A Call to Action Towards an Evidence-Based Approach to using Verbal Encouragement during Maximal Exercise Testing

By definition, maximal exercise testing inherently requires participants to give a maximal effort. This is an important practical issue as submaximal efforts can produce invalid test results. Verbal encouragement is commonly used to motivate participants to maintain or increase effort investment during maximal exercise testing. Accordingly, studies have reported significant increases in time to exhaustion of between 8% and 18% during VO 2max and multistage shuttle run tests, and a significant 30·5 m mean increase in 6-min walk test distance. Significant improvements during shorter tests, such as the Wingate and 2-min walk tests, have not been observed however. Although participants typically perceive verbal encouragement positively during maximal exercise testing, around one-third have neutral or negative perceptions. Despite the ubiquity and importance of verbal encouragement during maximal exercise testing, surprisingly little research has investigated the characteristics of effective encouragement with respect to its content, timing and frequency. The only randomized controlled trial to investigate one of these issues observed that verbal encouragement delivered every 20 s increased time to exhaustion during VO 2 max testing, but not every 60 or 180 s. Of particular concern is that several exercise testing guidelines have incorporated specific guidelines for the use of verbal encouragement, but not provided any theoretical or empirical justification, presumably because of the limited research to inform practice. Recent empirical research does provide some important insight into participant preference for the content and timing of verbal encouragement during maximal exercise testing; however, much more research is clearly required to establish comprehensive evidence-based guidelines. </p

Association of asthma with extra-respiratory symptoms in schoolchildren: two cross-sectional studies 6 years apart

Epidemiological information on symptoms affecting extra-respiratory organs and apparatuses in asthmatic children is scarce. The aim of this study therefore was to evaluate, at a population level, if and what extra-respiratory symptoms are associated with asthma. Two questionnaire-based, cross-sectional surveys were carried out on 1,262 students (651 males; mean age 9.57 years, age-range 6-14 years) in 1992 and on 1,210 students (639 males; mean age 9.02 years, age-range 6-14 years) in 1998, from two elementary and two junior high schools in Rome, Italy. Questionnaires included queries about asthma and its risk factors and extra-respiratory symptoms (headache, restlessness, sleep disturbances, urticaria, itching, and abdominal pain). Of responders, 11.9% (279/2,342) had a history of asthma. After adjustment for gender, family history of atopic disease, low birth weight, early respiratory problems, and damp house, asthma was significantly associated with recurrent abdominal pain (odds ratio [OR] 1.90; 95% confidence interval [CI]: 1.04, 3.16), itching (OR 3.15; 95% CI: 1.75, 5.68), and urticaria (OR 2.52; 95% CI: 1.02, 6.20). Asthma was reported by 10.2% (201/1,962) of children unaffected by this triad, by 20.1% (56/279; OR 2.20) with one of the symptoms, and by 31.6% (12/38; OR 4.04) with two or more symptoms. An emerging characteristic of pediatric asthma in our setting appears to be its association with certain extra-respiratory symptoms (abdominal pain, itching, and urticaria). A global, internistic approach to asthmatic children is increasingly required both in the clinical setting and in future epidemiological studies

Evolution of Asthma Concept and Effect of Current Asthma Management Guidelines

Concept of asthma has changed from symptom-complex or airway hypersensitivity to airway inflammation and airway remodeling. Based on this concept asthma management guidelines (JGL) has been developed in Japan. Death from asthma has decreased drastically since the publication of the guidelines, although it is still high in elderly population. Further works are expected for "zero-death" from asthma and for tighter control of airway inflammation and resultant airway remodeling

Maximal exercise in obese patients with COPD: the role of fat free mass

Abstract Background: Obese patients (OB) with COPD may better tolerate exercise as compared to normal weight (NW) COPD patients, even if the reason for this is not yet fully understood. We investigated the interactions between obesity, lung hyperinflation, fat-free mass (FFM) and exercise capacity in COPD. Methods: Forty-four patients (16 females; age 65 ± 8 yrs) were assessed by resting lung function and body composition and exercised on a cycle-ergometer to exhaustion. Results: Twenty-two OB and 22 NW patients did not differ in age, gender and airflow obstruction degree, but in FFM (p < 0.05). OB had significantly higher values in inspiratory capacity/total lung capacity ratio (IC/TLC) at rest (p < 0.01), but not at peak of exercise and showed significantly higher values in peak workload (p < 0.05) and in peak oxygen uptake (VO2), when expressed as absolute value (p < 0.05), but not when corrected by FFM. OB compared to NW experienced lower leg fatigue (p < 0.05), but similar dyspnea on exertion. In all patients, the regression equation by stepwise multiple regression analysis for peak workload and VO2, as dependent variables included both FFM and IC/TLC at rest, as independent variables (r2 = 0.43 and 0.37, respectively). Conclusions: OB with COPD, as compared to NW patients matched for age, gender and airflow obstruction, had greater FFM and less resting lung hyperinflation and showed greater maximal exercise capacity. Pulmonary and non-pulmonary factors may explain the preservation of exercise tolerance in patients with COPD associated with obesity. Keywords: Fat-free mass, Dynamic hyperinflation, Exercise, Obesity, COP

Echocardiography may help detect pulmonary vasculopathy in the early stages of pulmonary artery hypertension associated with systemic sclerosis

