Virtual Physical Prehabilitation in Lung Transplant Candidates: A Proof-of-Concept Study.

This study aimed to preliminary test the effectiveness of 12-week virtual physical prehabilitation program followed by a maintenance phase. The main objective was to estimate the extent to which it affects exercise capacity, frailty, lower limb strength and health-related quality of life (HRQOL) in lung transplant candidates. The program offered supervised strengthening exercises, independent aerobic exercises and weekly phone calls (maintenance phase). Primary outcome was the six-minute walk distance (6MWD). Secondary outcomes: the Short Physical Performance Battery (SPPB), five-times sit-to-stand test (5STS), the St George's Respiratory Questionnaire (SGRQ) for HRQOL. Twenty patients were included (mean age 57.9; 6 women/14 men); fourteen completed the prehabilitation program and 5 completed the maintenance phase. There was no statistically significant improvement in 6MWD, SPPB or SGRQ after the 12-week program. Most patients either maintained or improved the 6MWT and SPPB scores. There was a significant improvement in the 5STS. After the maintenance phase, most patients either improved or maintained their scores in all outcomes except for the sub-score of symptoms in the SGRQ. A 12-week virtual physical prehabilitation program with a 12-week maintenance phase can help lung transplant candidates improve or maintain their physical function while waiting for transplantation.

Exercise training in solid organ transplant candidates and recipients.

PURPOSE OF REVIEW: Exercise training programs are an integral part of the management of solid organ transplantation (SOT) candidates and recipients. Despite this, they are not widely available and specific guidelines on exercise parameters for each type of organ are not currently provided. A review of this topic could help clinicians to prescribe appropriate exercise regimens for their patients. RECENT FINDINGS: In this narrative review, we discuss the physical impairments of SOT candidates and recipients and how these affect their physical function and transplant outcomes. We examine recent systematic reviews, statements, and randomized controlled trials on exercise training in SOT candidates and recipients and present the current available evidence while providing some practical recommendations for clinicians based on the frequency, intensity, time, and type principle. SUMMARY: While randomized controlled trials of better methodology quality are needed to strengthen the evidence for the effects of exercise training and for the optimal training characteristics, the available evidence points to beneficial effects of many different types of exercise. The current evidence can provide some guidance for clinicians on the prescription of exercise training for transplant candidates and recipients.

European Society of Organ Transplantation (ESOT) Consensus Statement on Prehabilitation for Solid Organ Transplantation Candidates.

There is increasingly growing evidence and awareness that prehabilitation in waitlisted solid organ transplant candidates may benefit clinical transplant outcomes and improve the patient's overall health and quality of life. Lifestyle changes, consisting of physical training, dietary management, and psychosocial interventions, aim to optimize the patient's physical and mental health before undergoing surgery, so as to enhance their ability to overcome procedure-associated stress, reduce complications, and accelerate post-operative recovery. Clinical data are promising but few, and evidence-based recommendations are scarce. To address the need for clinical guidelines, The European Society of Organ Transplantation (ESOT) convened a dedicated Working Group "Prehabilitation in Solid Organ Transplant Candidates," comprising experts in physical exercise, nutrition and psychosocial interventions, to review the literature on prehabilitation in this population, and develop recommendations. These were discussed and voted upon during the Consensus Conference in Prague, 13-15 November 2022. A high degree of consensus existed amongst all stakeholders including transplant recipients and their representatives. Ten recommendations were formulated that are a balanced representation of current published evidence and real-world practice. The findings and recommendations of the Working Group on Prehabilitation for solid organ transplant candidates are presented in this article.

Implementation and maintenance of an enhanced pulmonary rehabilitation program in a single centre: An implementation study.

