Early Predictors of Recovery From Nonoperatively Treated Achilles Tendon Rupture: 1 Year Follow-Up Study.

PURPOSE: To investigate early structural and mechanical predictors of plantarflexor muscle strength and the magnitude of Achilles tendon (AT) nonuniform displacement at 6 and 12 months after AT rupture. METHODS: Thirty-five participants (28 males and 7 females; mean ± SD age 41.7 ± 11.1 years) were assessed for isometric plantarflexion maximal voluntary contraction (MVC) and AT nonuniformity at 6 and 12 months after rupture. Structural and mechanical AT and plantarflexor muscle properties were measured at 2 months. Limb asymmetry index (LSI) was calculated for all variables. Multiple linear regression was used with the 6 and 12 month MVC LSI and 12 month AT nonuniformity LSI as dependent variables and AT and plantarflexor muscle properties at 2 months as independent variables. The level of pre- and post-injury sports participation was inquired using Tegner score at 2 and 12 months (scale 0-10, 10 = best possible score). Subjective perception of recovery was assessed with Achilles tendon total rupture score (ATRS) at 12 months (scale 0-100, 100=best possible score). RESULTS: Achilles tendon resting angle (ATRA) symmetry at 2 months predicted MVC symmetry at 6 and 12 months after rupture (ß = 2.530, 95% CI 1.041-4.018, adjusted R2 = 0.416, p = 0.002; ß = 1.659, 95% CI 0.330-2.988, adjusted R2 = 0.418, p = 0.016, respectively). At 12 months, participants had recovered their pre-injury level of sports participation (Tegner 6 ± 2 points). The median (IQR) ATRS score was 92 (7) points at 12 months. CONCLUSION: Greater asymmetry of ATRA in the early recovery phase may be a predictor of plantarflexor muscle strength deficits up to 1 year after rupture. TRIAL REGISTRATION: This research is a part of "nonoperative treatment of Achilles tendon rupture in Central Finland: a prospective cohort study" that has been registered in ClinicalTrials.gov (NCT03704532).

Machine learning models for assessing risk factors affecting health care costs: 12-month exercise-based cardiac rehabilitation.

Introduction: Exercise-based cardiac rehabilitation (ECR) has proven to be effective and cost-effective dominant treatment option in health care. However, the contribution of well-known risk factors for prognosis of coronary artery disease (CAD) to predict health care costs is not well recognized. Since machine learning (ML) applications are rapidly giving new opportunities to assist health care professionals' work, we used selected ML tools to assess the predictive value of defined risk factors for health care costs during 12-month ECR in patients with CAD. Methods: The data for analysis was available from a total of 71 patients referred to Oulu University Hospital, Finland, due to an acute coronary syndrome (ACS) event (75% men, age 61 ± 12 years, BMI 27 ± 4 kg/m2, ejection fraction 62 ± 8, 89% have beta-blocker medication). Risk factors were assessed at the hospital immediately after the cardiac event, and health care costs for all reasons were collected from patient registers over a year. ECR was programmed in accordance with international guidelines. Risk analysis algorithms (cross-decomposition algorithms) were employed to rank risk factors based on variances in their effects. Regression analysis was used to determine the accounting value of risk factors by entering first the risk factor with the highest degree of explanation into the model. After that, the next most potent risk factor explaining costs was added to the model one by one (13 forecast models in total). Results: The ECR group used health care services during the year at an average of 1,624 ± 2,139€ per patient. Diabetes exhibited the strongest correlation with health care expenses (r = 0.406), accounting for 16% of the total costs (p < 0.001). When the next two ranked markers (body mass index; r = 0.171 and systolic blood pressure; r = - 0.162, respectively) were added to the model, the predictive value was 18% for the costs (p = 0.004). The depression scale had the weakest independent explanation rate of all 13 risk factors (explanation value 0.1%, r = 0.029, p = 0.811). Discussion: Presence of diabetes is the primary reason forecasting health care costs in 12-month ECR intervention among ACS patients. The ML tools may help decision-making when planning the optimal allocation of health care resources.

Low physical activity is a risk factor for sarcopenia: a cross-sectional analysis of two exercise trials on community-dwelling older adults.

