Comparison of upper-limb and lower-limb exercise training in patients with intermittent claudication.

To investigate the effects of a 24-week programme of upper- and lower-limb aerobic exercise training on walking performance and quality of life in patients with symptomatic peripheral arterial disease (PAD) and to study the mechanisms, which could influence symptomatic improvement. Following approval from the North Sheffield Local Research Ethics Committee, 104 patients (median age 69 y, range 50-85 y) with stable PAD were randomised into an upper- or lower-limb aerobic exercise training group, or to a nonexercise training control group. Training was performed twice weekly for 24-weeks at equivalent relative exercise intensities. An incremental arm- and leg-crank test (ACT and LCT, respectively) to maximum exercise tolerance was performed before and at 6-, 12-, 18- and 24-weeks of the intervention to determine peak oxygen consumption (VO[2]). Walking performance, defined as the claudication and maximum walking distance (CD and MWD respectively) achieved before intolerable claudication pain, was assessed at the same time-points using a shuttle-walk protocol. Peak blood lactate concentration, ratings of perceived exertion (Borg RPE) and pain (Borg CR-10) were recorded during all assessments. Physical activity status, community-based walking ability and quality of life were assessed throughout the intervention period. Assessments were repeated 6-, 12-, 24- and 48-weeks following the intervention period. Both CD and MWD increased over time (P <0.01) in both training groups.At 24-weeks, CD had improved by 56% and 65% and MWD had improved by 30% and 35% (P <0.01) in the upper-limb and lower-limb exercise groups, respectively. These changes were associated with improvements in community-based walking distance, speed and stair-climbing ability (P <0.01). All patients assigned to exercise training exhibited an increase in LCT peak VO[2] at the 24-week time-point in relation to baseline measures (P <0.01) and control patients (P <0.01), whereas ACT peak VO[2] at the 24-week time-point was only improved in the upper-limb exercise training group (P <0.05). An increase in peak blood lactate concentration (1.95 +/- 0.14 vs. 2.40 +/-0.17 mM, mean +/- SEM; P <0.05) and amount of pain experienced at MWD (P <0.05) was only observed in the upper-limb exercise training group. This suggests that an alteration in exercise pain tolerance accounted, at least in part, for the improvement in MWD in this group. Upon completing the intervention period the general health status of both exercise training groups was improved in relation to the control group (P <0.05). However, improvements in physical functioning and bodily pain in relation to baseline (P <0.05) and energy and vitality in relation to control patients (P <0.05) were only observed in the upper-limb training group. At 48-weeks follow-up, CD remained improved by 39% and 48% (P <0.05) and MWD remained improved by 18% and 26%(P <0.05) in the upper-limb and lower-limb exercise groups, respectively, compared to baseline measures. A retained improvement in walking confidence (P <0.01) and community-based walking distance (P <0.05) was also observed, however global physical activity status in both exercise trained patient groups, returned to baseline. Both upper- and lower-limb aerobic exercise training can be useful exercise training modalities for improving cardiovascular function, walking performance, exercise pain tolerance and quality of life in patients with symptomatic PAD. This study suggests that a combination of physiological adaptations and altered exercise pain tolerance might account for the improvement in walking performance achieved through upper-limb aerobic exercise training in patients with PAD. This study also indicates that although walking performance remained improved in both exercise trained patients at 48-weeks follow-up, as compared to baseline measures, a progressive dwindling of improvement was observed over this time period. Reluctance for the continuation of exercise in the home-setting was observed

Limb-specific and cross-transfer effects of arm-crank exercise training

Arm cranking is a useful alternative exercise modality for improving walking performance in patients with intermittent claudication; however, the mechanisms of such an improvement are poorly understood. The main aim of the present study was to investigate the effects of arm-crank exercise training on lower-limb O 2 delivery in patients with intermittent claudication. A total of 57 patients with intermittent claudication (age, 70 + − 8 years; mean + − S.D.) were randomized to an arm-crank exercise group or a non-exercise control group. The exercise group trained twice weekly for 12 weeks. At baseline and 12 weeks, patients completed incremental tests to maximum exercise tolerance on both an arm-crank ergometer and a treadmill. Respiratory variables were measured breath-by-breath to determine peakVO 2 (O 2 uptake) and ventilatory threshold. Near-IR spectroscopy was used in the treadmill test to determine changes in calf muscle StO 2 (tissue O 2 saturation). Patients also completed a square-wave treadmill-walking protocol to determineVO 2 kinetics. A total of 51 patients completed the study. In the exercise group, higher maximum walking distances (from 496 + − 250 to 661 + − 324 m) and peakVO 2 values (from 17.2 + − 2.7 to 18.2 + − 3.4 ml · kg − 1 of body mass · min − 1 ) were recorded in the incremental treadmill test (P &lt; 0.05). After training, there was also an increase in time to minimum StO 2 (from 268 + − 305 s to 410 + − 366 s), a speeding ofVO 2 kinetics (from 44.7 + − 10.4 to 41.3 + − 14.4 s) and an increase in submaximal StO 2 during treadmill walking (P &lt; 0.05). There were no significant changes in the control group. The results suggest that the improvement in walking performance after arm-crank exercise training in patients with intermittent claudication is attributable, at least in part, to improved lower-limb O 2 delivery

