Community-based Exercise Training Research Articles

Cost-effectiveness analysis of a cardio-oncology rehabilitation framework compared to an exercise intervention for cancer survivors with high cardiovascular risk.

A cardio-oncology rehabilitation model among cancer survivors showed superior results comparing to a community-based exercise intervention. However, questions remain about its cost-effectiveness. To assess the cost-effectiveness of a center-based cardiac rehabilitation (CBCR) program when compared to usual care encompassing a community-based exercise training (CBET), among cancer survivors with high cardiovascular risk. The CORE study was a single-center, prospective, randomized controlled trial; 80 adult cancer survivors with previous exposure to cardiotoxic cancer treatment and/or with previous cardiovascular disease were assigned (1:1 ratio) to an 8-week CBCR or CBET, twice/week. Cost-effectiveness was a pre-specified secondary endpoint. Outcomes included healthcare resource use and costs, quality-adjusted life-years (QALYs) and cost-effectiveness; incremental cost-effectiveness ratio (ICER) was computed from a societal perspective. 75 patients completed the study (CBCR N=38; CBET N=37). The CBCR had significantly higher cost per patient (477.76 ± 39.08€) compared to CBET group (339.32 ± 53.88€), with a significant between-group difference 138.44€ (95% CI, 116.82 to 160.05€, p<0.01). A between-group difference by 0.100 points in QALYs was observed, favouring the CBCR (95% CI, -0.163 to -0.037, p=0.002). When CBCR was compared with CBET, the ICER was €1,383.24 per QALY gained; at a willingness-to-pay threshold of €5,000 per QALY, the probability of CBCR being cost-effective was 99.9% (95% CI, 99.4 to 100.0). The CORE trial shows that a CBCR is a cost-effective intervention in the management of cancer survivors with high cardiovascular risk, reinforcing the potential benefits of this multidisciplinary approach in supportive care of this specific subset of cancer patients.

Cardio-Oncology Rehabilitation for Cancer Survivors With High Cardiovascular Risk

Cardiovascular disease is a leading cause of morbidity in cancer survivors, which makes strategies aimed at mitigating cardiovascular risk a subject of major contemporary importance. To assess whether a center-based cardiac rehabilitation (CBCR) framework compared with usual care encompassing community-based exercise training (CBET) is superior for cardiorespiratory fitness improvement and cardiovascular risk factor control among cancer survivors with high cardiovascular risk. This prospective, single-center, randomized clinical trial (CORE trial) included adult cancer survivors who had exposure to cardiotoxic cancer treatment and/or previous cardiovascular disease. Enrollment took place from March 1, 2021, to March 31, 2022. End points were assessed at baseline and after the 8-week intervention. Participants were randomly assigned in a 1:1 ratio to 8 weeks of CBCR or CBET. The combined aerobic and resistance exercise sessions were performed twice a week. The powered primary efficacy measure was change in peak oxygen consumption (V̇o2) at 2 months. Secondary outcomes included handgrip maximal strength, functional performance, blood pressure (BP), body composition, body mass index (BMI; calculated as weight in kilograms divided by height in meters squared), lipid profile, plasma biomarker levels, physical activity (PA) levels, psychological distress, quality of life (QOL), and health literacy. A total of 75 participants completed the study (mean [SD] age, 53.6 [12.3] years; 58 [77.3%] female), with 38 in the CBCR group and 37 in the CBET group. Participants in CBCR achieved a greater mean (SD) increase in peak V̇o2 than those in CBET (2.1 [2.8] mL/kg/min vs 0.8 [2.5] mL/kg/min), with a between-group mean difference of 1.3 mL/kg/min (95% CI, 0.1-2.6 mL/kg/min; P = .03). Compared with the CBET group, the CBCR group also attained a greater mean (SD) reduction in systolic BP (-12.3 [11.8] mm Hg vs -1.9 [12.9] mm Hg; P < .001), diastolic BP (-5.0 [5.7] mm Hg vs -0.5 [7.0] mm Hg; P = .003), and BMI (-1.2 [0.9] vs 0.2 [0.7]; P < .001) and greater mean (SD) improvements in PA levels (1035.2 [735.7] metabolic equivalents [METs]/min/wk vs 34.1 [424.4] METs/min/wk; P < .001), QOL (14.0 [10.0] points vs 0.4 [12.9] points; P < .001), and health literacy scores (2.7 [1.6] points vs 0.1 [1.4] points; P < .001). Exercise adherence was significantly higher in the CBCR group than in the CBET group (mean [SD] sessions completed, 90.3% [11.8%] vs 68.4% [22.1%]; P < .001). The CORE trial showed that a cardio-oncology rehabilitation model among cancer survivors with high cardiovascular risk was associated with greater improvements in peak V̇o2 compared with usual care encompassing an exercise intervention in a community setting. The CBCR also showed superior results in exercise adherence, cardiovascular risk factor control, QOL, and health literacy. ClinicalTrials.gov Identifier: NCT05132998.

