Showing papers in "Journal of Cardiopulmonary Rehabilitation in 2002"

Global initiative for chronic obstructive lung disease.

Abstract: Representatives from many countries serve as a network for the dissemination and implementation of programs for diagnosis, management, and prevention of COPD. The GOLD Board of Directors is grateful to the many GOLD National Leaders who participated in discussions of concepts that appear in GOLD reports.

Lipids, lipoproteins, and exercise.

Abstract: PURPOSE Dose-response relationships between exercise training volume and blood lipid changes suggest that exercise can favorably alter blood lipids at low training volumes, although the effects may not be observable until certain exercise thresholds are met. METHODS AND RESULTS Plasma triglyceride reductions are often observed after exercise training regimens requiring energy expenditures similar to those characterized to increase high-density lipoprotein cholesterol (HDL-C). Thresholds established from cross-sectional and longitudinal exercise training studies indicate that 15 to 20 miles/week of brisk walking or jogging, which elicit between 1,200 to 2,200 kcals of energy expenditure per week, is associated with triglyceride reductions of 5 to 38 mg/dL and HDL-C increases of 2 to 8 mg/dL. Exercise training seldom alters total cholesterol and low-density lipoprotein cholesterol (LDL-C) unless dietary fat intake is reduced and body weight loss is associated with the exercise training program, or both. Thus, for most individuals, the positive effects of regular exercise are exerted on blood lipids at low training volumes and accrue so that noticeable differences frequently occur with energy expenditures of 1,200 to 2,200 kcals/week. CONCLUSIONS It appears that weekly exercise caloric expenditures that meet or exceed the higher end of this range are more likely to produce the desired lipid changes. Regarding hyperlipidemic disorders, the primary means for intervention is pharmacologic, whereas diet modification, weight loss, and exercise, although important, are viewed as adjunctive therapies. Because much is known about the exercise training-induced plasma lipid and lipoprotein modifications as well as the mechanisms responsible for these changes, rehabilitation professionals can better develop a comprehensive medical management plan that optimizes pharmacologic, reduced dietary fat intake, weight loss, and exercise interventions.

Psychological predictors of adherence and outcomes among patients in cardiac rehabilitation.

Abstract: PURPOSEThe purpose of this study was to evaluate the effects of optimism, depression, and neuroticism on adherence and outcomes among patients in cardiac rehabilitation (CR).METHODSParticipants included 46 patients (34 men) with coronary heart disease (CHD) who completed measures of psychological fu

Efficacy of diaphragmatic breathing in persons with chronic obstructive pulmonary disease: a review of the literature.

Abstract: The evidence base for diaphragmatic breathing (DB) as an adjunctive treatment modality for persons with COPD is questionable. This article reviews the literature regarding the efficacy of DB in persons with chronic obstructive pulmonary disease (COPD), and reports on the beneficial and detrimental effects of DB in persons with COPD. Diaphragmatic breathing has been described as breathing predominantly with the diaphragm while minimizing the action of accessory muscles that may assist with inspiration. No single or combined patient characteristic has been identified consistently to help predict which person with COPD may benefit from DB. However, it has been suggested that persons with moderate to severe COPD and marked hyperinflation of the lungs without adequate diaphragmatic movement and increase in tidal volume during DB may be poor candidates for instruction in DB. Conversely, persons with COPD who have elevated respiratory rates, low tidal volumes that increase during DB, and abnormal arterial blood gases with adequate diaphragmatic movement may benefit from DB. Identification of an abdominal paradoxical breathing pattern and worsening dyspnea and fatigue during or after DB are criteria to modify or terminate DB. Persons with COPD demonstrating an abdominal paradox during DB may benefit from a more upright body position or trunk flexion. Several methods to examine diaphragmatic movement and the potential for success with DB will be discussed. Future research is needed to better identify which patients may benefit from DB.

Effects of long-term exercise rehabilitation on claudication distances in patients with peripheral arterial disease: a randomized controlled trial.

Abstract: PURPOSE To determine if improvements in physical function and peripheral circulation after 6 months of exercise rehabilitation could be sustained over a subsequent 12-month maintenance exercise program in older patients with intermittent claudication. METHODS Seventeen patients randomized to exercise rehabilitation and 14 patients randomized to usual care control completed this 18-month study. Patients exercised three times per week during the first 6 months of a progressive exercise program, followed by two times per week during the final 12 months of a maintenance program. Patients were studied at baseline, 6 months, and 18 months during the study. RESULTS Eighteen months of exercise rehabilitation increased the initial claudication distance by 373 meters (189%) (P <.001), the absolute claudication distance by 358 meters (80%) (P <.001), walking economy by 11% (P <.001), 6-minute walk distance by 10% (P <.001), daily physical activity by 31%, and maximal calf blood flow by 18% (P <.001). These changes were similar to those found after 6 months of exercise rehabilitation (P = NS), and were significantly greater than the changes in the control group throughout the study (P <.05). CONCLUSION Improvements in claudication distances, walking economy, 6-minute walk distance, physical activity level, and peripheral circulation after 6 months of exercise rehabilitation are sustained for an additional 12 months in older patients with intermittent claudication using a less frequent exercise maintenance program.

A representative study of cardiac rehabilitation activities in European Union Member States: the Carinex survey.