BACKGROUND: Physical inactivity is an important factor in the development of sarcopenia. This cross-sectional study explores the prevalence of sarcopenia and associations of physical activity (PA) with sarcopenia in two exercise trial populations. These study groups are clinically meaningful community-dwelling populations at increased risk for sarcopenia: older adults not meeting the PA guidelines and those with a recent hip fracture (HF). METHODS: Data from 313 older adults who did not meet the PA guidelines (60% women; age 74.5 ± 3.8, body mass index 27.9 ± 4.7) and 77 individuals with HF diagnosed on average 70 ± 28 days earlier (75% women; age 79.3 ± 7.1, body mass index 25.3 ± 3.6) were included in this study. Grip strength and muscle mass (Dual-energy X-ray absorptiometry [DXA] in older adults not meeting the PA guidelines and bioimpedance analysis in participants with HF) were used to assess sarcopenia according to the European Working Group in Older People 2019 (EWGSOP2) criteria. The current level of PA was self-reported using a question with seven response options in both study groups and was measured with a hip-worn accelerometer for seven consecutive days in older adults not meeting the PA guidelines. RESULTS: The prevalence of sarcopenia and probable sarcopenia was 3% (n = 8) and 13% (n = 41) in the older adults not meeting the PA guidelines and 3% (n = 2) and 40% (n = 31) in the HF group, respectively. In the age- and sex-adjusted logistic regression model, the lowest levels of self-reported PA were associated with increased probable sarcopenia and sarcopenia risk in older adults not meeting the PA guidelines (OR 2.8, 95% CI, 1.3-6.1, p = 0.009) and in the HF group (OR 3.9, 95% CI, 1.4-11.3, p = 0.012). No significant associations between accelerometer-measured PA and probable sarcopenia or sarcopenia were found. CONCLUSIONS: Probable sarcopenia is common among community-dwelling older adults not meeting the PA guidelines and very common among individuals recovering from HF who are able to be involved in exercise interventions. In addition, since low PA is associated with higher probable sarcopenia and sarcopenia risk, it is recommended to screen for sarcopenia and promote regular physical activity to prevent sarcopenia in these populations.

The Impact of Multimorbidity Patterns on Changes in Physical Activity and Physical Capacity Among Older Adults Participating in a Year-Long Exercise Intervention.

This study investigated the impact of multimorbidity patterns on physical activity and capacity outcomes over the course of a year-long exercise intervention, and on physical activity 1 year later. Participants were 314 physically inactive community-dwelling men and women aged 70-85 years, with no contraindications for exercise at baseline. Physical activity was self-reported. Physical capacity measurements included five-time chair-stand time, 6-minute walking distance, and maximal isometric knee-extension strength. The intervention included supervised and home-based strength, balance, and walking exercises. Multimorbidity patterns comprised physician-diagnosed chronic disease conditions as a predictor cluster and body mass index as a measure of obesity. Multimorbidity patterns explained 0%-12% of baseline variance and 0%-3% of the change in outcomes. The magnitude and direction of the impact of unique conditions varied by outcome, time point, and sex. Multimorbid older adults with no contraindications for exercise may benefit from multimodal physical training.

Baroreflex sensitivity following acute upper-body exercise in the cold among stable coronary artery disease patients.

Background: A cold environment and exercise separately affect the autonomic nervous system (ANS), baroreflex sensitivity (BRS), and blood pressure variability (BPV) but their combined effects on post-exercise recovery are not known. Our cross-over trial examined these responses following upper-body static and dynamic exercise performed in a cold and neutral environment in patients with coronary artery disease (CAD). Methods: 20 patients with stable coronary artery disease performed both graded static (10%-30% of maximal voluntary contraction) and dynamic (light, moderate and high perceived intensity) upper-body exercise at -15°C and +22°C for 30 min. Electrocardiogram and continuous blood pressure were measured to compute post-exercise (10 and 30 min after exercise) spectral powers of heart rate (HR), blood pressure variability and BRS at low (0.04-0.15 Hz) and high (0.15-0.4 Hz) frequencies. Results: Static upper-body exercise performed in a cold environment increased post-exercise high frequency (HF) spectral power of heart rate (HF RR) (p < 0.001) and reduced heart rate (p = 0.001) and low-to-high frequency (LF/HF) ratio (p = 0.006) more than in a neutral environment. In addition, post-exercise mean BRS (p = 0.015) and high frequency BRS (p = 0.041) increased more following static exercise in the cold than in a neutral environment. Dynamic upper-body exercise performed in a cold environment reduced post-exercise HF BRS (p = 0.019) and systolic blood pressure (p = 0.003). Conclusion: Static upper-body exercise in the cold increased post-exercise BRS and overall vagal activity but without reduced systolic blood pressure. Dynamic upper-body exercise in the cold reduced post-exercise vagal BRS but did not affect the other parameters. The influence of cold exposure on post-exercise autonomic and cardiovascular responses following static upper-body exercise require further studies. This information helps understanding why persons with cardiovascular diseases are vulnerable to low environmental temperature. ClinicalTrials.gov: NCT02855905 (04/08/2016).

