological quality was most often low. Subgroup analyses revealed positive effects for all health conditions except for trauma patients. Exercise characteristics from current existing guidelines are widely applicable. For vulnerable older adults, lower intensities and lower frequencies were beneficial. Some health conditions require specific adjustments. Information on adverse events was often lacking, but their occurrence seemed rare. CONCLUSION: Physical fitness training can be effective for vulnerable older adults. Exercise characteristics from current existing guidelines are widely applicable, although lower frequencies and intensities are also beneficial. For some conditions, adjustments are advised. PROSPERO REGISTRATION NUMBER: CRD42020140575.

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

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

Quantifying muscle fatigue during walking in people with multiple sclerosis.

BACKGROUND: This study aimed to examine muscle fatigue in lower leg muscles in of people with multiple sclerosis and healthy controls, and whether muscle fatigue coincided with potential changes in gait. METHODS: In this case-control study, people with multiple sclerosis (n = 8; 3male; mean age (SD) = 49.7 (9.6) yr) and age-matched healthy controls (n = 10; 4male; mean age (SD) = 47.4 (8.7) yr) walked on a treadmill for 12-min at self-paced speed. Muscle fatigue was indirectly quantified by a decrease in median frequency and increase in root mean square of surface electromyographic recordings of lower leg muscles. Walking speed, ankle push-off power and net ankle work were calculated from marker positions and force plate data using inverse dynamic calculations. RESULTS: People with multiple sclerosis showed larger decreases in median frequency of soleus (most affected leg: p = 0.003; least affected leg: p = 0.009) and larger increases in root mean square of soleus (most and least affected leg: p = 0.037), gastrocnemius medialis (most affected leg: p = 0.003; least affected leg: p = 0.005) and lateralis (most and least affected leg: p < 0.001) compared to controls. Walking speed (p = 0.001), ankle push-off power (most affected leg: p = 0.018; least affected leg: p = 0.001) and net work around the ankle (most affected leg: p = 0.046; least affected leg: p = 0.001) were lower in people with multiple sclerosis compared to controls, but increased in both groups. INTERPRETATION: The results yield preliminary evidence that soleus muscles of people with multiple sclerosis fatigue during prolonged walking. Changes in electromyography of gastrocnemius muscles could however be related to muscle fatigue, changes in gait or a combination.

Preliminary effectiveness of a sequential exercise intervention on gait function in ambulant patients with multiple sclerosis - A pilot study.

BACKGROUND: Patients with multiple sclerosis (pwMS) often experience a decline in motor function and performance during prolonged walking, which potentially is associated with reduced ankle push-off power and might be alleviated through structured exercise. The objectives of this pilot study were to assess ankle push-off power and walking performance in pwMS and healthy controls, and the preliminary effectiveness of a sequential exercise program (resistance training followed by walking-specific endurance training) on ankle push-off power and walking performance. METHODS: PwMS (N = 10) with self-reported reduced walking performance and healthy controls (N = 10; at baseline only) underwent 3D gait analysis during a self-paced 12-minute walking test to assess walking performance prior to and following a sequential exercise program. Secondary testing paradigms comprised isometric muscle testing (triceps surae), cardiopulmonary exercise testing and self-report measures. FINDINGS: PwMS had a shorter 12-minute walking distance, and lower peak ankle push-off power (most-affected leg) in comparison to healthy controls. There was no minute-to-minute decline in walking performance. The 8-week resistance training significantly improved walking distance. In parallel, higher peak and speed-normalized ankle push-off power were found in the less-affected side. No additional changes were found following the walking-specific endurance training phase. INTERPRETATION: There was no walking-related motor fatigue found during a self-paced 12-minute walking test despite reduced ankle push-off power, and self-reported walking problems. Preliminary effects suggest a positive effect of resistance training on walking performance, potentially associated with increases in ankle push-off power, interestingly, in the less-affected leg. The added effect of the walking-specific endurance training remains unclear.