Abstract: PURPOSE Empirical data on the level and nature of service delivery in cardiac rehabilitation (CR) in Europe are unavailable. Such information would facilitate service development across European Union (EU) Member States. A first EU-wide postal survey to provide baseline data was conducted. METHODS Organizations providing CR in 1995 were identified for 13 of 15 EU states (all except Luxembourg and Denmark). Using the World Health Organization definitions, 454 phase II (medium-term recovery after hospital release) and 383 phase III (long-term maintenance) centers were contacted in the relevant language. Staffing, content, duration, cost, and safety aspects of CR were queried. RESULTS Response rates were 57% (phase II) and 56% (phase III). Replies illustrate consistency across the EU; for instance, in having exercise as a core component of phase II programs. They also exemplify the diversity of services, particularly in phase III. The multidisciplinary aspect of CR is less developed in phase III. From this survey it is possible to make general estimates of the level of CR service coverage across EU States. Fewer than 50% of patients eligible to participant do so in most countries, with services in particularly short supply in countries with the greatest cardiovascular burden. CONCLUSION Many cardiac patients who could benefit from CR, an evidence-based treatment, do not participate in such programs. This survey provides important baseline and EU comparison data to monitor patterns of service development in the future.

Determinants of exercise blood pressure response in normotensive and hypertensive women: role of cardiorespiratory fitness.

Abstract: PURPOSE: Exaggerated blood pressure (BP) response during physical exertion is associated with increased risk for cardiovascular events. Furthermore, it may be the predisposing factor for myocardial infarction triggered by physical exertion. The authors have shown that systolic BP achieved after 6 minutes of exercise is the strongest predictor of left ventricular hypertrophy. Furthermore, a 37 mm Hg increase in systolic BP above resting BP at 6 minutes of exercise was the threshold for left ventricular hypertrophy. The purpose of this study was to determine predictors of exercise BP response in normotensive and hypertensive women. METHODS: An exercise tolerance test (Bruce) was performed by 1411 normotensive (resting BP or = 140/90 mm Hg) women. These women were faculty, students, and staff at the University of Maryland, College Park, Maryland, and the George Washington University Medical Center, as well as patients undergoing a routine exercise tolerance test at West Coast Cardiology, Pinellas Park, Florida. Two fitness categories (low-fit and high-fit) were established on the basis of treadmill time to exhaustion adjusted for age. RESULTS: Significant associations were observed among the 6-minute exercise BP and age, body mass index, resting systolic and diastolic BP, heart rate, and exercise time to exhaustion. In a stepwise multiple-regression analysis, the determinants of BP after 6 minutes of exercise were resting systolic BP and treadmill time to exhaustion (R2 = 0.36) for normotensive women and treadmill time to exhaustion and resting systolic BP (R2 = 0.30) for hypertensive women. When fitness categories were contrasted, low-fit women in both the normotensive and hypertensive categories had higher BP and rate-pressure product after 6 minutes of exercise than the high-fit women (P <.05). CONCLUSIONS: Resting systolic BP and cardiorespiratory fitness are determinants of a submaximal exercise BP response for both hypertensive and normotensive women. Low cardiorespiratory fitness is associated with a higher BP response during submaximal exercise, suggesting that increased fitness may attenuate this abnormal rise in BP. Thus, low- to moderate-intensity physical activities for most days of the week should be encouraged for all women to increase cardiorespiratory fitness. This is likely to attenuate an abnormal rise in systolic BP that may occur during routine daily activities and protect against the associated health consequences.

The acute effects of noninvasive ventilatory support during exercise on exercise endurance and dyspnea in patients with chronic obstructive pulmonary disease: a systematic review.

Abstract: PURPOSE: The objective of this study was to review studies systematically, in which the acute effects of noninvasive ventilatory support (NIVS) during exercise were evaluated in patients with chronic obstructive pulmonary disease (COPD). In addition, a quantitative analysis was performed on the effects of NIVS on exertional dyspnea and exercise endurance. METHODS: Literature was searched in electronic databases, and by scanning lists of references of studies and abstract books of annual congresses of the American Thoracic Society and European Respiratory Society. Preliminary data of a study by our own group into the effects of NIVS on exercise endurance in patients with COPD were added. The systematic review was carried out on the basis of a validated methodological screening list. For the quantitative analysis, Glass δ of individual studies were pooled to aggregate a summary effect size. RESULTS: Fifteen studies were identified. Seven of these studies met the inclusion criteria, including a total of 65 patients with COPD. The methodological quality of the included studies varied from 31% to 54% of the maximum score of 13 points. Statistically significant summary effect sizes were found in the analysis of exertional dyspnea (P < .05) as well as in the analysis of exercise endurance (P < .001), indicating improvements in these outcomes in favor of NIVS. CONCLUSIONS: The present systematic review suggests that NIVS during exercise may acutely reduce exertional dyspnea and improve exercise endurance, in patients with COPD.

Exercise training improves outcomes of a dyspnea self-management program.