The Staffordshire Arthritis, Musculoskeletal, and Back Assessment (SAMBA) Study: a prospective observational study of patient outcome following referral to a primary-secondary care musculoskeletal interface service

<p>Abstract</p> <p>Background</p> <p>Recent healthcare policy has shifted the management of musculoskeletal conditions in the UK away from secondary care towards Clinical Assessment and Treatment Services at the primary-secondary care interface. However, little is known about the outcome of patients with musculoskeletal conditions referred from primary care to Clinical Assessment and Treatment Services or how best to identify those patients at high risk of poor outcome in this setting. We describe the protocol for a twelve-month prospective observational study which aims to describe the outcome of patients referred to musculoskeletal and back pain services at the primary-secondary care interface and to develop simple prognostic measures to guide clinical prioritisation and triage.</p> <p>Methods/Design</p> <p>All patients referred over a twelve-month period from primary care to musculoskeletal and back pain clinics in the primary-secondary care interface Clinical Assessment and Treatment Service in North Staffordshire will be mailed a postal questionnaire prior to their consultation. This will collect information on quality of life, general health, anxiety and depression, pain, healthcare utilisation including medication use, occupational characteristics, and socio-demographics. At the consultation in the interface clinic, the clinical diagnosis, investigations requested, and clinical interventions will be recorded. Follow-up data for the twelve-month period subsequent to recruitment will be collected via mailed follow-up questionnaires at 6 and 12 months, and review of medical records.</p> <p>Discussion</p> <p>This twelve-month prospective observational study of patients referred to a musculoskeletal Clinical Assessment and Treatment Service will assess the management and outcome of musculoskeletal care at the primary-secondary care interface as proposed in the Musculoskeletal Services Framework.</p

Optimising outcomes of exercise and corticosteroid injection in patients with subacromial pain (impingement) syndrome: a factorial randomised trial

Objectives: To compare the clinical effectiveness of (1) physiotherapist-led exercise versus an exercise leaflet, and (2) ultrasound-guided subacromial corticosteroid injection versus unguided injection for pain and function in subacromial pain (formerly impingement) syndrome (SAPS).Methods: This was a single-blind 2×2 factorial randomised trial. Adults with SAPS were randomised equally to one of four treatment groups: (1) ultrasound-guided corticosteroid injection and physiotherapist-led exercise, (2) ultrasound-guided corticosteroid injection and an exercise leaflet, (3) unguided corticosteroid injection and physiotherapist-led exercise and (4) unguided corticosteroid injection and an exercise leaflet. The primary outcome was the Shoulder Pain and Disability Index (SPADI), collected at 6 weeks, 6 and 12 months and compared at 6 weeks for the injection interventions and 6 months for the exercise interventions by intention to treat.Results: We recruited 256 participants (64 treatment per group). Response rates for the primary outcome were 94% at 6 weeks, 88% at 6 months and 80% at 12 months. Greater improvement in total SPADI score was seen with physiotherapist-led exercise than with the exercise leaflet at 6 months (adjusted mean difference -8.23; 95% CI -14.14 to -2.32). There were no significant differences between the injection groups at 6 weeks (-2.04; -7.29 to 3.22), 6 months (-2.36; -8.16 to 3.44) or 12 months (1.59; -5.54 to 8.72).Conclusions: In patients with SAPS, physiotherapist-led exercise leads to greater improvements in pain and function than an exercise leaflet. Ultrasound guidance confers no additional benefit over unguided corticosteroid injection

Study protocol to investigate the effects of testosterone therapy as an adjunct to exercise rehabilitation in hypogonadal males with chronic heart failure