BACKGROUND: Pulmonary rehabilitation (PR) has major benefits for patients with chronic obstructive pulmonary disease (COPD). An enhanced PR program was developed with a self-management education intervention. The objective of our study was to evaluate the implementation of the enhanced PR program into a single centre. METHODS: Pre-post implementation study consisted of two evaluation periods: immediately after implementation and 18 months later. Guided by the RE-AIM framework, outcomes included: Reach, Effectiveness, Adoption, Implementation and Maintenance. RESULTS: Reach: 70-75% of referred patients agreed to a PR program (n = 26). Effectiveness: Clinically important improvements occurred in some patients in functional exercise capacity (64% of the patients achieved clinical important difference in 6-min walk test in the first evaluation period and 44% in the second evaluation period), knowledge, functional status, and self-efficacy in both evaluation periods. Adoption: All healthcare professionals (HCPs) involved in PR (n = 8) participated. Implementation: Fidelity for the group education sessions ranged from 76 to 95% (first evaluation) and from 82 to 88% (second evaluation). Maintenance: The program was sustained over 18 months with minor changes. Patients and HCPs were highly satisfied with the program. CONCLUSIONS: The enhanced PR program was accepted by patients and HCPs and was implemented and maintained at a single expert center with good implementation fidelity.

User-centered design features for digital health applications to support physical activity behaviors in solid organ transplant recipients: A qualitative study.

INTRODUCTION: Digital health tools may be effective in engaging solid organ transplant (SOT) recipients in physical activity (PA). This study examined the perspectives of SOT recipients regarding PA, and desired features for digital health tools. METHODS: Semi-structured interviews were used to explore perspectives of SOT recipients about barriers and motivators to physical activity, and core features of a digital health tool to support PA. Interviews were analyzed via thematic analysis. RESULTS: Participants included 21 SOT recipients (11 men, 10 women, 21-78 years, 1.5-16 years post-transplant) from various organ groups (four heart, five kidney, five liver, three lung, and four multi-organ). Barriers to PA included risk aversion, managing non-linear health trajectories, physical limitations and lack of access to appropriate fitness training. Facilitators of PA included desire to live long and healthy lives, renewed physical capabilities, access to appropriate fitness guidelines and facilities. Desired features of a digital health tool included a reward system, affordability, integration of multiple functions, and the ability to selectively share information with healthcare professionals and peers. CONCLUSIONS: SOT recipients identified the desired features of a digital health tool, which may be incorporated into future designs of digital and mobile health applications to support PA in SOT recipients.

The effects of exercise training in adult solid organ transplant recipients: A systematic review and meta-analysis.

Reduced exercise capacity can predispose solid organ transplant (SOT) recipients to higher risk of diabetes, cardiovascular complications, and mortality and impact their quality of life. This systematic review and meta-analysis investigated the effects of exercise training (versus no training) in adult SOT recipients. We conducted an electronic search of randomized controlled trials reporting on exercise interventions in SOT recipients. Primary outcomes were exercise capacity, quadriceps muscle strength, and health-related quality of life (HRQoL). Twenty-nine articles met the inclusion criteria. In 24 studies, there were either high risk of bias or some concerns about the potential risk of bias. There was an increase in exercise capacity (VO2 peak) (SMD: 0.40; 95%CI 0.22-0.57; P = 0.0) and quadriceps muscle strength (SMD: 0.38; 95%CI 0.16-0.60; P = 0.001) in the exercise vs control groups. There were also improvements in several domains of the SF-36. Diastolic blood pressure improved in the exercise group compared to controls (SMD: -0.22; 95%CI -0.41-0.03; P = 0.02). Despite the considerable variation in exercise training characteristics and high risk of bias in the included studies, exercise training improved maximal exercise capacity, quadriceps muscle strength, HRQoL, and diastolic blood pressure and should be an essential part of the post-transplant care.

Changes in 6-minute walking distance in lung transplant candidates while participating in a home-based pre-habilitation program-A retrospective chart review.