Abstract: PURPOSE: The purpose of this study was twofold: (1) to determine whether exercise training adds to the benefit of a dyspnea self-management (DM) program; and (2) to determine if there is a “dose response” to supervised exercise training (0, 4, or 24 sessions) in dyspnea, exercise performance, and health-related quality of life. METHODS: Subjects with chronic obstructive pulmonary disease (n = 103, 46 men, 57 women; age 66 ± 8 years; forced expiratory volume in 1 second 44.8 ± 14% predicted) were randomized to DM, DM-exposure, or DM-training. Dyspnea self-management included individualized education about dyspnea management strategies, a home-walking prescription, and daily logs. Outcomes were measured at baseline and 2 months as part of a 1-year longitudinal randomized clinical trial. Outcomes included dyspnea during laboratory exercise and with activities of daily living (Chronic Respiratory Questionnaire [CRQ]), Shortness of Breath Questionnaire, Baseline/Transitional Dyspnea Index), exercise performance (incremental treadmill tests (ITTs) and endurance treadmill tests (ETTs), 6-minute walk (6MW), and health-related quality of life (SF-36). RESULTS: The DM-training group had significantly greater improvements than the DM-exposure and the DM groups in dyspnea at isotime during ITT (P = .006); exercise performance during ITT (P = .005), ETT (P = .003), and 6MW (P = .01); SF-36 Vitality (P = .031); and CRQ mastery (P = .007). There was a dose-dependent improvement in CRQ dyspnea scores (P < .05) with significant improvements only in the DM-training and DM-exposure groups. CONCLUSION: Exercise training substantially improved the impact of a dyspnea self-management program with a home walking prescription (DM). This impact tended to be dependent on the “dose” of exercise.

Patient characteristics and outcomes of cardiac rehabilitation.

Abstract: PURPOSE: To investigate changes in physical fitness and psychological characteristics of patients after cardiac rehabilitation, and to assess predictors of defaulting from the program. METHODS: A prospective study of 1902 consecutive patients admitted to a community-based, hospital-linked cardiac rehabilitation program was conducted over a period of 6 years and 7 months. The cardiac rehabilitation program centered on a 2-to 6-month circuit training course with education, stress management, relaxation, and risk factor monitoring. Before and after the program, measures of physical fitness and of hospital anxiety and depression were performed. RESULTS: The course was completed by 1443 patients (76%), with 240 patients (13%) defaulting. For those who completed the course, peak oxygen consumption per minute increased by 3.2 mL/min/kg (95% confidence interval [CI], 3.1-3.4) or 19% (95% CI, 17.7%-20.3%). According to the hospital anxiety and depression scores, anxiety fell by 1.1 (95% CI, -1.3 to -0.98) and depression by 1.3 (95% CI, -1.4 to -1.2). The main predictors of defaulting were depression (patients with depression were twice as likely to default as nondepressed patients) and diagnosis (patients who had experienced angina or percutaneous transluminal coronary angioplasty were twice as likely to default as those who had experienced infarct or coronary artery bypass graft). CONCLUSIONS: The identification of depressed coronary patients known to be at increased risk should be a priority for cardiac rehabilitation coordinators. Every effort should be made to keep them in the cardiac rehabilitation program.

Criterion validity of the Duke Activity Status Index for assessing functional capacity in patients with chronic obstructive pulmonary disease.

Abstract: PURPOSE This study evaluated the concurrent criterion validity of the Duke Activity Status Index (DASI) with respect to standard physiologic work capacity indices in patients with chronic obstructive pulmonary disease (COPD) and compared its performance with similar surrogates. METHODS 119 patients with moderate to severe COPD (86 men, 33 women) completed medical and smoking histories, physical examination, pulmonary function testing (PFT), cycle ergometry (CE), arm ergometry (AE), and 6-minute walk distance (6MWD), DASI, the Sickness Impact Profile-68 (SIP-68) and the Chronic Respiratory Disease Questionnaire (CRDQ). Correlation methods were used to assess the validity of the potential surrogates DASI and the domain scores for SIP-68 and CRDQ, with the standards CE, AE, PFT, and 6MWD (as a standard). RESULTS The mean DASI score was 33.4 +/- 13.0. Significant Pearson correlations (P <.01) were observed between the DASI and PFT outcomes maximum voluntary ventilation (r =.28); peak expiratory flow (r =.21); diffusion capacity of lung for carbon monoxide (r =.30). For CE, the correlations with DASI were oxygen consumption (VO(2))(r =.34); minute ventilation (r =.25); watts (r =.37). For AE, the correlations with DASI were VO(2) (r=.38); watts (r =.47). For 6MWD, the correlation was r =.53. Higher correlations were obtained for the distance completed during the first minute of the 6MWD and ergometric indices as well as DASI scores: watts(AE) (r =.39); VO(2AE) (r =.45); watts(CE) (r =.50); VO(2CE) (r =.44). Correlation coefficients for all SIP-68 and CRDQ domain and total scores were lower than corresponding correlations obtained for the DASI. Regression analysis demonstrated that the DASI and 6MWD were important (P <.05) for predicting VO(2) or work for CE while DASI and SIP range or CRDQ dyspnea entered for AE, when gender, age, BMI, and the FEV1 were forced into the model. In forward stepwise analyses, DASI entered first for AE, and 6MWD entered first for CE. The DASI was selected in 3 of 4 models with R(2) values ranging from.47 to.70. SIP-68 and CRDQ subscores were significant as additional predictors. CONCLUSIONS DASI has high criterion validity for predicting CE and/or AE outcomes in the COPD population. It is warranted in addition to the 6MWD, and its predictive significance and simplicity recommends it over several other self-administered instruments for evaluating functional capacity.

Hemodynamic responses during aerobic and resistance exercise.