Cardiac Autonomic Function and Functional Capacity in Post-COVID-19 Individuals with Systemic Arterial Hypertension.

Individuals diagnosed with systemic arterial hypertension (SAH) are considered risk groups for COVID-19 severity. This study assessed differences in cardiac autonomic function (CAF) and functional capacity (FC) in SAH individuals without COVID-19 infection compared to SAH individuals post-COVID-19. Participants comprised 40 SAH individuals aged 31 to 80 years old, grouped as SAH with COVID-19 (G1; n = 21) and SAH without COVID-19 (G2; n = 19). CAF was assessed via heart rate variability (HRV), measuring R-R intervals during a 10-min supine period. Four HRV indices were analyzed through symbolic analysis: 0V%, 1V%, 2LV%, and 2UV%. FC assessment was performed by a 6-min walk test (6MWT). G1 and G2 showed no significant differences in terms of age, anthropometric parameters, clinical presentation, and medication use. G2 exhibited superior 6MWT performance, covering more distance (522 ± 78 vs. 465 ± 59 m, p < 0.05). Specifically, G2 demonstrated a moderate positive correlation between 6MWT and the 2LV% index (r = 0.58; p < 0.05). Shorter walking distances were observed during 6MWT in SAH individuals post-COVID-19. However, the study did not find impaired cardiac autonomic function in SAH individuals post-COVID-19 compared to those without. This suggests that while COVID-19 impacted FC, CAF remained relatively stable in this population.

Machine learning models in predicting health care costs in patients with a recent acute coronary syndrome: A prospective pilot study.

Background: Health care budgets are limited, requiring the optimal use of resources. Machine learning (ML) methods may have an enormous potential for effective use of health care resources. Objective: We assessed the applicability of selected ML tools to evaluate the contribution of known risk markers for prognosis of coronary artery disease to predict health care costs for all reasons in patients with a recent acute coronary syndrome (n = 65, aged 65 ± 9 years) for 1-year follow-up. Methods: Risk markers were assessed at baseline, and health care costs were collected from electronic health registries. The Cross-decomposition algorithms were used to rank the considered risk markers based on their impacts on variances. Then regression analysis was performed to predict costs by entering the first top-ranking risk marker and adding the next-best markers, one by one, to build up altogether 13 predictive models. Results: The average annual health care costs were €2601 ± €5378 per patient. The Depression Scale showed the highest predictive value (r = 0.395), accounting for 16% of the costs (P = .001). When the next 2 ranked markers (LDL cholesterol, r = 0.230; and left ventricular ejection fraction, r = -0.227, respectively) were added to the model, the predictive value was 24% for the costs (P = .001). Conclusion: Higher depression score is the primary variable forecasting health care costs in 1-year follow-up among acute coronary syndrome patients. The ML tools may help decision-making when planning optimal utilization of treatment strategies.

Physical fitness characteristics and neck and shoulder pain incidence in school-aged children-A 2-year follow-up.