Home-based exercise programs may offer a less costly alternative to providing exercise pre-transplant to a large number of patients. We describe the changes in 6-minute walk distance (6MWD) in lung transplant candidates who participated in a home-based exercise program and their relationship to post-transplant outcomes. Retrospectively, we investigated 159 individuals while awaiting transplantation who performed the surgery between 2011 and 2015. Primary outcome was 6MWD at time of assessment for transplant, last test prior to transplant and one-month post-transplant. 6MWD decreased by 28 ± 93.9 m between the time of assessment and the last 6MWD prior to transplantation (P < .001). Forty-one patients (25.8%) increased their 6MWD (mean + 85.8 ± 42.8 m); 72 patients (45.3%) decreased their 6MWD (mean -109.8 ± 71.2 m); and 46 patients (28.9%) had no change in 6MWD (-1.5 ± 15.7 m). There was a moderate correlation (r = .528; P < .001) between the last 6MWD prior to transplant and 6MWD post-transplant. Change in 6MWD prior to transplant weakly correlated with length of time on mechanical ventilation (r = -.185; P = .034). When adjusted for covariates, change in 6MWD prior to transplant was not associated with length of time on mechanical ventilation, total hospital LOS, or intensive care unit LOS. The majority of the patients were able to either increase or maintain their 6MWD while participating in a home-based pre-habilitation program during the waiting list period. Prospective research is needed to evaluate the effects of home-based pre-habilitation program for lung candidates.

Exercise interventions in solid organ transplant candidates: A systematic review.

INTRODUCTION: Exercise training may be recommended to solid organ transplant (SOT) candidates to improve fitness and tolerance before surgery. We aimed to determine the acceptance, safety, and effectiveness of exercise interventions in SOT candidates. METHODS: Online databases were searched. Studies of any design were included. Outcomes of interest were acceptance, safety, exercise capacity, and health-related quality of life. RESULTS: Twenty-three articles were included. Acceptance ranged from 16% to 100%. In the fifteen studies that assessed adverse events, none mentioned any adverse events occurring during the study. Five out of seven studies reported an increase in maximal exercise capacity post-exercise in the intervention group (range of mean change: 0.45 to 2.9 mL/kg). Eight out of fourteen studies reported an increase in 6-minute walking distance in the intervention group after the training period (range of mean change: 40-105 m). Two articles showed an improvement in the mental composite scores as well as in the physical composite scores post-exercise in the intervention group. CONCLUSION: There was a lack of significant findings among most randomized controlled trials. Exercise training is acceptable and safe for selective SOT candidates. The effects of exercise training on exercise capacity and quality of life in SOT candidates are unclear.

Physiological and Symptomatic Responses to Arm versus Leg Activities in People with Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis.

While the mechanisms underlying exercise limitations and symptoms during leg activities have been investigated in detail, knowledge of potential differences between leg and arm activities are not well understood and results from individual studies are contradictory. Thus, the aim of the present study was to synthesize physiological and symptomatic responses during activities involving the arms relative to activities involving the legs in people with Chronic Obstructive Pulmonary Disease (COPD). Any study with a cross-sectional comparison of acute physiological (cardiorespiratory, metabolic) and symptomatic responses to activities performed with the arms versus the legs were included. Studies were sub-grouped based on the type of activity performed (cycle ergometer, resistance exercises, or functional test/activities). Eighteen studies with 423 individuals with COPD were included. Leg cycle ergometer resulted in greater tidal volume (137 mL), minute ventilation (4.8 L/min), and oxygen consumption (164 mL/min) than arm cycle ergometer, while symptomatic responses were similar. Resistance exercises resulted in similar physiological and symptomatic responses irrespective of whether the legs or the arms were involved while studies on functional activities report different results depending on the type and intensity of the activity performed. With the exception of cycle ergometer activities, physiological and symptomatic responses do not seem to depend on whether the arms or the legs are used, but rather seem to be task and intensity dependent. These novel findings suggest, for example, that strategies used to increase exercise tolerance should not be dependent on whether the arms or the legs are used, but rather the intensity of specific activity performed.

Improving acceptance and uptake of pulmonary rehabilitation after acute exacerbation of COPD: Acceptability, feasibility, and safety of a PR "taster" session delivered before hospital discharge.