Abstract: Purpose Resistance training has become an accepted part of cardiac rehabilitation programs. Because of the potential for a high afterload to have a negative impact on left ventricular function, there has been concern regarding the safety of resistance training for patients with congestive heart failure. Methods This study addressed this concern by studying 12 healthy volunteers, 12 patients with stable coronary artery disease, and 12 patients with stable congestive heart failure during upright cycling at 90% of ventilatory threshold, and during one set of 10 repeated leg presses, shoulder presses, and biceps curls at 60% to 70% of 1-repetition maximum. Left ventricular function was measured by echocardiography. Results The pattern of changes in heart rate, blood pressure, left ventricular ejection fraction, wall thickness, and left ventricular internal diameters was similar across all three groups of subjects, although there were large differences in absolute values. Despite elevations in diastolic and mean arterial pressures during resistance exercise, there was no evidence of significant rest-to-exercise deterioration in left ventricular function during leg press (ejection fraction, 60%-59%, 56%-55%, and 38%-37%), shoulder press (66%-65%, 59%-53%, and 38%-35%), or biceps curls (63%-58%, 53%-54%, and 35%-36%), as compared with cycle ergometry (63%-69%, 51%-57%, and 35%-42%) in the healthy control subjects, the patients with coronary artery disease, and the patients with congestive heart failure, respectively. Conclusions Left ventricular function remains stable during moderate-intensity resistance exercise, even in patients with congestive heart failure, suggesting that this form of exercise therapy can be used safely in rehabilitation programs.

Neurobehavioral improvement after brief rehabilitation in patients with chronic obstructive pulmonary disease.

Abstract: � PURPOSE: Depressive symptoms, physiologic function, and cognition were examined in patients with chronic obstructive pulmonary disease (COPD) after 3 weeks of rehabilitation. � METHODS: Patients with COPD completed measures of depression, neuropsychological function, exercise, and spirometry before and after a 3-week rehabilitation program. The 30 rehabilitation patients with COPD were compared with 29 untreated patients with COPD and 21 healthy controls similar in age, education, and gender. � RESULTS: A significant group by time interaction effect was found on the Beck Depression Inventory (BDI). A significant interaction effect was also found on the 6-minute walk. Patients in the COPD rehabilitation program had decreased depressive symptoms and increased 6-minute walk distance compared with the untreated groups. Across the 3 groups, no significant interaction effects were found on neuropsychological tests. However, clinically significant improvement in sustained visual attention, verbal retention, and visuospatial ability were reported in the most impaired patients with COPD in the rehabilitation group. � CONCLUSION: Compared with control groups, decline in depressive symptoms and increased exercise capacity occurred in patients with COPD after brief rehabilitation. Clinical improvement in visual attention, verbal memory, and visuospatial functions occurred in the impaired patients with COPD participating in treatment. Neurobehavioral improvements after such a brief rehabilitation intervention are relevant for clinical care and warrant continued investigation in well-designed clinical trials.

Validation of the Cardiovascular Limitations and Symptoms Profile (CLASP) in chronic stable angina.

Abstract: PURPOSE: This study aimed to establish the reliability, validity, and sensitivity of the Cardiovascular Limitations and Symptoms Profile (CLASP) in a group of patients with chronic stable angina. METHODS: After 226 patients with angina had been recruited, they were randomly allocated to one of three groups: a 10-week hospital-based angina management program (n = 75; men = 56; age = 60 ± 8 years), routine care (n = 74; men = 52; age = 61 ± 7 years), and exercise therapy (n = 77; men = 60; age = 60 ± 7 years). All the patients were assessed with CLASP on two occasions: at baseline and at 10 weeks. The Sickness Impact Profile (SIP), the Hospital Anxiety and Depression Scale (HADS), and the Sleep Problems Questionnaire (SPQ) also were administered at the same time. RESULTS: Significant positive correlations between the actual number of angina episodes and the CLASP angina subscale scores (r = .60, P < .001) were observed. The CLASP subscale scores for shortness of breath (r = -.36;P < .001) and ankle swelling (r = -.24;P < .001) were significantly correlated with the total treadmill time. The CLASP tiredness subscale score showed a significant positive correlation with the SPQ score (r = .48;P < .001). The CLASP subscale scores were significantly correlated with their corresponding SIP subscale scores: the tiredness score with the sleep and rest score (r = .49;P < .001), the social and leisure score with the recreation and pastimes score (r = .41;P < .001), the home score with the home management score (r = .45;P < .001), and the mobility score with the mobility (r = .37;P < .001) and total treadmill time scores (r = -.49;P < .001). CONCLUSIONS: The findings show CLASP to be a reliable, valid, sensitive measure of health-related quality of life in patients with chronic stable angina. Before it can be recommended for all patients with heart disorders, similar data will be required from other diagnostic groups such as patients with heart failure or those who have sustained an acute myocardial infarction. © 2002 Lippincott Williams & Wilkins, Inc.

Predictors of smoking cessation in patients with a diagnosis of coronary artery disease.