BACKGROUND: Testosterone deficiency is a common occurrence in men with chronic heart failure (CHF) and may underpin features of advanced disease, including reduced skeletal muscle mass and fatigue. It is positively correlated with cardiac output and exercise capacity in patients with CHF, whereas a significant improvement in both these parameters has been observed following testosterone replacement therapy. Testosterone therapy has also been shown to reduce circulating levels of inflammatory markers, (TNF-α, sICAM-1 and sVCAM-1) in patients with established coronary artery disease and testosterone deficiency. This pilot study will assess the feasibility of a combined exercise rehabilitation and adjunctive testosterone therapy intervention for evoking improvements in exercise capacity, circulating inflammatory markers, cardiac and skeletal muscle function, indices of psychological health status and quality of life in hypogonadal males with chronic heart failure. METHODS/DESIGN: Following ethical approval, 36 patients will be randomly allocated to one of two groups: testosterone or placebo therapy during exercise rehabilitation. A combined programme of moderate intensity aerobic exercise and resistance (strength) training will be used. The primary outcome measure is exercise capacity, assessed using an incremental shuttle walk test. Secondary outcome measures include measures of peak oxygen uptake, cardiac function, lower-limb skeletal muscle contractile function and oxygenation during exercise, circulating inflammatory markers, psychological health status and quality of life. DISCUSSION: Exercise rehabilitation can safely increase exercise capacity in stable CHF patients but there is a need for studies which are aimed at evaluating the long-term effects of physical training on functional status, morbidity and mortality. This pilot study will provide valuable preliminary data on the efficacy of testosterone therapy as an adjunct to exercise rehabilitation on a range of functional, physiological and health-related outcomes in this patient population. Preliminary data will be used in the design of a large-scale randomised controlled trial, aimed at informing clinical practice with respect to optimisation of exercise rehabilitation in this patient group

Comparison of upper-limb and lower-limb exercise training in patients with intermittent claudication

EThOS - Electronic Theses Online ServiceGBUnited Kingdo

Peripheral arterial disease/ intermittent claudication

Peripheral arterial disease (PAD) is a common circulatory problem characterised by obstruction of blood flow in the arteries outside of the heart and brain. It is usually caused by atherosclerosis, a hardening and narrowing of the arteries. As atherosclerosis is a systemic disease process, many patients with PAD also have coronary artery and cerebrovascular disease (Norgren et al., 2007). For the purpose of this chapter, PAD refers to advanced arterial atherosclerosis of the lower-limbs

Peripheral arterial disease/ intermittent claudication

Peripheral arterial disease (PAD) is a common circulatory problem characterised by obstruction of blood flow in the arteries outside of the heart and brain. It is usually caused by atherosclerosis, a hardening and narrowing of the arteries. As atherosclerosis is a systemic disease process, many patients with PAD also have coronary artery and cerebrovascular disease (Norgren et al., 2007). For the purpose of this chapter, PAD refers to advanced arterial atherosclerosis of the lower-limbs

El oro en las prácticas religiosas de los muiscas

De los datos consignados en las fuentes históricas de la Conquista se desprende el hecho de que el grupo muisca, después de que hubo perdido el dominio de los territorios que caían sobre las riberas del río Magdalena, en los actuales departamentos de Cundinamarca y Boyacá, debido a la presión a que fue sometido por las tribus enemigas, como las de los panches, muzos y colimas, careció casi por completo de fuentes de abastecimiento de oro en su propio territorio, por lo cual se vio forzado a obtenerlo por medio de tratos comerciales y de acciones guerreras, los primeros sostenidos con sus amigos los poinas o yaporoges, y las segundas libradas contra los grupos hostiles que bordeaban el flanco occidental de la región que ocupaban después de la pérdida de buena parte de sus antiguos dominios territoriales.

Upper- versus lower-limb aerobic exercise training on health-related quality of life in patients with symptomatic peripheral arterial disease

OBJECTIVE This randomized controlled trial investigated the effects of upper- and lower-limb aerobic exercise training on disease-specific functional status and generic health-related quality of life (QOL) in patients with intermittent claudication. METHODS The study recruited 104 patients (mean age, 68 years; range, 50-85) from the Sheffield Vascular Institute. Patients were randomly allocated to groups that received upper-limb (ULG) or lower-limb (LLG) aerobic exercise training, or to a nonexercise control group. Exercise was performed twice weekly for 24 weeks at equivalent limb-specific relative exercise intensities. Main outcome measures were scores on the Walking Impairment Questionnaire (WIQ) for disease-specific functional status, the Medical Outcomes Study Short Form version 2 (SF-36v2), and European Quality of Life Visual Analog Scale (EQ-VAS) for health-related QOL. Outcomes were assessed at baseline, and at 6, 24, 48, and 72 weeks. RESULTS After 6 weeks, improvements in the perceived severity of claudication (P = .023) and stair climbing ability (P = .011) vs controls were observed in the ULG, and an improvement in the general health domain of the SF-36v2 vs controls was observed in the LLG (P = .010). After 24 weeks, all four WIQ domains were improved in the ULG vs controls (P ≤ .05), and three of the four WIQ domains were improved in the LLG (P < .05). After 24 to 72 weeks of follow-up, more consistent changes in generic health-related QOL domains were apparent in the ULG. CONCLUSIONS These findings support the use of alternative, relatively pain-free forms of exercise in the clinical management of patients with intermittent claudication