Evaluation of determinants of walking fitness in patients attending cardiac rehabilitation

ABSTRACT Aim: This study aims to investigate the ability of patients’ baseline characteristics to predict the distance walked during the incremental shuttle walk test (ISWT) in the cardiac rehabilitation (CR) population and to produce reference values to guide practice. Methods: Secondary analysis was conducted on National Audit Cardiac Rehabilitation data collected between 2010 and 2015. Patients (n=8863) were included if they were aged 18 years and had a recorded ISWT score assessed before starting CR. Stepwise regression was used to identify factors predicting the ISWT distance. Age, gender, body mass index, height, weight; presence of hypertension, dyslipidemia or diabetes; smoking and physical activity were independent variables. ISWT distance was the dependent variable. The 25th, 50th and 75th percentiles of the ISWT distance were used as reference values. Results: Age and gender explained 27% of the variance of the distance covered in the ISWT (R2 =0.27, adjusted R2 =0.27,Standard Error of the Estimate (SEE) = 148.7, p<0.001). Reference values using age and gender categories were developed. Conclusion: Age and gender were the significant factors for predicting the walking fitness in the CR population, with age being the best predictor. The age and gender reference values produced represent a potentially valuable tool to be used in the clinical setting

Modes of exercise training for intermittent claudication

Background According to international guidelines and literature, all patients with intermittent claudication should receive an initial treatment of cardiovascular risk modification, lifestyle coaching, and supervised exercise therapy. In the literature, supervised exercise therapy often consists of treadmill or track walking. However, alternative modes of exercise therapy have been described and yielded similar results to walking. This raises the following question: which exercise mode produces the most favourable results? This is the first update of the original review published in 2014.ObjectivesTo assess the effects of alternative modes of supervised exercise therapy compared to traditional walking exercise in patients with intermittent claudication.Search methodsThe Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 4 March 2019. We also undertook reference checking, citation searching and contact with study authors to identify additional studies. No language restriction was applied.Selection criteriaWe included parallel-group randomised controlled trials comparing alternative modes of exercise training or combinations of exercise modes with a control group of supervised walking exercise in patients with clinically determined intermittent claudication. The supervised walking programme needed to be supervised at least twice a week for a consecutive six weeks of training.Data collection and analysisTwo review authors independently selected studies, extracted data, and assessed the risk of bias for each study. As we included studies with different treadmill test protocols and different measuring units (metres, minutes, or seconds), the standardised mean difference (SMD) approach was used for summary statistics of mean walking distance (MWD) and pain-free walking distance (PFVVD). Summary estimates were obtained for all outcome measures using a random-effects model. We used the GRADE approach to assess the certainty of the evidence.Main results For this update, five additional studies were included, making a total of 10 studies that randomised a total of 527 participants with intermittent claudication (IC). The alternative modes of exercise therapy included cycling, lower-extremity resistance training, upper-arm ergometry, Nordic walking, and combinations of exercise modes. Besides randomised controlled trials, two quasi-randomised trials were included.Overall risk of bias in included studies varied from high to low. According to GRADE criteria, the certainty of the evidence was downgraded to low, due to the relatively small sample sizes, clinical inconsistency, and inclusion of three studies with risk of bias concerns. Overall, comparing alternative exercise modes versus walking showed no clear differences for MVVD at 12 weeks (standardised mean difference (SMD)-0.01, 950/o confidence interval (CI)-0.29 to 0.27; P = 0.95; 6 studies; 274 participants; low-certainty evidence); or at the end of training (SMD-0.11, 95% CI-0.33 to 0.11; P = 0.32; 9 studies; 412 participants; low-certainty evidence). Similarly, no clear differences were detected in PFWD at 12 weeks (SMD-0.01, 950/o CI-0.26 to 0.25; P= 0.97; 5 studies; 249 participants; low-certainty evidence); or at the end of training (SMD-0.06, 95% CI-0.30 to 0.17; P = 0.59; 8 studies, 382 participants; low-certainty evidence). Four studies reported on health-related quality of life (HR-QoL) and three studies reported on functional impairment. As the studies used different measurements, meta-analysis was only possible for the walking impairment questionnaire (WIQ) distance score, which demonstrated little or no difference between groups (MD-5.52, 95% CI-17A1 to 6.36; P = 0.36; 2 studies; 96 participants; low-certainty evidence).Authors' conclusionsThis review found no clear difference between alternative exercise modes and supervised walking exercise in improving the maximum and pain-free walking distance in patients with intermittent claudication. The certainty of this evidence was judged to be low, due to clinical inconsistency, small sample size and risk of bias concerns. The findings of this review indicate that alternative exercise modes may be useful when supervised walking exercise is not an option. More RCTs with adequate methodological quality and sufficient power are needed to provide solid evidence for comparisons between each alternative exercise mode and the current standard of supervised treadmill walking. Future RCTs should investigate outcome measures on walking behaviour, physical activity, cardiovascular risk, and HRQoL, using standardised testing methods and reporting of outcomes to allow meaningful comparison across studies.</p