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

[This corrects the article DOI: 10.1371/journal.pone.0159280.].

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

OBJECTIVE: To explore reasons for the lack of efficacy of a high intensity aerobic exercise program in post-polio syndrome (PPS) on cardiorespiratory fitness by evaluating adherence to the training program and effects on muscle function. DESIGN: A process evaluation using data from an RCT. PATIENTS: Forty-four severely fatigued individuals with PPS were randomized to exercise therapy (n = 22) or usual care (n = 22). METHODS: Participants in the exercise group were instructed to exercise 3 times weekly for 4 months on a bicycle ergometer (60-70% heart rate reserve). RESULTS: The attendance rate was high (median 89%). None of the participants trained within the target heart rate range during >75% of the designated time. Instead, participants exercised at lower intensities, though still around the anaerobic threshold (AT) most of the time. Muscle function did not improve in the exercise group. CONCLUSION: Our results suggest that severely fatigued individuals with PPS cannot adhere to a high intensity aerobic exercise program on a cycle ergometer. Despite exercise intensities around the AT, lower extremity muscle function nor cardiorespiratory fitness improved. Improving the aerobic capacity in PPS is difficult through exercise primarily focusing on the lower extremities, and may require a more individualized approach, including the use of other large muscle groups instead. TRIAL REGISTRATION: Netherlands National Trial Register NTR1371.

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

PURPOSE: This study investigates the effectiveness of Lokomat + conventional therapy in recovering walking ability in non-ambulatory subacute stroke subjects involved in inpatient rehabilitation. METHOD: Thirty first-ever stroke patients completed 8 weeks of intervention. One group (n = 16) received Lokomat therapy twice a week, combined with three times 30 min a week of conventional overground therapy. The second group (n = 14) received conventional assisted overground therapy only, during a similar amount of time (3.5 h a week). The intervention was part of the normal rehabilitation program. Primary outcome measure was walking speed. Secondary outcome measures assessed other walking- and mobility-related tests, lower-limb strength and quality of life measures. All outcome measures were assessed before and after the intervention and at wk 24 and wk 36 after start of the intervention. RESULTS: Patients showed significant (p < 0.05) gains in walking speed, other walking- and mobility related tests, and strength of the paretic knee extensors relative to baseline at all assessments. However, there were no significant differences in improvements in any of the variables between groups at any time during the study. CONCLUSION: These results indicate that substituting Lokomat therapy for some of conventional therapy is as effective in recovering walking ability in non-ambulatory stroke patients as conventional therapy alone. Implications for Rehabilitation Recovery of walking after stroke is important. Robot-assisted therapy is currently receiving much attention in research and rehabilitation practice as devices such as the Lokomat seem to be promising assistive devices. Technical developments, sub-optimal study designs in literature and new therapy insights warrant new effectiveness studies. RESULTS of a financially and practically feasible study indicate that substituting Lokomat therapy for some of conventional therapy is as effective in recovering walking ability in non-ambulatory stroke patients as compared to conventional overground therapy alone.

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

OBJECTIVE: To assess the reliability of contractile properties of the knee extensor muscles in 23 individuals with post-polio syndrome (PPS) and 18 age-matched healthy individuals. METHODS: Contractile properties of the knee extensors were assessed from repeated electrically evoked contractions on 2 separate days, with the use of a fixed dynamometer. Reliability was determined for fatigue resistance, rate of torque development (MRTD), and early and late relaxation time (RT50 and RT25), using the intraclass correlation coefficient (ICC) and standard error of measurement (SEM, expressed as % of the mean). RESULTS: In both groups, reliability for fatigue resistance was good, with high ICCs (>0.90) and small SEM values (PPS: 7.1%, healthy individuals: 7.0%). Reliability for contractile speed indices varied, with the best values found for RT50 (ICCs>0.82, SEM values <2.8%). We found no systematic differences between test and retest occasions, except for RT50 in healthy subjects (p = 0.016). CONCLUSIONS: In PPS and healthy individuals, the reliability of fatigue resistance, as obtained from electrically evoked contractions is high. The reliability of contractile speed is only moderate, except for RT50 in PPS, demonstrating high reliability. SIGNIFICANCE: This was the first study to examine the reliability of electrically evoked contractile properties in individuals with PPS. Our results demonstrate its potential to study mechanisms underlying muscle fatigue in PPS and to evaluate changes in contractile properties over time in response to interventions or from natural course.