<p>Abstract</p> <p>Background</p> <p>Pulmonary arterial hypertension (PAH) in patients with systemic sclerosis is associated with a poor prognosis, but this can be improved by early disease detection. Abnormal pulmonary and cardiac function can be detected early by means of echocardiography, whereas right heart catheterization is usually performed later.</p> <p>Objectives</p> <p>The purpose of this prospective study was to detect early the presence of pulmonary artery vasculopathy in patients with verified systemic sclerosis without significant pulmonary fibrosis, normal lung volumes and a mildly reduced lung diffusion capacity of carbon monoxide (DLCO).</p> <p>Methods</p> <p>Nineteen consecutive female NYHA class I-II patients with scleroderma and a PAPs of < 35 mm/Hg measured by echocardiography, were enrolled between September 2007 and September 2009. They had a mean age of 51 ± 13 years, body mass index of 25 ± 5 kg/m²). They all underwent complete Doppler echocardiography, CPET, a pulmonary ventilation test (carbon monoxide lung diffusion, DLCO), HRCT. To investigate PAH by means of complete resting Doppler echocardiography estimates of systolic pulmonary artery pressure (PAPs) derived from tr icuspid regurgitation, mean PAP derived from pulmonary regurgitation, pulmonary vessel resistance (PVR) derived from the acceleration time of the pulmonary outflow tract (ACTpo), and right ventricular function derived from tricuspid annular plane systolic excursion (TAPSE). Right heart catheterisation was conducted only, if pulmonary hypertension was suggested by echocardiography and an abnormal ventilator test.</p> <p>The data are given as mean values ± SD, unless otherwise stated. The correlations between the variables were analysed using Pearson's <it>r </it>coefficient, and the predictive value of the variables was calculated using linear regression analysis. A p value of > 0.05 was considered significant.</p> <p>Results</p> <p>Right heart catheterization detected PAH in 15/19 patients; mean PAP was 30.5 mm/Hg and RVP 3.6 UW. Coronary angiography of the patients aged more than 55 years showed some evidence of significant coronary artery disease. Echocardiography showed high systolic PAP values (46 ± 8 mmHg), whereas right ventricular function was normal (TAPSE 23 ± 3 mm), and in line with the NYHA class. ACTpo was reduced in the patients with a systolic PAP of < 46 mm/Hg (p > 0.001) and positively correlated with DLCO (p > 0.001) and the hemodynamic data.</p> <p>There was a good correlation between ACTpo and PVR (hemodynamic data) (r = -0615; p > 0.01).</p> <p>Conclusions</p> <p>Although they need to be confirmed by studies of larger series of patients, our findings suggest that, in comparison with hemodynamic data, non-invasive echocardiographic measurements are an excellent means of identifying early-stage PAH.</p

Association between preoperative haemoglobin concentration and cardiopulmonary exercise variables: a multicentre study

Background: Preoperative anaemia and low exertional oxygen uptake are both associated with greater postoperative morbidity and mortality. This study reports the association among haemoglobin concentration ([Hb]), peak oxygen uptake (V_O2 peak) and anaerobic threshold (AT) in elective surgical patients. Methods: Between 1999 and 2011, preoperative [Hb] and cardiopulmonary exercise tests were recorded in 1,777 preoperative patients in four hospitals. The associations between [Hb], V_O2 peak and AT were analysed by linear regression and covariance. Results: In 436 (24.5%) patients, [Hb] was <12 g dl-1 and, in 83 of these, <10 g dl-1. Both AT and V_O2 peak rose modestly with increasing [Hb] (r2 = 0.24, P <0.0001 and r2 = 0.30, P <0.0001, respectively). After covariate adjustment, an increase in [Hb] of one standard deviation was associated with a 6.7 to 9.7% increase in V_O2 peak, and a rise of 4.4 to 6.0% in AT. Haemoglobin concentration accounted for 9% and 6% of the variation in V_O2 peak and AT respectively. Conclusions: To a modest extent, lower haemoglobin concentrations are independently associated with lower oxygen uptake during preoperative cardiopulmonary exercise testing. It is unknown whether this association is causative

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

Background: The standard treatment pathway for locally advanced rectal cancer is neoadjuvant chemoradiotherapy (CRT) followed by surgery. Neoadjuvant CRT has been shown to decrease physical fitness, and this decrease is associated with increased post-operative morbidity. Exercise training can stimulate skeletal muscle adaptations such as increased mitochondrial content and improved oxygen uptake capacity, both of which are contributors to physical fitness. The aims of the EMPOWER trial are to assess the effects of neoadjuvant CRT and an in-hospital exercise training programme on physical fitness, health-related quality of life (HRQoL), and physical activity levels, as well as post-operative morbidity and cancer staging. Methods/Design: The EMPOWER Trial is a randomised controlled trial with a planned recruitment of 46 patients with locally advanced rectal cancer and who are undergoing neoadjuvant CRT and surgery. Following completion of the neoadjuvant CRT (week 0) prior to surgery, patients are randomised to an in-hospital exercise training programme (aerobic interval training for 6 to 9 weeks) or a usual care control group (usual care and no formal exercise training). The primary endpoint is oxygen uptake at lactate threshold ( V · o 2 at δ L ) measured using cardiopulmonary exercise testing assessed over several time points throughout the study. Secondary endpoints include HRQoL, assessed using semi-structured interviews and questionnaires, and physical activity levels assessed using activity monitors. Exploratory endpoints include post-operative morbidity, assessed using the Post-Operative Morbidity Survey (POMS), and cancer staging, assessed by using magnetic resonance tumour regression grading. Discussion: The EMPOWER trial is the first randomised controlled trial comparing an in-hospital exercise training group with a usual care control group in patients with locally advanced rectal cancer. This trial will allow us to determine whether exercise training following neoadjuvant CRT can improve physical fitness and activity levels, as well as other important clinical outcome measures such as HRQoL and post-operative morbidity. These results will aid the design of a large, multi-centre trial to determine whether an increase in physical fitness improves clinically relevant post-operative outcomes