The objectives of this study were to (1) assess the acceptability, feasibility, and safety of delivering a pulmonary rehabilitation (PR) "taster" session to patients hospitalized with acute exacerbations of chronic obstructive pulmonary disease; (2) evaluate the changes in patient knowledge and readiness to commence PR; and (3) make recommendations for future intervention iterations. Acceptability was measured by the proportion of patients that accepted to participate. Feasibility was measured by the proportion of eligible participants. Knowledge was evaluated using the modified versions of the Understanding COPD (UCOPD) and Bristol COPD Knowledge (BCKQ) questionnaires. Readiness to commence PR was measured by a modified version of the Readiness to Change Exercise Questionnaire. All measures were delivered pre- and post-intervention. Thirty-one of 34 eligible individuals were able to be approached. Prospective acceptability was low, with 24 individuals declining the intervention, 1 being discharged without making a decision, and only 6 participating. Positive median change was recorded in the modified UCOPD questionnaire (+8), but not the BCKQ (0). Three of the patients were already in the action phase pre-intervention, with all but one in that phase post-intervention. The delivery of a PR "taster" session was not prospectively acceptable to a large portion of patients and only feasible with modifications to the original protocol.

Neuromuscular electrostimulation for adults with chronic obstructive pulmonary disease.

BACKGROUND: In people with chronic obstructive pulmonary disease (COPD), the use of neuromuscular electrostimulation (NMES) either alone, or together with conventional exercise training, might improve the condition of the peripheral muscles, increase exercise capacity and functional performance, reduce symptoms and improve health-related quality of life (HRQoL). OBJECTIVES: To determine the effects of NMES, applied in isolation or concurrently with conventional exercise training to one or more peripheral muscles, on peripheral muscle force and endurance, muscle size, exercise capacity, functional performance, symptoms, HRQoL and adverse events in people with COPD. SEARCH METHODS: We searched the Cochrane Airways Group Specialised Register, the Physiotherapy Evidence Database, clinical trial registries and conference abstracts on 14 March 2018. SELECTION CRITERIA: Randomised controlled trials that recruited adults with COPD if they had compared outcomes between a group that received NMES and a group that received usual care or compared outcomes between a group that received NMES plus conventional exercise training and a group that participated in conventional exercise training alone. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed risk of bias using the Cochrane 'Risk of bias' tool. We expressed continuous data as either the standardised mean difference (SMD) or mean difference (MD) with the corresponding 95% confidence interval (CI). We assessed the quality of evidence using the GRADE approach. MAIN RESULTS: Nineteen studies met the inclusion criteria of which 16 contributed data on 267 participants with COPD (mean age 56 to 76 years and 67% were men). Of these 16 studies, seven explored the effect of NMES versus usual care and nine explored the effect of NMES plus conventional exercise training versus conventional exercise training alone. Six studies utilised sham stimulation in the control group. When applied in isolation, NMES produced an increase in peripheral muscle force (SMD 0.34, 95% CI 0.02 to 0.65; low-quality evidence) and quadriceps endurance (SMD 1.36, 95% CI 0.59 to 2.12; low-quality evidence) but the effect on thigh muscle size was unclear (MD 0.25, 95% CI -0.11 to 0.61; low-quality evidence). There were increases in six-minute walk distance (6MWD) (MD 39.26 m, 95% CI 16.31 to 62.22; low-quality evidence) and time to symptom limitation exercising at a submaximal intensity (MD 3.62 minutes, 95% CI 2.33 to 4.91). There was a reduction in the severity of leg fatigue on completion of an exercise test (MD -1.12 units, 95% CI -1.81 to -0.43). The increase in peak rate of oxygen uptake (VO2peak) was of borderline significance (MD 0.10 L/minute, 95% CI 0.00 to 0.19).For NMES with conventional exercise training, there was an uncertain effect on peripheral muscle force (SMD 0.47, 95% CI -0.10 to 1.04; very low-quality evidence) and there were insufficient studies to undertake a meta-analysis on the effect on quadriceps endurance or thigh muscle size. However, there was an increase in 6MWD in favour of NMES combined with conventional exercise training (MD 25.87 m, 95% CI 1.06 to 50.69; very low-quality evidence). In people admitted to either in an intensive care unit or a respiratory high dependency centre, NMES combined with conventional exercise reduced the time taken for participants to first sit out of bed by 4.98 days (95% CI -8.55 to -1.41; very low-quality evidence), although the statistical heterogeneity for this analysis was high (I2 = 60%). For both types of studies (i.e. NMES versus usual care and NMES with conventional exercise training versus conventional exercise training alone), there was no risk difference for mortality or minor adverse events in participants who received NMES. AUTHORS' CONCLUSIONS: NMES, when applied in isolation, increased quadriceps force and endurance, 6MWD and time to symptom limitation exercising at a submaximal intensity, and reduced the severity of leg fatigue on completion of exercise testing. It may increase VO2peak, but the true effect on this outcome measure could be trivial. However, the quality of evidence was low or very low due to risk of bias within the studies, imprecision of the estimates, small number of studies and inconsistency between the studies. Although there were no additional gains in quadriceps force with NMES plus conventional exercise training, there was evidence of an increase in 6MWD. Further, in people who were the most debilitated, the addition of NMES may have accelerated the achievement of a functional milestone, that is, the first time someone sits out of bed.