Protocol for Community-Based Exercise Training after Discharge from Hospital-Based Stroke Rehabilitation: A Multicenter, Randomized, Parallel-Group, Double-Blind Controlled Pilot and Feasibility Trial.

Exercise training participation of patients with stroke in the community after discharge from the hospital has many benefits for physical, social, and psychological rehabilitation and improves their quality of life. However, in the Republic of Korea, studies on stroke survivors who can participate in an exercise training program have not been conducted. This trial aims to investigate the effectiveness of exercise training programs after patients with stroke are discharged from the hospital with a doctor's note and referred to a community exercise center, as there is a lack of studies on this population. This multicenter, randomized, parallel-group, double-blind controlled pilot and feasibility trial will randomly assign 120 patients with stroke to either 8 weeks of a community-based exercise training program (experimental group) or activities of daily living (control group). The primary outcomes will be muscle strength, cardiorespiratory fitness, body composition, physical performance, and gait. The secondary outcomes will be quality of life and activities of daily living. This study's results may add new insights into the effectiveness of community-based exercise training programs after patients with stroke are discharged from the hospital with a doctor's note and referred to a community exercise center. The success of the new exercise training approach could offer valuable information for developing more inclusive protocols for patients with stroke in the future if it proves to be efficacious.

Impact of a cardio-oncology rehabilitation framework among high cardiovascular risk cancer survivors: results from the CORE trial

Abstract Funding Acknowledgements Type of funding sources: None. Background Cancer survivors are challenging patients, as they often present increased cardiovascular (CV) risk. In this background, cardio-oncology rehabilitation frameworks for specific cancer patients have been proposed. However, optimal program designs, as well as their overall safety and efficacy in different subsets of patients, are not fully ascertained. Purpose To assess the impact of a cardio-oncology rehabilitation based framework for cancer patients at increased CV risk, compared to a community-based exercise training (CBET), on cardiorespiratory fitness (CRF) and cardiovascular risk factor (CVRF) control. Methods The CORE study was a single-center, prospective, randomized controlled trial enrolling adult cancer survivors exposed to cardiotoxic cancer treatment (anthracycline, radiotherapy on thoracic wall, anti-human epidermal growth factor receptor-type 2 drugs) and/or with previous CV disease. Participants were randomized to an 8-week center-based CR program (CBCR) or CBET, twice a week. Primary endpoint was CRF (assessed by the VO2peak, derived from a symptom-limited cardiopulmonary exercise test, performed on a treadmill); secondary endpoints were physical activity [International Physical Activity Questionnaire (IPAQ)], psychosocial parameters [Hospital Anxiety and Depression Scale (HADS)], blood pressure, body composition, lipid profile and health literacy [Newest Vital Sign (NVS) questionnaire]. Results 80 patients were included (mean age 54.5±14,12, 61 women; 66% breast cancer, 27.5% lymphoma); 75 patients completed the intervention (CBCR N= 38; CBET N=37). There was a significant improvement in the CBCR compared to the CBET group in VO2peak (∆ +2.1±2.8 vs +0.8±2.5 mL.kg-1.min-1, p=0.033) and in the following outcomes: resting systolic blood pressure (p&amp;lt;0.0001); body mass index (p&amp;lt;0.0001), lean and fat body mass (p&amp;lt;0.0001), waist circumference (p&amp;lt;0.0001); total cholesterol (p =0.001), triglycerides (p =0.008) and LDL cholesterol (p =0.003); HADS Anxiety score (p =0.003) and Depression score (p =0.009), weekly physical activity levels (p&amp;lt;0.0001) and health literacy scores (p&amp;lt;0.0001). No major CV events were reported. Conclusion The CORE trial demonstrates superior results of a CBCR regarding CRF and CVRF control. Given the higher cardiovascular risk in several groups of cancer patients, our data provides novel insights into optimized preventive strategies in this complex patient population.