Abstract: PURPOSE This study aimed to examine demographic, psychosocial, and clinical variables as predictors of smoking cessation in patients with coronary artery disease. METHODS Smoking status and psychosocial variables were obtained at baseline. Participants were followed up at 3 months then annually up to 6 years for smoking status. Participants were recruited from the population of patients undergoing coronary angiography from 1986 through 1990. Patients were included in the study if they reported smoking at baseline and had valid data for demographic and clinical measures of interest. Depending on the psychosocial measure analyzed, sample size ranged from 525 to 303. Age, gender, education, marital status, disease severity, cardiac procedure, hostility, and four ratings of distress were evaluated as predictors of smoking cessation. RESULTS Of the full sample, 40% (n = 210) quit smoking without relapse. Education (odds ratio [OR] 0.61; 95% confidence interval [CI] 0.44-0.84; P <.003), disease severity (OR 0.58; 95% CI 0.40-0.84; P <.004), and coronary artery bypass surgery (OR 0.60; 95% CI 0.43-0.85; P <.004) were associated with a lower likelihood of relapse. Higher levels of hostility (OR 2.36; 95% CI 1.46-3.84; P <.001), concern about health (OR 1.90; 95% CI 1.33-2.74; P <.001), tension (OR 1.60; 95% CI 1.12-2.30; P <.012), and depressive feelings (OR 1.60; 95% CI 1.12-2.27; P <.010) were associated with a higher risk of continuing to smoke. CONCLUSIONS These findings describe demographic, clinical, and psychological mechanisms that might underlie successful smoking cessation and also may guide the identification of patients in need of special intervention.

Weight reduction in the cardiac rehabilitation setting.

Abstract: � BACKGROUND: Most patients with coronary heart disease are overweight. However, only minimal weight loss occurs with participation in a standard cardiac rehabilitation (CR) program. � METHODS: The study investigated 82 patients with coronary heart disease who entered an outpatient CR program and completed 36 sessions of exercise over a 12-week period. The effects of a structured, nurse-coordinated, weight loss intervention during phase 2 CR were compared with those observed in a CR control group receiving usual care. � RESULTS: The intervention group lost an average of 4.3 ± 2.8 kg (P .0001), as compared with a weight loss of 1.7 ± 2.6 kg (P .001) in the control group (P .005 between groups). The effect of the weight loss intervention on total cholesterol (172 ± 34 to 166 ± 29 mg/dL) differed from the response in a control group receiving usual care (180 ± 30 to 187 ± 28 mg/dL) (P .05 between groups). The weight loss group experienced a significantly greater improvement (P .05) than the control group in the physical function score on the Medical Outcomes Study SF-36 questionnaire. A significant correlation was found between the number of weight loss sessions an individual attended and the amount of weight loss experienced (R = 0.39; P .05). � CONCLUSIONS: The current study demonstrated that a behavioral weight loss intervention is effective in reducing body weight in a CR setting. Participants in the intervention group experienced significantly greater improvements in body weight, body mass index, and total cholesterol than a control group. Additionally, participants in the weight loss program reported greater improvements in their physical function score than the control patients.

Exercise Consultation Improves Short-term Adherence to Exercise During Phase Iv Cardiac Rehabilitation: A Randomized, Controlled Trial

Abstract: This randomized-controlled trial demonstrates that an exercise consultation, based on the transtheoretic model of exercise behavior change, significantly improves short-term adherence to exercise.

Number needed to treat in cardiac rehabilitation.

Abstract: Clinicians, patients, and health policy-makers must judge whether healthcare interventions are worth the side effects, inconvenience, and costs. The number needed to treat (NNT) provides an estimate of the number of patients who need to be treated to attain an additional favorable outcome, or to prevent an additional adverse outcome, and is the reciprocal of the absolute risk reduction. The closer the NNT is to 1.0-meaning that every patient who is treated achieves a benefit-the more effective the treatment. Traditionally, mortality has been considered a primary outcome measure of the effectiveness of cardiac rehabilitation and, if the event rates in two groups (ie, rehabilitation and usual care) are known, the absolute risk reduction can be calculated and the NNT estimated. Mortality data were derived from three meta-analyses of cardiac rehabilitation trials: one published in 1988 (n = 3614), one in 1989 (n = 4247), and one in 2001 (n = 7683). The respective estimated NNT for mortality in the meta-analyses were 32, 46, and 72 (95% confidence intervals [95% CI] 19, 1403). Improved exercise tolerance and patient-perceived health-related quality of life (HRQL) are also considered important and attainable outcomes of cardiac rehabilitation but are continuous, not dichotomous, variables. If the minimal important difference for a continuous outcome is known, then the proportions of patients who improve, remain the same, or deteriorate can be determined and the NNT estimated. Exercise tolerance and HRQL data from two randomized controlled trials of 8 weeks of rehabilitation after myocardial infarction, the Cardiac Rehabilitation in Advanced Age trial (CR-AGE; n = 270) and the McMaster Early Rehabilitation Study (MERS; n = 201) were used to estimate the NNT. In CR-AGE, the improvement in exercise tolerance was significantly greater in the rehabilitation than usual care group and the estimated NNT was 5 (95% CI 3, 13). The generic global HRQL score increased significantly in CR-AGE with rehabilitation with an estimated NNT of 12 (95% CI 5, 26) but, as the subscale group differences were not significant, the NNT was not estimated. The NNT for exercise tolerance was not estimated in MERS, as the group difference was not significant. On the other hand, specific HRQL scores in MERS increased significantly with rehabilitation giving an estimated NNT for global HRQL of 6 (95% CI 3, 21) and 6 to 10 for the HRQL sub-scales. The data and the estimated NNT from the meta-analyses of cardiac rehabilitation in large numbers of patients suggest a limited mortality effect, probably reflecting current cardiology practice. The estimated NNT from the two trials with relatively small numbers of patients suggest inconsistent exercise tolerance effects and a relatively short duration for improved HRQL. Along with the classic reporting scales, information about clinical and laboratory variables, and patient preferences, the NNT is a useful additional measure of effectiveness that provides both clinicians and patients with information about the impact of cardiac rehabilitation as secondary prevention therapy.