Οργάνωση ανακουφιστικής φροντίδας σε ασθενείς με καρδιακή ανεπάρκεια

Εισαγωγή: Η Καρδιακή Ανεπάρκεια (ΚΑ) συνιστά μια κλινική κατάσταση, της οποίας η επίπτωση ολοένα και αυξάνεται. Παρά την πληθώρα των θεραπειών, η ΚΑ είναι μια αναπόφευκτα θανατηφόρα νόσος. Ως εκ τούτου η παροχή Ανακουφιστικής Φροντίδας (ΑΦ) σε ασθενείς με προχωρημένη ΚΑ, σε κατάλληλα οργανωμένες δομές και υπηρεσίες, είναι μείζονος σημασίας τόσο για την υποστηρικτική φροντίδα των ασθενών αυτών, όσο και των οικογενειών τους. Σκοπός: Η ανάδειξη της σημασίας και της χρησιμότητας παροχής ΑΦ σε ασθενείς με προχωρημένη ΚΑ μέσα από οργανωμένες δομές ΑΦ, με στόχο την εκπαίδευση των ασθενών και τη διαχείριση των συμπτωμάτων της νόσου. Επιπροσθέτως, ο προσδιορισμός της οργάνωσης των διαφόρων δομών και υπηρεσιών ΑΦ για ασθενείς με ΚΑ. Υλικό και Μέθοδος: Πραγματοποιήθηκε συστηματική βιβλιογραφική ανασκόπηση των ηλεκτρονικών βάσεων δεδομένων Pubmed και Google Scholar. Τα βασικά κριτήρια ένταξης αποτέλεσαν η αγγλική γλώσσα και η χρονική αναζήτηση από το 2000-2017 καθώς η ΑΦ έχει γνωρίσει ανάπτυξη την τελευταία δεκαετία. Οι λέξεις κλειδιά που χρησιμοποιήθηκαν είναι οι εξής: ΄΄ heart failure΄΄ , ΄΄heart disease ΄΄, ΄΄ advanced heart failure΄΄ , ΄΄palliative care΄΄, ΄΄symptom management ΄΄, ΄΄palliative care services΄΄, ΄΄hospice΄΄, ΄΄end of life΄΄. Η χρονική περίοδος αναζήτησης πραγματοποιήθηκε από τον Απρίλιο έως τον Ιούνιο 2017. Αποτελέσματα: Εντοπίστηκαν συνολικά 23 άρθρα με βασική χώρα διεξαγωγής τις Η.Π.Α ως κύρια χώρα άνθισης της ΑΦ. Τα άρθρα αφορούσαν την οργάνωση διαφόρων υπηρεσιών ΑΦ με ιδιαίτερη έμφαση στα hospices και στην κατ’ οίκον φροντίδα. Τονίστηκε ο ρόλος της διεπιστημονικής ομάδας ΑΦ καθώς και αυτός των φροντιστών ως στυλοβάτες στη διαχείριση της οργάνωσης της ΑΦ για τους ΚΑ ασθενείς και αναδείχθηκαν ορισμένα εμπόδια στην παραπομπή σε υπηρεσίες ΑΦ. Συμπεράσματα: Ένας ολοένα και αυξανόμενος αριθμός ασθενών με ΚΑ χρήζουν ΑΦ. Η ΑΦ μπορεί να παραχθεί από κατάλληλη οργάνωση διαφόρων υπηρεσιών και δομών όπως hospice, ή κατ’ οίκον με το συντονισμό και τη συνεργασία της διεπιστημονικής ομάδας και των φροντιστών, δίνοντας λύση σε τυχόν υπαρκτά εμπόδια παραπομπής των ασθενών σε τέτοιες δομές. Έτσι, είναι μείζονος σημασίας η συμμετοχή και των Ελλήνων νοσηλευτών στη οργάνωση τέτοιων δομών και προγραμμάτων ΑΦ.Introduction: Heart failure (HF) is a clinical condition, whose impact growing. Despite the plethora of treatments HF, is an inevitably fatal disease. Therefore, the provision of Palliative Care (PC) in patients with advanced HF, in suitably organized structures and services are of major importance for both the supportive care of these patients and their families. Objectives: To highlight the importance and the usefulness of the provision of PC to patients with HF, through organized structures PC in order to educate patients and manage symptoms of the disease. Additionally, the determination of the organization of the various structures and services PC for patients with HF. Material and Methods: A systematic literature review was performed of electronic databases Pubmed and Google Scholar. The basic inclusion criteria were the English language and the search of the 2000-2017 as on the PC has seen growth in the last decade. The words keys used are as follows: :΄΄ heart failure΄΄ , ΄΄heart disease ΄΄,΄΄ advanced heart failure΄΄ , ΄΄palliative care΄΄, ΄΄symptom management ΄΄, ΄΄palliative care services ΄΄, ΄΄hospice ΄΄, ΄΄end of life΄΄. The time looking period ran from April to June 2017. Results: Identified a total of 23 articles with basic country the U.S.A as a main country of bloom on the PC. Articles related to the organization of various services on the PC, with special emphasis on hospice and home care. Highlighted the role of multi-professional group and that of caregivers as pillars in the management of the organization of PC for HF patients and brought up some obstacles in referral to services on the PC. Conclusions: An ever increasing number of patients with HF need PC. Palliative care can be produced by proper organization and structures of various services such as hospice, or home with the coordination and cooperation of the multi-professional team members and caregivers, giving solution to any existent obstacles referral of patients to such structures. Therefore, it is of major importance the participation of Greek nurses in organizing of such structures and programs