Impact of a COmprehensive cardiac REhabilitation framework among high cardiovascular risk cancer survivors: Protocol for the CORE trial

BackgroundCancer survivors are challenging patients, as they often present increased cardiovascular risk. In this background, cardio-oncology rehabilitation frameworks for specific cancer patients have been proposed. However, optimal program designs, as well as their overall safety and efficacy in different subsets of patients, are not fully ascertained. DesignSingle-center, pragmatic, prospective, randomized controlled trial performed in Portugal aiming to evaluate the impact of a center-based cardiac rehabilitation program, consisting of exercise training, nutritional counselling, psychosocial management and lifestyle behavior change, compared to community-based exercise training, in cancer survivors. MethodsAdult cancer survivors (N = 80) exposed to cardiotoxic cancer treatment and/or with previous cardiovascular disease will be randomized (1:1) to receive either an eight-week cardiac rehabilitation program or community-based exercise training. Primary endpoint is cardiorespiratory fitness; secondary endpoints are physical activity, psychosocial parameters, blood pressure, body composition, lipids and inflammatory parameters. Physical function, quality of life, fatigue, health literacy, and feasibility will be assessed; a cost-effectiveness evaluation will also be performed. Between-group differences at baseline and in the change from baseline to the end of the study will be tested with unpaired t-tests or Mann-Whitney U test. Paired t-tests or Wilcoxon signed-rank test will be performed for within-group comparisons. ConclusionThis trial will address the overall impact of a contemporary cardiac rehabilitation program framework in cancer survivors, as compared to a community-based exercise training. Given the higher cardiovascular risk in several groups of cancer patients, our results could provide novel insights into optimized preventive strategies in this complex patient population.

Perceptions of wellbeing and quality of life following participation in a community-based pre-operative exercise programme in men with newly diagnosed prostate cancer: A qualitative pilot study.

BackgroundMen with a newly diagnosed prostate cancer are often treated by surgery. The time window between cancer diagnosis and surgery causes high levels of uncertainty and stress, which negatively impact quality of life (QoL). We previously reported a larger intervention pilot study which demonstrated that participation in a community-based pre-operative exercise programme significantly improved physical fitness and health-related quality of life in men with prostate cancer prior to surgery. The aim of the current pilot study was to get an insight into men’s perceptions of wellbeing and QoL following completion of the pre-operative exercise programme.MethodsFrom November 2017 to June 2018, men scheduled for prostate cancer surgery were recruited and took part in a prescribed community-based pre-operative exercise programme in the time available between referral and surgery. Following completion of the pre-operative exercise programme (within 1 week before surgery), participants took part in one semi-structured interview which explored four broad QoL domains: physical, psychological, social, and spiritual wellbeing. Data were analysed using thematic analysis (a bottom up/inductive analysis).ResultsEleven men were recruited: mean standard deviation (SD) age was 60 ± 7 years. Data supported four main themes. Participation in the community-based pre-operative exercise training programme (over a mean (SD) of 4 ± 2 weeks) provided participants with: 1) a teachable moment; 2) a journey of preparation; 3) a sense of optimism; and 4) social connectedness prior to surgery.ConclusionThis study provides an insight into how the exercise programme impacted wellbeing and QoL in men preparing for prostate cancer surgery. These findings highlight the important role that exercise prehabilitation plays for men preparing for prostate cancer surgery. Such exercise programmes can be easily implemented into standard cancer pathways by establishing relationships between hospital teams and community exercise programmes.

High versus Low-Moderate Intensity Exercise Training Program as an Adjunct to Antihypertensive Medication: A Pilot Clinical Study.

Objective: In this pilot clinical study we investigated the effect on blood pressure (BP) of two community-based exercise training programs of high (HIT) vs. low-moderate intensity (LMIT) in hypertensive individuals receiving at least one antihypertensive drug. Methods: The study included two phases of physical exercises based on 1-h session, 3 days/week for 12 and 16 weeks, respectively, separately by a 7-week resting period. Each phase was preceded by a four-week conditioning training period. According to the average maximal heart rate at baseline, participants were randomized to HIT (80–90%), LMIT (50–70%) or no-exercise (control). Heart rate was monitored during workout and BP profiles were registered by ambulatory BP monitoring at the beginning and end of each phase. Results: Of 60 individuals randomized, 44 completed the study (HIT, n = 10; LMIT, n = 16; controls, n = 18). BP levels were significantly reduced after the second phase for both LMIT (SBP −3.1 mmHg, DBP −2.4 mmHg) and HIT (SBP −10.8 mmHg, DBP −8.3 mmHg). Similar levels of improvement were also found in daytime and night-time BP. Mean attendance of the prescribed training sessions was 87.4 ± 6.2% for HIT and 87.4 ± 5.3% for LMIT during the first phase and 84.1 ± 5.0% and 85.2 ± 5.9% during the second phase, respectively (p = 0.047). Conclusion: Both HIT and LMIT exercise training programs reduced BP but the HIT modality showed a lower rate of compliance with proposed training schedule. Intensity of training should be individually prescribed to improve tolerance to more high intensity exercises.