Physical activity in solid organ transplant recipients: Participation, predictors, barriers, and facilitators.

BACKGROUND: Our objectives were to describe the physical activity (PA) levels, predictors, barriers, and facilitators to PA in solid organ transplant (SOT) recipients. METHODS: A web-based questionnaire was sent to members of the Canadian Transplant Association including the Physical Activity Scale for the Elderly (PASE), and questions regarding barriers and facilitators of PA. RESULTS: One hundred and thirteen SOT recipients completed the survey. The median PASE score was 164.5 (24.6-482.7). Re-transplantation was the only statistically significant predictor of levels of PA. The most common facilitators of PA included a feeling of health from activity (94%), motivation (88%), social support (76%), knowledge and confidence about exercise (74%) and physician recommendation (59%). Influential barriers were cost of fitness centers (42%), side effects post-transplant or from medications (41%), insufficient exercise guidelines (37%), and feelings of less strength post-transplant (37%). CONCLUSION: There is a large variation in PA levels among SOT recipients. Multiple factors may explain the variance in PA levels in SOT recipients. Identification of facilitators and barriers to PA can inform the development of health and educational promotion strategies to improve participation among SOT recipients with low activity levels.

Does limb partitioning and positioning affect acute cardiorespiratory responses during strength exercises in patients with COPD?

BACKGROUND AND OBJECTIVE: Cardiorespiratory responses and symptoms in response to endurance exercise in patients with COPD vary with the number and position of involved limbs. Responses to such variations have never been quantified for strength exercises. We therefore assessed acute cardiorespiratory responses during brief bouts of weight lifting exercises. METHODS: We compared double- versus single-limb leg extensions and arm elevations, as well as arm elevation done above or below shoulder level in patients with moderate to severe COPD (n = 10, 6 males, 66 (8.1 years), forced expiratory volume on 1 s (FEV1 ) % predicted = 34% (14%)). Minute ventilation, oxygen uptake, oxygen saturation, heart rate (HR), blood pressure (BP), rate of perceived exertion (RPE) and recovery time were collected during single sets of each exercise (10 repetitions at 80% of one repetition maximum). RESULTS: Ventilatory and gas exchange responses were not affected by the number of exercising limbs. Changes in HR, BP and RPE scores during arm elevation above shoulder level were greater after double- compared with single-arm elevation (P ≤ 0.001) and greater when exercising above compared with below shoulder level (P ≤ 0.01). Double-arm elevation above shoulder level required 1.5 min longer HR recovery time (P ≤ 0.041) compared with other exercises. CONCLUSION: Double-arm elevation above shoulder level appears to be more challenging than other strength exercise variations. Partitioning exercises and limb position may reduce perceived exertion during training.

Development of a Theory-Based Intervention to Increase Clinical Measurement of Reactive Balance in Adults at Risk of Falls.