Pulmonary rehabilitation compared with brief advice given for severe chronic obstructive pulmonary disease.

Abstract: PURPOSEThe objective of this study was to compare the effectiveness of a short-term pulmonary rehabilitation program with brief advice given to patients with severe ventilatory impairment due to chronic obstructive pulmonary disease (COPD).METHODSOne hundred three patients with severe COPD, defined

Smoking cessation in pulmonary rehabilitation: goal or prerequisite?

Abstract: It has been more than 35 years since the Surgeon General of the United States released the first report of the Advisory Committee on Smoking and Health Cigarette smoking has been identified as the most important source of preventable morbidity and premature mortality in North America During the 1990s, tobacco was the largest single cause of premature death in the developed world Smoking cessation is followed by immediate health benefits in terms of symptoms and organ function It dramatically reduces the risk of most smoking-related diseases, including chronic obstructive pulmonary disease and lung cancer Respiratory rehabilitation has been defined as a multidimensional continuum of services directed to persons with pulmonary disease and their families, usually by an interdisciplinary team of specialists, with the goal of achieving and maintaining the individual's maximum level of independence and functioning in the community A European Respiratory Society task force on rehabilitation recently commented that respiratory rehabilitation must address medical management including reinforcement of smoking cessation, education of the patient and family, exercise reconditioning, physical and occupational therapy, nutritional support, and long-term oxygen therapy Many patients have quit smoking by the time they enroll in a pulmonary rehabilitation program Nevertheless, the inclusion of smokers in respiratory rehabilitation programs remains controversial Among 14 trials included in a meta-analysis of respiratory rehabilitation of patients with chronic obstructive pulmonary disease (COPD), the smoking status of the patients was reported in 9 of the trials, and only 2 trials stated that smoking was an absolute exclusion criterion for enrollment Some investigators have used a trial of smoking cessation as an index of the patient's motivation to improve his or her health status This article describes the effect of smoking on the course of COPD and the opportunity to address smoking in the context of comprehensive rehabilitation The authors' line of reasoning is that (1) smoking causes COPD and perpetuates the pathophysiologic processes defining the disease, (2) symptomatic COPD does not facilitate smoking cessation, (3) smoking may alter rehabilitation outcomes, and (4) if smoking cessation is not a prerequisite to pulmonary rehabilitation, then a smoking cessation intervention should at least he offered as part of such a program

The metabolic demand of golf in patients with heart disease and in healthy adults.

Abstract: Purpose To evaluate the metabolic cost of golf, while pulling a cart, in a group of patients with heart disease (HD) and healthy adults with a wide range of functional capacities. Methods Twenty male golfers aged 49 to 78 years participated in this study. All participants underwent a graded exercise test (GXT) with expired gas analysis to determine functional capacity. Each patient with HD (n = 10) was matched with a healthy adult of similar age. Each pair completed 9 holes of golf while pulling a cart, during which oxygen consumption was monitored continuously via the Cosmed K4b2 portable unit. Results The average metabolic equivalent (MET) value (1 MET = 3.5 mL x kg(-1) x min(-1)) (mean +/- SEM) for 9 holes of golf in this group of men with HD (4.1 +/- 0.1 METs) was similar to that previously reported value of 4.3 METs. Whereas the average MET responses were similar between the groups, when expressed relative to peak oxygen consumption, on average, patients with HD worked at a significantly higher percentage of their functional capacity (57 +/- 2.7%) compared to the healthy adults (46 +/- 2.6%). Some patients with HD exceeded 100% of GXT MET level during golf. In contrast, some healthy adults failed to reach 60% of GXT MET level during golf. Conclusions Based on these data, walking the golf course while pulling a cart appears to provide an adequate training stimulus for most patients with HD. However, some lower fit patients with HD ( or = 8 METs), golf does not appear to provide the stimulus generally associated with improvement in functional capacity.

Influence of venous function on exercise tolerance in chronic heart failure.

Abstract: PURPOSE The clinical phase of chronic heart failure (HF) includes a marked decline in exercise tolerance, in part due to impaired skeletal muscle blood flow delivery. Interestingly, the role of the venous system on exercise tolerance in patients with HF has not received much attention, despite evidence of changes in venous structure and function. The purpose of this study was to examine the relationship between forearm arterial and venous function, and exercise tolerance in patients with HF and age-matched controls. METHODS Vascular function and exercise tolerance was examined in 20 patients with HF (age 59 +/- 13 years) and 10 control subjects (age 51 +/- 16 years). Nondominant forearm arterial inflow, vascular resistance, venous capacitance, and venous outflow were evaluated at rest and after 5 minutes of upper arm occlusion, using strain gauge plethysmography. Exercise tolerance was measured as the maximum walking distance achieved on a 6-minute walking test. RESULTS Maximum walking distance (HF: 178 +/- 65 m; controls: 562 +/- 136 m, P=.0001), and forearm vascular function after occlusion were significantly different between groups (forearm arterial inflow: HF 15.3 +/- 6; controls 22 +/- 6.7; forearm venous capacitance: HF 1.4 +/- 0.5; controls 2.0 +/- 0.4; forearm venous outflow: HF 24.5 +/- 9.4; controls: 33 +/- 10 mL x 100 mL tissue(-1) x min(-1); and forearm vascular resistance: HF 7.8 +/- 3; controls 4.6 +/- 1.4 U). Correlation analysis revealed significant associations between all forearm vascular measurements after occlusion and maximum walking distance. CONCLUSION These data confirm previous studies indicating the importance of arterial reactivity on exercise tolerance in patients with HF. Additionally, the results suggest the importance of venous function as a contributing factor to exercise performance.