Exercise Training Improves Microvascular Function in Burn Injury Survivors.

Vasodilator function is impaired in individuals with well-healed burn injuries; however, therapeutic interventions that lessen or reverse this maladaptation are lacking. The purpose of this study was to test the hypothesis that a 6-month community-based exercise training program would increase microvascular dilator function in individuals with well-healed burn injuries, irrespective of the magnitude of the injured body surface area. Further, we hypothesize that macrovascular dilator function would remain unchanged posttraining. Microvascular function (forearm reactive hyperemia), macrovascular function (brachial artery flow-mediated dilation), and the maximal vasodilatory response after ischemic handgrip exercise (an estimate of microvascular remodeling) were assessed before and after exercise training in nonburned control subjects (n = 11) and individuals with burn injuries covering a moderate body surface area (26% ± 7%; n = 13) and a high body surface area (59% ± 15%; n = 19). Peak vascular conductance and area under the curve during postocclusive reactive hyperemia increased from pretraining to posttraining in control and burn injury groups (both P < 0.05), the magnitude of which did not differ between groups (both P = 0.6). Likewise, the maximal vasodilatory response after ischemic handgrip exercise increased in all groups after exercise training (P < 0.05). Macrovascular dilator function did not differ across time or between groups (P = 0.8). These data suggest that a community-based exercise training program improves microvascular function in individuals with well-healed burn injuries, which may be due in part to vascular remodeling.

Effects Of Community-based Exercise Training And Detraining On Hemodynamic Variables In Older Women: Role Of Intensity And Modality

Regular exercise is associated with a reduced risk of developing chronic diseases and improved physical capacity. However, to our knowledge, the effects of modality, intensity and consequences of detraining have not yet been investigated in the elderly population. We sought to evaluate and compare the effect of modality and intensity (moderate intensity continuous aerobic training - MICT, high intensity interval aerobic training - HIIT, resistance training - RT, or combined - MICT + RT and HIIT + RT) of a training program. on the behavior of hemodynamic and functional variables of elderly women after 12 weeks of training and 16 weeks after their interruption. PURPOSE: To verify the effect of exercise modality and intensity on the hemodynamic variables of the elderly. METHODS: 69 elderly women (69.19 ± 7.89 years) were randomized into MICT (n = 29), RT (n = 15), MICT + RT (n = 12), and HIIT + RT (n = 13). Participants performed physical exercises twice a week during 60 minutes. The variables investigated were blood pressure (BP), heart rate (HR), abdominal circumference (AC) at pre, after 12 weeks of intervention, and after 16 weeks of training interruption (detraining). RESULTS: Diastolic blood pressure decreased in HIIT + RT between pre and untrained (p <0.01) and in RT between post and untrained (p <0.02). There was a significant increase in HR between post and detraining MICT (p <0.02) and a decrease in MICT + RT between pre and post training (p <000), with no significant difference in detraining. AC decreased in HIIT + RT between pre and post (p <0.01), in RT between pre and detraining (p <0.009) and post and detraining (p <0.00). There was an increase in post and detraining WC for MICT (p <0.05) and MICT + RT (p <0.03). CONCLUSION: Isolated or combined aerobic training can be effective in reducing blood pressure levels. Resistance training was also effective for reducing abdominal fat levels.Table 1.: Blood pressure, heart rate and abdominal circumference during follow-up

A Randomized Community-based Exercise Training Trial in African American Men: Aerobic Plus Resistance Training and Insulin Sensitivity in African American Men.