Determining the anaerobic threshold in postpolio syndrome: comparison with current guidelines for training intensity prescription.

OBJECTIVES: To determine whether the anaerobic threshold (AT) can be identified in individuals with postpolio syndrome (PPS) using submaximal incremental exercise testing, and to compare current guidelines for intensity prescription in PPS with the AT. DESIGN: Cohort study. SETTING: Research laboratory. PARTICIPANTS: Individuals with PPS (N=82). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Power output, gas exchange variables, heart rate, and rating of perceived exertion (RPE) were measured in an incremental submaximal cycle ergometry test. Two independent observers identified the AT. Comparison of current guidelines for training intensity prescription in PPS (40%-60% heart rate reserve [HRR] or RPE of 12) with the AT was based on correlations between recommended heart rate and the heart rate at the AT. In addition, we determined the proportion of individuals that would have been recommended to train at an intensity corresponding to their AT. RESULTS: The AT was identified in 63 (77%) of the participants. Pearson correlation coefficients between the recommended heart rate and the heart rate at the AT were lower in cases of 40% HRR (r=.56) and 60% HRR (r=.50) than in cases of prescription based on the RPE (r=.86). Based on the RPE, 55% of the individuals would have been recommended to train at an intensity corresponding to their AT. This proportion was higher compared with 40% HRR (41%) or 60% HRR (18%) as criterion. CONCLUSIONS: The AT can be identified in most individuals with PPS offering an individualized target for aerobic training. If the AT cannot be identified (eg, because gas analysis equipment is not available), intensity prescription can best be based on the RPE.

Fatigue resistance of the knee extensor muscles is not reduced in post-polio syndrome.

The present study investigated whether intrinsic fatigability of the muscle fibers is reduced in patients with post-polio syndrome (PPS). This may contribute to the muscle fatigue complaints reported by patients with PPS. For this purpose, we assessed contractile properties and fatigue resistance of the knee extensor muscles using repeated isometric electrically evoked contractions in 38 patients with PPS and 19 age-matched healthy subjects. To determine whether any difference in fatigue resistance between both groups could be attributed to differences in aerobic capacity of the muscle fibers, 9 patients with PPS and 11 healthy subjects performed the same protocol under arterial occlusion. Results showed that fatigue resistance of patients with PPS was comparable to that in controls, both in the situation with intact circulation and with occluded blood flow. Together, our findings suggest that there are no differences in contractile properties and aerobic muscle capacity that may account for the increased muscle fatigue perceived in PPS.

Neuromuscular properties of the thigh muscles in patients with Ehlers-Danlos syndrome.

INTRODUCTION: Ehlers-Danlos syndrome (EDS), a connective tissue disorder, may lead to impaired contractile function of lower limb muscles. METHODS: To test this hypothesis and to understand the possible mechanisms involved, isometric function of the thigh muscles was investigated at different joint angles (30°, 60°, and 90° of knee flexion) in 7 tenascin-X (TNX)-deficient EDS patients. RESULTS: There was reduced maximal voluntary torque of the knee extensors (but not knee flexors) across all joint angles in the patients. Time to reach maximal rate of torque development was delayed, and voluntary activation capacity was reduced in patients compared with controls, particularly at 30°. CONCLUSIONS: EDS is associated with muscle weakness, most likely due to increased compliance of the series-elastic component of muscle tissue and failure of maximal voluntary muscle activation. Further research is required to understand the influence of reduced voluntary activation on the severe fatigue reported by EDS patients.