Central pain processing is altered in people with Achilles tendinopathy.

Background: Tendinopathy is often a chronic condition. The mechanisms behind persistent tendon pain are not yet fully understood. It is unknown whether, similar to other persistent pain states, central pain mechanisms contribute to ongoing tendon pain. Aim: We investigated the presence of altered central pain processing in Achilles tendinopathy by assessing the conditioned pain modulation (CPM) effect in people with and without Achilles tendinopathy. Methods: 20 people with Achilles tendinopathy and 23 healthy volunteers participated in this cross-sectional study. CPM was assessed by the cold pressor test. The pressure pain threshold (PPT) was recorded over the Achilles tendon before and during immersion of the participant's hand into cold water. The CPM effect was quantified as the absolute difference in PPT before and during the cold pressor test. Results: An increase in PPT was observed in the Achilles tendinopathy and control group during the cold pressor test (p<0.001). However, the CPM effect was stronger in the control group (mean difference=160.5 kPa, SD=84.9 kPa) compared to the Achilles tendinopathy group (mean difference=36.4 kPa, SD=68.1 kPa; p<0.001). Summary: We report a reduced conditioned pain modulation effect in people with Achilles tendinopathy compared to people without Achilles tendinopathy. A reduced conditioned pain modulation effect reflects altered central pain processing which is believed to contribute to the persistence of pain in other conditions. Altered central pain processing may also be an important factor in persistent tendon pain that has traditionally been regarded to be dominated by peripheral mechanisms