To examine the impact of a community-based exercise training intervention on cardiometabolic outcomes in African American men who have a family history of type 2 diabetes. The Aerobic Plus Resistance Training and Insulin Sensitivity in African American Men (ARTIIS) study randomized participants into either an exercise training intervention or an information only control group for 5 months. The exercise training intervention consisted of 150 min of moderate intensity aerobic activity and 2 d of resistance training per week, consistent with the current federal physical activity guidelines. Participants in the control group received monthly newsletters featuring topics focused heavily on type 2 diabetes education and prevention. Outcome data were analyzed using repeated-measures ANCOVA models and incorporating both intention-to-treat and per-protocol principles. Adherence to the aerobic and resistance training prescriptions were between 77% and 79%. Despite significant within group improvements in glucose and insulin levels (fasting, 2 h, 2 h minus baseline) and Homeostatic Model 2-Insulin Resistance, there were not significant between group differences. There was a marginally significant between group difference for Homeostatic Model 2-Beta (P < 0.06), and significant between group differences in peak cardiorespiratory fitness (P < 0.001) and waist circumference (P = 0.03). These findings suggest that exercise training in accordance with the current national recommendations is effective in improving some health parameters in middle-age African American men who have a family history of type 2 diabetes, but did not have a significant impact on glycemic status.

Progressive exercise training improves maximal aerobic capacity in individuals with well-healed burn injuries.

Long-term rehabilitative strategies are important for individuals with well-healed burn injuries. Such information is particularly critical because patients are routinely surviving severe burn injuries given medical advances in the acute care setting. The purpose of this study was to test the hypothesis that a 6-mo community-based exercise training program will increase maximal aerobic capacity (V̇o2max) in subjects with prior burn injuries, with the extent of that increase influenced by the severity of the burn injury (i.e., percent body surface area burned). Maximal aerobic capacity (indirect calorimetry) and skeletal muscle oxidative enzyme activity (biopsy of the vastus lateralis muscle) were measured pre- and postexercise training in noninjured control subjects (n = 11) and in individuals with well-healed burn injuries (n = 13, moderate body surface area burned; n = 20, high body surface area burned). Exercise training increased V̇o2max in all groups (control: 15 ± 5%; moderate body surface area: 11 ± 3%; high body surface area: 11 ± 2%; P < 0.05), though the magnitude of this improvement did not differ between groups (P = 0.7). Exercise training also increased the activity of the skeletal muscle oxidative enzymes citrate synthase (P < 0.05) and cytochrome c oxidase (P < 0.05), an effect that did not differ between groups (P = 0.2). These data suggest that 6 mo of progressive exercise training improves V̇o2max in individuals with burn injuries and that the magnitude of body surface area burned does not lessen this adaptive response.

Feasibility and Effectiveness of Community-Based Virtual Reality Group Exercise Training in Persons with Spinal Cord Injury

Persons with spinal cord injury (SCI) are at an increased risk of physiological morbidity compared to their ambulatory counterparts in whom well-established, beneficial correlations exist between exercise, cardiorespiratory health and body composition. Furthermore, SCI who participate in sport may have reduced risk of physiological morbidity than SCI who are sedentary. PURPOSE: This pilot study was two-fold: 1) to determine whether differences exist in cardiorespiratory health and body composition between SCI athletes (ATHL) and sedentary SCI (SED), and 2) to determine whether an 8-week handcycle exercise training program is feasible in an SED SCI population, and if improvements in cardiorespiratory fitness and body composition occur. METHODS: Twenty-seven SED and six ATHL were recruited to participate in the study. All SCI completed a graded hand cycling maximal exercise test for cardiorespiratory fitness (VO2max) and body composition testing (iDEXA). SED participants were then randomized into a virtual reality intervention (VR) or waitlist (WL) group (e.g. offered VR after 8 weeks of WL). The intervention consisted of an 8-week community-based VR group hand cycling exercise training with a USA level 1 coach two days/week. Pre-post outcomes were measured in each group. RESULTS: Thirty-three SCI were recruited to participate (SED n=27; ATHL n=6). All ATHL and 17 SED participants (VR=9, WL=8) completed study protocol, with 10 (VR=1 and WL=9) lost to follow up. One participant was dropped from analysis due to not giving a full effort during testing as determined by investigators. ATHL had 23 physiological and anthropometric variables that were significantly different (p≤0.01) compared to SED including higher VO2max (19.1 ml/kg/min), lower BMI (-4.6 kg/m2), and lower total body fat percentage (-10.4%). VO2max increased 16% in VR and 9% in WL, which was not statistically different. CONCLUSION: This study demonstrates the feasibility of a hand cycling program in SCI. ATHL had better outcomes associated with long term health compared to their SED counterparts. Though no significant changes were noted in VR compared to WL, changes in VO2max may be clinically relevant. A larger sample size or longer training period may be needed to observe significant differences in physiological health in an SED SCI population.

