Exercise Outcomes after Pulmonary Rehabilitation Depend on the Initial Mechanism of Exercise Limitation Among Non-oxygen-dependent COPD Patients. Plankeel JF, McMullen B, MacIntyre NR. Reprinted with permission from Chest. 2005;127:110-116. © 2005 American College of Chest Physicians.
Study Objectives: Pulmonary rehabilitation (PR) that includes exercise training can improve exercise tolerance and quality of life for patients with COPD. However, the degree of benefit from PR is variable. We hypothesized that the exercise response to PR varies depending on the initial factors that limit exercise. Design, Setting, Participants, and Measurements: We retrospectively analyzed the change in exercise capacity after PR in 290 nonhypoxemic patients with COPD. We classified patients into the following subgroups based on the primary limitation seen on initial exercise testing: (1) ventilatory-limited (VL); (2) cardiovascular-limited (CVL); (3) mixed ventilatory/cardiovascular-limited (VLCVL); and (4) non-cardiopulmonary-limited (NL). We compared outcomes among subgroups. Results: In the entire study population, PR led to increased timed walk distance (30.3%; P
It has been shown previously that the outcomes of pulmonary rehabilitation differ greatly depending on the specific limitation to exercise initially seen in patients with pulmonary diseases. In this study, the authors did a retrospective analysis of a large group of participants in their pulmonary rehabilitation program. Those patients who were limited by cardiovascular deconditioning were able to improve maximal oxygen consumption much more than those who had ventilatory limitation. Interestingly, patients with ventilatory, cardiovascular, and mixed limitation to exercise all improved timed walk distance equally. This finding suggests that other mechanisms than improvement in maximal oxygen consumption contribute to improvements in walk distance, and supports the continued use of pulmonary rehabilitation for patients with all types of exercise limitation.
Health-related Quality of Life in Patients with Pulmonary Arterial Hypertension. Shafazand S, Goldstein MK, Doyle RL, Hlatky MA, Could MK. Reprinted with permission from Chest. 2004;1 26:1452-1459. © 2004 American College of Chest Physicians.
Study Objectives: Patients with pulmonary arterial hypertension (PAH) often present with dyspnea and severe functional limitations, but their health-related quality of life (HRQOL) has not been studied extensively. This study describes HRQOL in a cohort of patients with PAH. Design: Cross-sectional study. Setting: A tertiary care, university hospital-based, pulmonary hypertension (PH) clinic. Participants: We studied HRQOL in 53 patients with PAH (mean age, 47 years; median duration of disease, 559 days). Eighty-three percent were women, 53% received epoprostenol, and 72% reported moderate-to-severe functional limitations with a New York Heart Association class 3 or 4 at enrollment. Measurements and Results: We examined HRQOL by administering the Nottingham Health Profile, Congestive Heart Failure Questionnaire, and Hospital Anxiety and Depression Scale. We used the Visual Analog Scale and standard gamble (SG) techniques to measure preferences for current health (utilities). Compared with population norms, participants reported moderate-to-severe impairment in multiple domains of HRQOL, including physical mobility, emotional reaction, pain, energy, sleep, and social isolation. Mean SG utilities were 0.71, suggesting that, on average, participants were willing to accept a 29% risk of death in order to be cured of PH. Conclusions: PAH is a devastating condition that affects predominately young women in the prime of their life. Understanding HRQOL and preferences are important in the care and management of these patients. Compared with population norms, patients with PAH have substantial functional and emotional limitations that adversely affect their HRQOL.
This study examined the effect of pulmonary artery hypertension, also known as primary pulmonary hypertension, on quality of life. Factors related to the disease, such as dyspnea, anxiety, and depression, as well as adverse effects of treatment, may decrease the quality of life in these persons. When compared to norms, these patients were found to have significant impairment in their perception of health-related quality of life. They also showed a strong tendency to be willing to take significant risks in order to be cured of their disease. Few studies have examined patient perceptions in this condition and it is important to consider how adversely persons with pulmonary artery hypertension feel the disease impacts their lives.
An Assessment of Back Pain and the Prevalence of Sacroiliitis in Sarcoidosis. Erb N, Cushley MJ, Kassimos DG, Shave RM, Kitas GD. Reprinted with permission from Chest. 2005;127:192-196. © 2005 American College of Chest Physicians.