Reliability of isokinetic strength and aerobic power testing for patients with chronic heart failure.

Abstract: PURPOSE: The objective of this study was to assess the reliability of testing skeletal muscle strength and peak aerobic power in a clinical population of patients with chronic heart failure (CHF). METHODS: Thirty-three patients with CHF (New York Heart Association (NYHA) Functional Class 2.3 ± 0.5; left ventricular ejection fraction 27% ± 7%; age 65 ± 9 years; 28:5 male-female ratio) underwent two identical series of tests (T1 and T2), 1 week apart, for strength and endurance of the muscle groups responsible for knee extension/flexion and elbow extension/flexion. The patients also underwent two graded exercise tests on a bicycle ergometer to measure peak oxygen consumption (VO 2peak ). Three months later, 18 of the patients underwent a third test (T3) for each of the measures. Means were compared using MANOVA with repeated measures for strength and endurance, and ANOVA with repeated measures for VO 2peak . RESULTS: Combining data for all four movement patterns, the expression of strength increased from T1 to T2 by 12% ± 25% ( P .001; intraclass correlation coefficient [ICC] = 0.89). Correspondingly, endurance increased by 13% ± 23% (P = .004; ICC = 0.87). Peak oxygen consumption was not significantly different (16.2 ± 0.8 and 16.1 ± 0.8 mL·kg -1 ·min -1 for T1 and T2, respectively; P = .686; ICC = 0.91). There were no significant differences between T2 and T3 for strength (2% ± 17%; P = .736; ICC = 0.92) or muscle endurance (-1% ± 15%;P = .812; ICC = 0.96), but VO 2peak decreased from 16.7 ± 1.2 to 14.9 ± 0.9 mL·kg -1 ·min -1 (-10% ± 18%; P = .021; ICC = 0.89). CONCLUSIONS: These data suggest that in a population of patients with CHF, a familiarization trial for skeletal muscle strength testing is necessary. Although familiarization is not required for assessing oxygen consumption as a single measurement, VO 2peak declined markedly in the 3-month period for which these patients were followed. Internal consistency within patients was high for the second and third strength trials and the first and second tests of VO 2peak .

The flutter device and expiratory pressures.

Abstract: PURPOSE Flutter therapy uses a handheld instrument that consists of a pipe-like device with a ball in the central core that oscillates during exhalation, providing oscillating positive expiratory pressure. The purpose of this study was to determine the effect of airflow and the incline of the device at the mouth on expiratory pressure and oscillation frequency. METHODS A Flutter device was attached to a circuit that consisted of a pneumotachograph and a ventilator. The ventilator generated different flows and expiratory pressure was measured with a pressure transducer. The angles considered were +40 degrees to -40 degrees in increments of 10 degrees , with the reference for incline being the horizontal line. Expiratory pressure, airflow, angle of incline, and oscillation frequency were measured. RESULTS There was a strong and significant correlation between flow and expiratory pressure at each level of incline (P 0.93). There also was a significant and strong correlation between expiratory pressure and oscillation frequency (P <.05; r = 0.81-0.97). There was a significant reduction in expiratory pressure at a negative incline of -40 degrees. CONCLUSIONS The results of this study indicate that a positive incline and a large airflow result in an increase in expiratory pressure. This information will assist clinicians to better understand the effects of the Flutter device.

Relationship between the Minnesota Living With Heart Failure Questionnaire and key ventilatory expired gas measures during exercise testing in patients with heart failure.

Abstract: PURPOSE This study assessed the relationship between the Minnesota Living With Heart Failure Questionnaire (MLWHFQ) and key ventilatory expired gas measures during a symptom-limited exercise test in the heart failure (HF) population. Specifically, is there evidence to indicate that perceived quality of life (QOL) influences exercise performance independent of physiologic function in the HF population? METHODS Thirty-one subjects (21 male/10 female), diagnosed with compensated HF, underwent exercise testing and completed the MLWHFQ. Mean age and left ventricular ejection fraction were 52.8 years and 27.2%, respectively. Partial correlation, controlling for age and sex, assessed the relationship between MLWHFQ (overall and subscores) and key ventilatory expired gas measures. Intraclass correlation coefficient (ICC) analysis was used to determine reliability of the MLWHFQ. RESULTS MLWHQ overall score (mean = 38.9, median = 36.0), physical subscore (mean = 14.8, median = 16.0), and psychosocial/symptomatology subscore (mean = 24.1, median = 19.0), were significantly correlated (P < or =.05) with peak oxygen consumption (VO2). The relationship between MLWHFQ and the minute ventilation-carbon dioxide production (VE/VCO2) slope was, however, not significant. ICC analysis revealed high reliability (0.95) for the MLWHFQ. CONCLUSIONS The MLWHFQ demonstrates a significant relationship with peak VO2, a measure whose validity is dependent upon subject effort. VE/VCO2 slope, which is independent of subject effort and therefore potentially a better predictor of true physiologic function, does not appear to have a relationship with perceived QOL. These findings have implications for how the MLWHFQ is assessed, related to an exercise test, and used during clinical practice.