97 Six Months of Exercise Training and Aerobic Capacity in Well-Healed Burn Survivors: Effect of Body Surface Area Burned

Aerobic exercise is an important component towards the full rehabilitation of burn survivors, yet aerobic capacity is reduced in this population. No studies have examined the benefits of long-term aerobic exercise training in well-healed burn survivors, particularly stratified by the severity of the burn injury. This study tested the hypothesis that a community-based 6-month exercise training regimen would improve aerobic capacity in burn survivors, with the magnitude of this improvement being influenced by body surface area (BSA) burned. Eleven unburned control subjects (34±8 y), 12 low BSA burn survivors (38±14 y; 27±7% BSA burned), and 11 high BSA burn survivors (39±12 y; 58±16% BSA burned) participated in a 6-month community-based aerobic exercise training regimen. Burn survivors were assessed a minimum of 2 years after the injury. Both prior to and after this exercise regimen, subjects performed steady-state cycle exercise (50 and 75 Watts) and two graded maximal cycle exercise tests, where maximal oxygen uptake (VO2max) was obtained. For both pre- and post-training periods, the greater of the two VO2max values was selected and analyzed. Exercise training improved VO2max in all groups (Control: 2.94±0.76 to 3.19±0.61 L/min; low burned: 2.24±0.52 to 2.48±0.54 L/min; high burned: 2.47±0.50 to 2.54±0.48 L/min; P<0.001 main effect of pre/post training), without any differences in the magnitude of the improvement between groups (P=0.27 for the interaction). Perhaps equally important was a ~10 beat per min lowering of heart rate post-exercise training in all groups during steady-state exercise of 50 and 75 Watts, demonstrating lower cardiovascular stress post-training at workloads that approximate activities of daily living (e.g., ~2 to 4 METS). These data demonstrate that well-healed burn survivors have the capability to appropriately improve their aerobic capacity through an aggressive long-term exercise training regimen. Counter to our hypothesis, there was no difference between the magnitude of the improvements in VO2max and the percent BSA burned, though the high burn group had an appreciably lower mean elevation in VO2max post-training. As a population, burn survivors have a reduced aerobic capacity relative to unburned peers, with these lower values being related to higher morbidity and all-cause mortality. Thus, without an intervention to improve aerobic capacity, burn survivors will experience the negative sequelae associated with a sedentary lifestyle. The present data demonstrate that burn survivors generally have the capability to improve their aerobic capacity via a long-term aerobic exercise regimen. Funded by: NIH - GM68865

Experience Implementing Supervised Exercise Therapy for Peripheral Artery Disease.

Supervised exercise therapy (SET) is a cornerstone of treatment for improving walking distance for individuals with symptomatic peripheral artery disease and claudication. High quality randomized controlled trials have documented the efficacy of SET as a claudication treatment and led to the recent Centers for Medicare and Medicaid decision to cover supervised exercise therapy (SET). However, to date, the translation of highly controlled, laboratory based SET programs in real world cardiopulmonary rehabilitation settings has been unexplored. In this article, we describe our experience integrating SET into existing cardiopulmonary rehabilitation programs, focusing on patient evaluation, exercise prescription, outcome assessments, strategies to maximize program adherence, and transitioning to home and community-based exercise training. Our team has over 3 years experience successfully implementing SET in cardiac rehabilitation settings. The experiences communicated within can serve as a model for rehabilitation therapists to follow as they begin to incorporate SET in their rehabilitation programs. CMS reimbursement has the potential to change clinical practice and utilization of SET for patients with symptomatic peripheral artery disease. The experience we have gained through implementation of SET programs across the M Health and Fairview Health Systems and in other Minnesota communities, including specific elements in our programs and the lessons learned from our clinical experience, can inform and help to guide development of new programs. The recent Centers for Medicare and Medicaid decision to cover supervised exercise therapy (SET) for beneficiaries with peripheral artery disease (PAD) has the potential to transform practice. In this article, we describe our experience integrating SET into existing cardiopulmonary rehabilitation programs, which could serve as a model for new programs.