Objectives: Sarcoidosis is a chronic granulomatous multisystem disease in which arthritis is relatively common. Arthritis of the sacroiliac joints (sacroiliitis) has been described in sarcoidosis but is thought to be rare. The objective of this study was to determine the prevalence of sacroiliitis in a secondary-care population of patients with sarcoidosis. Methods: Patients attending a specialist secondary-care sarcoidosis clinic underwent evaluation of spinal symptoms using a standard back pain questionnaire, examination of spinal mobility, and laboratory measurements of erythrocyte sedimentation rate, C-reactive protein, serum angiotensin-converting enzyme, and neopterin/ creatinine ratio. Tissue typing for the presence of the human leukocyte antigen (HLA)-B27 allele was undertaken. Radiographs of the sacroiliac joints were obtained in each patient and reviewed independently by two observers; a further observer reviewed disputed radiographs. Results: Sixty-one patients completed the assessments (80.3% of all patients invited to participate). Forty-nine of 61 patients (80.3%) reported having back pain at some point in their lives. Thirty-one of 61 patients (50.8%) had a score on the back pain questionnaire suggestive of inflammatory spinal disease, but only 3 of these patients had erosive damage of the sacroiliac joints on radiography indicating sacroiliitis. One further patient had erosive damage on radiography, making a total of four individuals with evidence of sacroiliitis, a prevalence of 6.6%. Four patients (one patient with sacroiliitis) were positive for HLA-B27. The back pain questionnaire had a sensitivity of 75% and a specificity of 51% for sacroiliitis in this population. Conclusion: The prevalence of spondyloarthropathy in the normal population has been estimated to be 1.9%. In the sarcoid population studied the prevalence was 6.6% suggesting a possible association between these two conditions. The standard back pain questionnaire for the identification of inflammatory spinal disease had a low sensitivity and specificity in this population.
Sarcoidosis is a systemic disease with the most notable effects on the respiratory system. However, this study illustrates that other body systems can be, and are, affected by the disease. The finding of a higher incidence of sacroiliitis in patients with sarcoidosis illustrates the need for physical therapists to consider this systemic disease when examining patients with complaint of low back pain. Studies such as this one provide important information for the primary-care physical therapy model, as well as illustrating a little-known complication of the disease.
Endothelial Function in Coronary Arterioles from Pigs with Early-stage Coronary Disease Induced by High-fat, High-cholesterol Diet: Effect of Exercise. Henderson KK, Turk JR, Rush JW, Laughlin MH. Reprinted with permission J Appl Physiol. 2004;97:1159-1168. © 2004 American Physiological Society.
Because hypercholesterolemia can attenuate endothelial function and exercise training can augment endothelial function, we hypothesized that exercise training would improve endothelial function of coronary arterioles from pigs in the early stages of cardiovascular disease induced by a high-fat, high-cholesterol (HF) diet. Yucatan miniature swine were fed a normal-fat (NF) diet or HF diet (2% cholesterol) for 20 wk in which 8 and 46% of their calories were derived from fat, respectively. Both groups were subdivided into sedentary (Sed) or exercise-trained (Ex) groups. This resulted in four experimental groups: NFSed, NFEx, HFSed, and HFEx. Endothelial function was assessed in coronary arterioles 75-100 µm in diameter dissected from the left ventricular apex. Responses to endothelial-dependent dilation induced by bradykinin (BK), ADP, and flow were similar in all four groups, whereas dilation to aggregating platelets in the presence of indomethacin and ketanserin was attenuated in HFSed arterioles (P = 0.01). The attenuated response to aggregating platelets was prevented or reversed in HFEx arterioles (P= 0.03). In HFSed arterioles, BK induced release of an indomethacin-sensitive prostanoid constrictor. In contrast, after exercise training, there was no evidence of this constrictor and BK-induced release of an indomethacin-sensitive prostanoid dilator in HFEx arterioles (P = 0.04). Endothelial nitric oxide synthase protein in arterioles was significantly reduced in HF groups (P
This study is part of a body of work attempting to determine the mechanisms of coronary disease related to known risk factors, including a high lipid diet. Endothelial function is impaired in coronary disease and leads to lack of vasodilation of these vessels in response to stimulation by known vasodilators. Exercise training has been shown to have some protective effect on endothelial function; however, the impact on vascular function in the presence of a high-lipid diet is not fully known. The current study used a model of endurance training to determine if exercise could prevent the effects of the high-lipid diet on causing endothelial dysfunction. The finding that regular exercise can blunt or prevent the vascular dysfunction provides important support for the use of cardiac rehabilitation and other forms of exercise training in persons at risk for coronary disease due to their diets.
Anne Swisher, PT, PhD, CCS
West Virginia University
Copyright Cardiopulmonary Physical Therapy Journal Jun 2005
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