Effects of cardiac rehabilitation on self-reported health status after coronary artery bypass surgery.

Abstract: PURPOSE To examine the effectiveness of cardiac rehabilitation on health status following coronary artery bypass surgery. METHODS A prospective cohort study of patients having coronary artery bypass surgery at 14 centers in the state of Washington. Baseline clinical and demographic data were collected, as was information from the Rand Short Form, 36 (SF-36), the Seattle Angina Questionnaire, and other questions regarding health status before surgery and at 6 and 12 months after surgery. In the 12-month follow-up survey, subjects were asked to complete questions pertaining to their participation in postdischarge cardiac rehabilitation programs. RESULTS A total of 947 subjects from 13 centers received 1-year follow-up surveys, with 75% responding. Of these, 691 (95%) answered questions about participation in cardiac rehabilitation programs. SF-36 and Seattle Angina Questionnaire scores improved significantly after surgery for both cardiac rehabilitation participants and nonparticipants. Although more than 90% of subjects who participated in the cardiac rehabilitation programs stated that they were beneficial, for eight SF-36 domains and five Seattle Angina Questionnaire domains, no significant associations were found with participation in cardiac rehabilitation. When the participation status was defined as only those participants who completed at least 8 weeks of cardiac rehabilitation, only 1 of 13 health status domains favored cardiac rehabilitation. Responses to a series of questions about perceptions of change in general and cardiac-specific health did not differ among participants and nonparticipants. CONCLUSIONS Although patients report favorable impressions of cardiac rehabilitation after coronary artery bypass surgery, it does not appear to provide a measurable benefit in self-reported health status beyond that achieved from the revascularization procedure itself.

Assessing inpatient pulmonary rehabilitation using the patient's view of outcome.

Abstract: patient'spatient'sviewof outcome inpulmonary rehabilitation 14557.11 Abstract Purpose:Purpose:Assessmentofthepatient'sviewofoutcomeshouldcomplementstandardizedevaluationnmethods,especiall yi nmultiinterventio nrehabilitationprogrammes.Assessmentoffindividualizedoutcomeshasnotbeenusedpreviouslyinpulmonaryrehabilitationstudies..Thereforew edevelopedamethodforassessingth epatient'sviewofoutcome.Methods:Methods:Patientsandtheirtherapistsscoredthesubjectiveattainmentlevelofindividualizeddtreatmentgoalsonasixpointresponsescale.Meanattainmentscores,sensitivityyt ochange,reliabilityandvaliditywerecomputed.Results:Results:79patients(20wit hasthmaand59withchronicobstructivepulmonarydisease)whooparticipatedi na ninpatien tpulmonaryrehabilitationprogramhad54 0treatmen tgoals(rangee21 2goalsperpatient).Thepatientshadasignificantlyhighermedianattainmentscoreetha nth emaintherapists(5versus4 ,n = 286 ,p<0.0001).Sensitivityt ochangeo ftheattainmenttscoresfrompatientswasveryhigh.Thepatients(n= 42 )hadastandardizedresponseemeanof3.57fortheattainmentscores,ascompare dt o1.01forthetotalscoreoffth eQualityo fLifefo rRespiratoryIllnessQuestionnaire.Attainmentscoreso ftreatmentgoalsswit hatleast1 0occurrence swer esignificantlycorrelatedwit hcloselyrelatedexternaloutcomes..Interrateragreementsbetweenpatientsandtherapistsaswellasamongtherapistsswerelow(weightedkappa<0.35).Conclusions:Conclusions:Thepatient'svie wwasusedt odescribeth eoutcomeo finpatientpulmonaryrehabilitation..Attainmentscoringhasa highsensitivityt ochangeandasatisfyingvalidity.Theelowreliabilitybetweentheindividual'spointofviewandthatofthetherapistnecessitateeacleardescriptionofthedifferentlevelsofexpectedoutcome.Theindividualizeddgoalattainmen tmethodseemsa promisin gcomplementar ywa yo fevaluatingpulmonaryyrehabilitation7.22 Introduction Patientsswit hasthmao rchronicobstructivepulmonarydisease(COPD)oftenexperiencesevereedisabilitie san dhandicap sdespit eoptima lmedicaltreatment .Outpatien tpulmonaryrehabilitationnhasprove nt ob ea neffectiv etreatmentinmos to fthes epatient s[ 1] .Standar dtreatmenttprogrammesarehowevernotsufficientinseverelyimpairedpatients[2]whohaveea nunstabl ediseas epatter nand/o ra hig hburde no fdisease ,characterize db yfrequenthospitalization,,ahighmedicationusage,somaticcomorbidityand/orseveredeconditioning..Thesomaticseverityisofte ncomplicatedbypsychosocialproblemssuchassanxiety ,depression ,relationa land/o roccupationa lproblems.Standardize dprogrammes,suchhasmos toutpatientandhomerehabilitationprogrammes[36],maynotmeetal lthe