Commentary on “Group-Based Exercise Combined with Dual-Task Training Improves Gait but not Vascular Health in Active Older Adults without Dementia” - Missed Opportunities for Mediation Analyses

This commentary considers the implications of the findings related to the effect of a community-based, multiple modality and dual-task exercise training program in the Archives of Gerontology and Geriatrics. Findings from this study suggest that participants who performed the multiple modality and dual-task exercise intervention experienced greater improvements in global cognition, greater elevations in dual-task gait speed and dual-task step-length and greater reductions in dual-task stride time variability when compared to participants who did not perform the dual-task component of the exercise training program. The ability of exercise to impart cognitive and other physiological benefits has been long understood; however, the mechanisms that facilitate these training-induced improvements remain elusive. Mediation analyses provide a unique avenue to investigate the relationship between various physiological measures and can provide insight related to the causal sequence that drives the beneficial physiological and psychological response to an intervention. Recent works have incorporated mediation analyses within their study designs and the insight provided therein has revealed a number of intriguing intricacies with respect to cognition in aging and the effect of exercise on the body and brain. Mediation analyses are rarely utilized in neurophysiological research; however, the complex phenomenological relationships that can be revealed using this method will be crucially required for the identification of factors responsible for improvements in cognition following pharmacological or lifestyle-based interventions, and the development of effective management strategies for older adults with cognitive impairment.

Building consensus for provision of breathlessness rehabilitation for patients with chronic obstructive pulmonary disease and chronic heart failure.

The study aimed to gain consensus on key priorities for developing breathlessness rehabilitation services for patients with chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF). Seventy-four invited stakeholders attended a 1-day conference to review the evidence base for exercise-based rehabilitation in COPD and CHF. In addition, 47 recorded their views on a series of statements regarding breathlessness rehabilitation tailored to the needs of both patient groups. A total of 75% of stakeholders supported symptom-based rather than disease-based rehabilitation for breathlessness with 89% believing that such services would be attractive for healthcare commissioners. A total of 87% thought patients with CHF could be exercised using COPD training principles and vice versa. A total of 81% felt community-based exercise training was safe for patients with severe CHF or COPD, but only 23% viewed manual-delivered rehabilitation an effective alternative to supervised exercise training. Although there was strong consensus that exercise training was a core component of rehabilitation in CHF and COPD populations, only 36% thought that this was the ‘most important’ component, highlighting the need for psychological and other non-exercise interventions for breathlessness. Patients with COPD and CHF face similar problems of breathlessness and disability on a background of multi-morbidity. Existing pulmonary and cardiac rehabilitation services should seek synergies to provide sufficient flexibility to accommodate all patients with COPD and CHF. Development of new services could consider adopting a patient-focused rather than disease-based approach. Exercise training is a core component, but rehabilitation should include other interventions to address dyspnoea, psychological and education needs of patients and needs of carers.

Independent, Community-Based Aerobic Exercise Training for People With Moderate-to-Severe Traumatic Brain Injury

ObjectiveTo determine whether people with moderate-to-severe traumatic brain injury (TBI) can adhere to a minimally supervised, community-based, vigorous aerobic exercise program. DesignProspective trial. SettingYoung Men's Christian Association (YMCA) facilities. ParticipantsCommunity-dwelling volunteers (N=10; 8 men, 2 women; age range, 22–49y) 6 to 15 months after moderate-to-severe TBI. InterventionParticipants received memberships to local YMCAs and brief orientations to exercise. They were then asked to independently complete ≥12 weeks of ≥3 training sessions per week, performed at 65% to 85% of maximum heart rate for ≥30 minutes per session. Participants could self-select exercise modality, provided they met intensity and duration targets. Programmable heart rate monitors captured session intensity and duration. Main Outcome MeasuresIndependence with equipment and facility use and compliance with training goals (session frequency, duration, intensity, total weeks of training). ResultsAll participants achieved independence with equipment and facility use. All met at least 2 of 4 training goals; half met all 4 goals. Participants averaged (±SD) 3.3±0.7 sessions per week for 13 weeks (range, 6–24). Average ± SD session duration was 62±23 minutes, of which 51±22 minutes occurred at or above individuals' heart rate training targets. ConclusionsPeople in recovery from moderate-to-severe TBI can, with minimal guidance, perform vigorous, community-based exercise. This suggests that decentralized exercise may be logistically and economically sustainable after TBI, expanding its potential therapeutic utility and rendering longer-duration exercise studies more feasible.

Fitness outcomes from a randomised controlled trial of exercise training for men with prostate cancer: the ENGAGE study.