Left/right discrimination is not impaired in people with unilateral chronic Achilles tendinopathy

Objective: Impaired left/right discrimination of an affected body part has been observed in various chronic pain states. This study aimed to examine whether people with unilateral chronic Achilles tendinopathy also present with impaired left/right discrimination. Design: Cross-sectional study. Methods: Nineteen runners with persistent unilateral Achilles tendinopathy and 19 matched healthy volunteers performed a left/right discrimination task in a laboratory setting. Participants were shown pictures of feet, hands and Shepard-Metzler figures and were asked to decide as accurately and as fast as possible whether the body part belonged to the left or right side of the body, or whether the Shepard-Metzler figures were rotated or mirrored. Performance was evaluated in terms of accuracy and response time. Data were analysed with mixed-design ANOVAs. Results: The decline in left/right discrimination ability at group level, if present, between affected and unaffected side, or compared to healthy participants, was negligible for both accuracy ( 0.36) or response time (p > 0.69). Conclusions: People with Achilles tendinopathy recognised the affected side as accurately and as fast as the non-affected side and their performance was comparable to healthy participants. The absence of impaired left/right discrimination despite the chronicity of the condition may be attributable to the typical intermittent nature of Achilles tendinopathy pain and/or maintained sports activity

Effects of joint and nerve mobilisation on neuroimmune responses in animals and humans with neuromusculoskeletal conditions: a systematic review and meta-analysis

Several animal and human studies revealed that joint and nerve mobilisations positively influence neuroimmune responses in neuromusculoskeletal conditions. However, no systematic review and meta-analysis has been performed. Therefore, this study aimed to synthesize the effects of joint and nerve mobilisation compared with sham or no intervention on neuroimmune responses in animals and humans with neuromusculoskeletal conditions. Four electronic databases were searched for controlled trials. Two reviewers independently selected studies, extracted data, assessed the risk of bias, and graded the certainty of the evidence. Where possible, meta-analyses using random effects models were used to pool the results. Preliminary evidence from 13 animal studies report neuroimmune responses after joint and nerve mobilisations. In neuropathic pain models, meta-analysis revealed decreased spinal cord levels of glial fibrillary acidic protein, dorsal root ganglion levels of interleukin-1β, number of dorsal root ganglion nonneuronal cells, and increased spinal cord interleukin-10 levels. The 5 included human studies showed mixed effects of spinal manipulation on salivary/serum cortisol levels in people with spinal pain, and no significant effects on serum β-endorphin or interleukin-1β levels in people with spinal pain. There is evidence that joint and nerve mobilisations positively influence various neuroimmune responses. However, as most findings are based on single studies, the certainty of the evidence is low to very low. Further studies are needed

Upper versus lower limb exercise training in patients with intermittent claudication: A systematic review

Lower extremity (LE) exercise training has been shown to contribute to improvements in Maximum Walking Distance (MWD), Claudication Distance (CD), peak oxygen uptake (VO2peak) and Quality of Life (QoL) in patients with intermittent claudication (IC). However, little is known regarding the efficacy of upper extremity (UE) exercise training in comparison to the widely used LE training. The objective of this systematic literature review is to identify and synthesize the available literature on the effects of UE versus LE exercises using the International Classification of Functioning (ICF) conceptual framework. A total of 6 randomized controlled trials comparing UE to LE exercises were included in this study. Two of the articles were considered to be of high quality using the PEDro grading list. Both UE and LE training groups demonstrated significant improvements in MWD, CD, VO2peak and QoL in comparison to the control group but LE was not better than UE training. This supports the use of UE training as an alternative to LE, which could provide symptomatic relief to patients with IC without the discomfort caused during the LE training.3.942 JCR (2015) Q1, 12/63 Peripheral vascular diseaseUE