BACKGROUND: Effective balance reactions are essential for avoiding falls, but are not regularly measured by physical therapists. Physical therapists report wanting to improve reactive balance assessment, and theory-based approaches are recommended as the foundation for the development of interventions. This article describes how a behavior change theory for health care providers, the theoretical domains framework (TDF), was used to develop an intervention to increase reactive balance measurement among physical therapists who work in rehabilitation settings and treat adults who are at risk of falls. CASE DESCRIPTION: We employed published recommendations for using the TDF-guided intervention development. We identified what health care provider behavior is in need of change, relevant barriers and facilitators, strategies to address them, and how we would measure behavior change. In this case, identifying strategies required selecting both a reactive balance measure and behavior change techniques. Previous research had determined that physical therapists need to increase reactive balance measurement, and identified barriers and facilitators that corresponded to 8 TDF domains. A published review informed the selection of the Balance Evaluation Systems Test (Reactive Postural Responses Section) as addressing the barriers and facilitators, and existing research informed the selection of 9 established behavior change techniques corresponding to each identified TDF domain. OUTCOMES: The TDF framework were incorporated into a 12-month intervention with interactive group sessions, local champions, and health record modifications. Intervention effect can be evaluated using health record abstraction, questionnaires, and qualitative semistructured interviews. SUMMARY: Although future research will evaluate the intervention in a controlled study, the process of theory-based intervention development can be applied to other rehabilitation research contexts, maximizing the impact of this work.Video Abstract is available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A123).

Factors affecting discharge destination following lung transplantation.

BACKGROUND: Lung transplant (LT) recipients requiring additional care may be referred to inpatient rehabilitation prior to discharge home. This study seeks to describe discharge destinations following LT, compare the characteristics of patients discharged to different destinations, and identify the predictors of discharge destination. METHODS: Retrospective study of 243 LT recipients who survived to hospital discharge between 2006 and 2009. LT recipients were compared based on discharge destination on data pertaining to demographics, clinical characteristics, and healthcare utilization. RESULTS: Of the 243 recipients, 197 (81%) were discharged home, 42 (17%) to inpatient rehabilitation, and 4 (2%) to other medical facilities. Age, pulmonary diagnosis, most recent six-minute walk distance (6 MWD) prior to transplant, pre-transplant mechanical ventilation, priority listing status, pre- and post-transplant intensive care unit length of stay (ICU LOS), post-transplant LOS, total LOS, and participation in pre-transplant rehabilitation were statistically different between patients that were discharged home versus inpatient rehabilitation. Age, most recent 6 MWD prior to transplant, pre-transplant mechanical ventilation, and total LOS were found to be independent predictors of discharge destination. CONCLUSION: Clinical factors can help identify patients more likely to require inpatient rehabilitation. Identification of these factors has the potential to facilitate early discharge planning and optimize continuity of care.

Skeletal muscle atrophy in advanced interstitial lung disease.

BACKGROUND AND OBJECTIVE: A limited number of studies examine skeletal muscle dysfunction in individuals with interstitial lung disease (ILD). We compared upper and lower limb muscle size and strength in individuals with advanced ILD with healthy controls. Second, the relationships of muscle size to muscle strength and function were explored. METHODS: Individuals with advanced ILD listed for lung transplant and healthy control subjects were studied. B-mode ultrasound was performed to assess cross-sectional area (CSA) of rectus femoris and thickness of gastrocnemius and soleus and biceps brachii. Subjects performed isometric muscle strength testing, Short Physical Performance Battery, Timed Up and Go, and Unsupported Upper Limb Exercise Test. RESULTS: Twenty-six individuals with advanced ILD (61 ± 8 years; 73% males; forced vital capacity: 2 ± 0.8 L, 49 ± 13% predicted; diffusing capacity of carbon monoxide: 9.3 ± 4 mL/min/mm Hg, 51 ± 20% predicted) and 12 healthy age and gender-matched controls (56 ± 9.5 years; 50% males) were included. Compared with controls, people with ILD had a smaller CSA of rectus femoris (7.6 ± 2.1 vs 9.4 ± 2.4 cm(2) ; P = 0.03) and lower strength of knee extensors (119 ± 35 vs 147 ± 39 Nm; P = 0.02) and plantarflexors (37 ± 19 vs 50 ± 15 Nm; P = 0.02), but not of biceps. Individuals with ILD also had impaired performance on all functional tests (P < 0.02). Moderate correlations were found between rectus femoris CSA and knee extensor strength (r = 0.63; P < 0.01) and biceps thickness and elbow flexor strength (r = 0.78; P < 0.01) in the ILD group. CONCLUSIONS: Individuals with advanced ILD presented with lower limb muscle atrophy and weakness. Future studies should evaluate the effectiveness of exercise training on muscle function in advanced ILD.