Effect of robotic gait training on cardiorespiratory system in incomplete spinal cord injury.

The objectives in this study were to investigate the effect of robot-assisted gait training on cardiorespiratory fitness in subjects with motor incomplete spinal cord injury and document the exercise intensity of robotic walking in comparison with the recommended guidelines. Ten patients followed a 24-session training program with a robotic gait orthosis in addition to physiotherapy sessions completed within 10 to 16 wk. Cardiorespiratory fitness was determined in a graded arm crank exercise test before and after the training program. To assess the intensity of robot-assisted walking, oxygen consumption (VO2) and heart rate (HR) were measured during a training session early in and at the end of the training program, and exercise intensity measures (percentage of VO2 reserve [%VO2R], percentage of HR reserve [%HRR], and metabolic equivalents [METs]) were calculated. Whereas no changes were found in peak VO2, the resting and submaximal HR at a constant work load were significantly lower after training. Most subjects exercised at low intensity (<30%VO2R, <30%HRR, <3.0 METs), and only two subjects exercised at moderate intensity (>3.0 METs). In spite of the low exercise intensity of the training program and no changes in peak VO2, robot-assisted gait training induced some improvement in cardiorespiratory fitness, as suggested by lower resting and submaximal HR values.

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

OBJECTIVE: There is increasing evidence that robot-assisted treadmill training might be useful for gait rehabilitation after stroke. The aim of this study was to evaluate the muscle activity of stroke patients during robot-assisted walking and overground walking, and of a group of able-bodied subjects during overground walking. DESIGN: Case-control observational study. SUBJECTS: Ten stroke subjects and 10 able-bodied control subjects. METHODS: Electromyography measurements of 7 lower-limb muscles were made in 3 trials: robotic walking, in which stroke subjects walked in a robot-assisted gait orthosis; overground walking for the same group of stroke subjects; and overground walking for control subjects. Trials were compared with respect to electromyography amplitude of selected leg muscles. RESULTS: Higher muscle activity during overground walking compared with robotic walking was found in several muscles during several phases of the gait cycle. A significant trial × leg interaction revealed smaller differences in muscle activity between the paretic and non-paretic leg during robotic walking compared with overground walking. Furthermore, the muscle activity pattern was not significantly different between control walking and robotic walking, while it was different between control walking and overground walking. CONCLUSION: Despite lower muscle activity, robot-assisted treadmill training may elicit a more symmetrical pattern of leg muscle activity, which approaches that of able-bodied individuals.

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

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

Enhanced physiological tremor deteriorates plantar flexor torque steadiness after bed rest.

This study evaluated the effectiveness of resistance training to preserve submaximal plantar flexor (PF) torque steadiness following 60 days of bed rest (BR). Twenty-two healthy male subjects underwent either BR only (CTR, n=8), or BR plus resistance training (RT, n=14). The magnitude of torque fluctuations during steady submaximal isometric PF contractions (20%, 40%, 60% and 80% of maximum) were assessed before and after BR. Across contraction intensities, torque fluctuations (coefficient of variation, CV) increased more (P<0.05) after BR for CTR (from 0.31±0.10 to 0.92±0.63; P<0.001), than for RT (from 0.30±0.09 to 0.54±0.27; P<0.01). A shift in the spectral content of torque fluctuations towards increased rhythmic activity between 6.5 and 20Hz was observed in CTR only (P<0.05). H-reflex amplitude (H(max)/M(max) ratio) declined across groups from 0.57±0.18 before BR to 0.44±0.14 following BR (P<0.01) without correlation to CV. The present study showed that increased torque fluctuation after BR resulted from enhanced physiological tremor. Resistance training prevented the spectral shift in isometric PF torque fluctuation and offset ∼50% of the decline in performance associated with long-term BR.