PurposeThe main purpose of this study was to investigate the effects of a 12-week, clinician-referred, community-based exercise training program with supervised and unsupervised sessions for men with prostate cancer. The secondary purpose was to determine whether androgen deprivation therapy (ADT) modified responses to exercise training.MethodsSecondary analysis was undertaken on data from a multicentre cluster randomised controlled trial in which 15 clinicians were randomly assigned to refer eligible patients to an exercise training intervention (n = 8) or to provide usual care (n = 7). Data from 119 patients (intervention n = 53, control n = 66) were available for this analysis. Outcome measures included fitness and physical function, anthropometrics, resting heart rate, and blood pressure.ResultsCompared to the control condition, men in the intervention significantly improved their 6-min walk distance (M diff = 49.98 m, p adj = 0.001), leg strength (M diff = 21.82 kg, p adj = 0.001), chest strength (M diff = 6.91 kg, p adj = 0.001), 30-s sit-to-stand result (M diff = 3.38 reps, p adj = 0.001), and reach distance (M diff = 4.8 cm, p adj = 0.024). A significant difference (unadjusted for multiplicity) in favour of men in the intervention was also found for resting heart rate (M diff = −3.76 beats/min, p = 0.034). ADT did not modify responses to exercise training.ConclusionsMen with prostate cancer who act upon clinician referrals to community-based exercise training programs can improve their strength, physical functioning, and, potentially, cardiovascular health, irrespective of whether or not they are treated with ADT.Implications for Cancer SurvivorsClinicians should inform men with prostate cancer about the benefits of exercise and refer them to appropriately qualified exercise practitioners and suitable community-based programs.Trial registrationAustralia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12610000609055

Effects of community-based exercise in children with severe burns: A randomized trial

ObjectiveTo counteract long-lasting muscle break down, muscle weakness, and poor physical fitness resulting from severe burns, we recommend a 12-week in-hospital exercise training rehabilitation program. Unfortunately, this in-hospital training program requires time away from home, family, school or work. This study was undertaken to evaluate an alternative exercise rehabilitation strategy involving a 12-week community-based exercise training rehabilitation program (COMBEX) carried out at or near the patient and caretaker's home. Study design and participantsPediatric patients (7–18 years) with ≥30% of total body surface area (TBSA) burns were randomized to participate in COMBEX (N=12) or an outpatient exercise program (EX) at the hospital (N=22). Both programs were started after hospital discharge and consisted of 12 weeks of progressive resistive and aerobic exercise. COMBEX was performed in community fitness centers near the patients’ home. Endpoints were assessed at discharge (pre-exercise) and after the 12-week program. Primary endpoints were lean body mass (dual energy X-ray absorptiometry), muscle strength (isokinetic dynamometry), and peak aerobic capacity (indirect calorimetry). ResultsDemographics, length of hospitalization, and TBSA burned were comparable between groups (P>0.05). Both groups exhibited a significant (P≤0.01 for all) increase (mean±SEM) in lean muscle mass (EX: 6.9±1.7%; COMBEX: 6.5±1.1%), muscle strength (EX: 67.1±7.0%; COMBEX: 49.9±6.8%), and peak aerobic capacity (EX: 35.5±4.0%; COMBEX: 46.9±7.7%). Furthermore, the magnitude of these increases were not different between groups (P>0.12). ConclusionsBoth EX and COMBEX are efficacious in improving lean mass, strength, and cardiopulmonary capacity in severely burned children.

Metabolic Syndrome (MetS) in an HIV Cohort on Antiretroviral Therapy (ART)

ObjectiveThe purpose of this study was to evaluate the prevalence of MetS characteristics, and factors associated with the presence of MetS, in 89 people living with HIV (PLWH) on ART enrolled in a community‐based exercise training and nutrition education program targeting individuals of low socioeconomic status.ResultsOne in three PLWH met Adult Treatment Panel (ATP) III criteria for MetS and it was mostly due to high waist circumference and elevated blood pressure. Higher use of protease inhibitors, elevated hemoglobin A1C (HbA1c), greater self‐reported daily caloric intake and consumption of carbohydrates, sugar, added sugar, and higher glycemic load were found among the individuals with MetS, compared to those without it. Elevated HbA1c and high total sugar consumption were the strongest predictors and accounted for 30% of the occurrence of MetS.ConclusionsThe overall prevalence of MetS observed was higher than previously reported in the general population and other PLWH cohorts. Additional work is needed to determine whether MetS is a more disease/treatment or lifestyledependent condition in PLWH. This material is based on work supported by AstraZeneca HealthCare Foundation's Connections for Cardiovascular Health SM(CCH) program.