An international comparison of pulmonary rehabilitation: a systematic review.

BACKGROUND: Despite the strong evidence base, the perception remains that the provision of pulmonary rehabilitation (PR) services are extremely limited. Imbalances in PR delivery give rise to unnecessary health costs and underserviced populations. We conducted a systematic review to characterize the international provision of PR, comparing its structure and delivery across countries, and gaining insight into the availability of PR in relation to geographical prevalence. METHODS: Electronic databases were searched from inception to September 2013 using the key words "pulmonary rehabilitation" and "survey." Two authors independently reviewed studies and assessed study quality. Data was extracted and double-checked to ensure accuracy. RESULTS: The majority of programs (55-99%) were offered in an outpatient setting with the exception of Ireland, where the majority of programs were offered in the community (65%). Exercise was the primary component across all programs (77-100%), followed by education (74-100%). Physical therapists were the most common member of the PR team (49-100%). Functional walk tests were the most frequently used outcome measure, although the specific test utilized varied across countries. The current availability of PR services ≤1.2% of individuals with COPD. CONCLUSION: Components provided in PR are similar, irrespective of country, while patient outcome measures demonstrated variation across countries. Recent surveys report the use of community resources for the delivery of PR programs, although the majority are outpatient based. The small number of potential individuals enrolled in PR suggests that an international increase in access and capacity would improve quality of life and reduce healthcare utilization in this population.

Exercise Effects on Maternal Vascular Health and Blood Pressure during Pregnancy and Postpartum: A Systematic Review and Meta-Analysis.

AIM: This systematic review aimed to assess the effects of exercise training during pregnancy and the postpartum period on maternal vascular health and blood pressure (BP). METHODS: The outcome of interest were pulse wave velocity (PWV), flow-mediated dilation (FMD), and BP from pregnancy until 1-year postpartum. Five databases, including Ovid MEDLINE, EMBASE, CINAHL, Web of Science, and Cochrane Library, were systematically searched from inception to August 2023. Studies of randomized controlled trials (RCTs) comparing the effects of prenatal or postpartum exercise to a non-exercise control group were included. The risk of bias and the certainty of evidence were assessed. Random-effects meta-analyses and sensitivity analyses were conducted. RESULTS: In total, 20 RCTs involving 1,221 women were included. Exercise training, initiated from week 8 during gestation or between 6-14 weeks after delivery, with the program lasting for a minimum of 4 weeks up to 6 months, showed no significant impact on PWV and FMD. However, it resulted in a significant reduction in systolic BP (SBP) (MD: -4.37 mmHg; 95% CI: -7.48 to -1.26; p = 0.006) and diastolic BP (DBP) (MD: -2.94 mmHg; 95% CI: -5.17 to -0.71; p = 0.01) with very low certainty. Subgroup analyses revealed consistent trends across different gestational stages, types of exercise, weekly exercise times, and training periods. CONCLUSION: Exercise training during pregnancy and the postpartum period demonstrates a favorable effect on reducing maternal BP. However, further investigations with rigorous methodologies and larger sample sizes are needed to strengthen these conclusions.

This systematic review of the literature demonstrates that exercise training during pregnancy and postpartum can reduce blood pressure in women. Key findings: Exercise training significantly decreased both systolic and diastolic blood pressure values in pregnant and postpartum women.The positive exercise effects on maternal blood pressure were consistently observed regardless of the specific stage of pregnancy, type of exercise, frequency of weekly exercise sessions, or duration of the training programs.