Background and Aims: Neck and shoulder pain (NSP) is common in school age, but preventative factors have not been identified. The purpose was to study whether a fitness test could be used to predict the incidence of NSP and determine whether good physical fitness characters would be associated with lower NSP incidence in school-aged children at 2-year follow-up. Methods: After the invitation to nine schools, 970 children (10-15 years old) agreed to participate. Flexibility, fundamental movement skills, musculoskeletal fitness, and cardiorespiratory fitness measurements included in Finnish Schools on the Move! monitoring system for physical functional capacity were measured at baseline in 2013. The NSP incidence was assessed by an online survey during school hours after 1 and 2 years. Logistic regression was used to analyze associations between physical fitness characteristics and NSP incidence. Results: The mean prevalence of NSP was 26% at baseline. The NSP incidence was 15% in the first and 18% in the second follow-up year. Good physical fitness was not associated with lower NSP incidence in the 2-year follow-up. Successful lower back extension (odds ratio [OR] = 2.83) and good scores in curl-up (OR = 1.80) adjusted with age, gender, and body mass index, were associated with higher NSP incidence between T0 and T2. Throwing-catching combination (OR = 0.55) was associated with a lower NSP incidence in unadjusted analysis, but the association did not remain after adjustments. Conclusion: Good physical fitness characteristics were not consistently associated with a lower NSP incidence in school-aged children in a 2-year follow-up. The role of general field-based physical fitness test as a screening tool for NSP incidence remains unconfirmed. More longitudinal studies are needed to detect the factors underlying NSP incidence in school-aged children.

Physical activity, screen time and the incidence of neck and shoulder pain in school-aged children.

This study investigated the associations of accelerometer-measured physical activity, sedentary time and screen time with the incidence of neck and shoulder pain in school-aged children over a two-year follow-up. Children (aged 10-15) were measured at baseline 2013 (T0) (n = 970) and at follow-ups 2014 (T1) and 2015 (T2). Neck and shoulder pain frequency and screen time were determined with a web-based questionnaire. Daytime moderate to vigorous physical activity and sedentary time were measured with an accelerometer. Logistic regression was applied, and the results were adjusted for age, gender, body mass index and bedtime. Accelerometer-measured physical activity or sedentary time at baseline were not associated with the incidence of neck and shoulder pain at the two-year follow-up. Associations of neck and shoulder pain incidence with overall screen time (p = 0.020), and especially with passive gaming time (p = 0.036) and social media time (p = 0.023) were found at the first but not the second follow-up. The neck and shoulder pain incidence associated with overall screen time, passive gaming time and social media time at the first follow-up. The importance of limiting screen time, should be explored in order to find new approaches in preventing neck and shoulder pain in school-aged children.

Cardiovascular responses to dynamic and static upper-body exercise in a cold environment in coronary artery disease patients.

PURPOSE: Upper-body exercise performed in a cold environment may increase cardiovascular strain, which could be detrimental to patients with coronary artery disease (CAD). This study compared cardiovascular responses of CAD patients during graded upper-body dynamic and static exercise in cold and neutral environments. METHODS: 20 patients with stable CAD performed 30 min of progressive dynamic (light, moderate, and heavy rating of perceived exertion) and static (10, 15, 20, 25 and 30% of maximal voluntary contraction) upper body exercise in cold (- 15 °C) and neutral (+ 22 °C) environments. Heart rate (HR), blood pressure (BP) and electrocardiographic (ECG) responses were recorded and rate pressure product (RPP) calculated. RESULTS: Dynamic-graded upper-body exercise in the cold increased HR by 2.3-4.8% (p = 0.002-0.040), MAP by 3.9-5.9% (p = 0.038-0.454) and RPP by 18.1-24.4% (p = 0.002-0.020) when compared to the neutral environment. Static graded upper-body exercise in the cold resulted in higher MAP (6.3-9.1%; p = 0.000-0.014), lower HR (4.1-7.2%; p = 0.009-0.033), but unaltered RPP compared to a neutral environment. Heavy dynamic exercise resulted in ST depression that was not related to temperature. Otherwise, ECG was largely unaltered during exercise in either thermal condition. CONCLUSIONS: Dynamic- and static-graded upper-body exercise in the cold involves higher cardiovascular strain compared with a neutral environment among patients with stable CAD. However, no marked changes in electric cardiac function were observed. The results support the use of upper-body exercise in the cold in patients with stable CAD. TRIAL REGISTRATION: Clinical trial registration NCT02855905 August 2016.

Standing time and daily proportion of sedentary time are associated with pain-related disability in a one month accelerometer measurement in adults with overweight or obesity.

OBJECTIVES: The association between the subjective experience of pain-related disability (PRD) and device-measured physical activity (PA) and sedentary behavior (SB) in overweight and obese adults is not well known. The aim of this study was to investigate the associations of pain markers with accelerometer-measured SB duration and different intensities of PA among physically inactive middle-aged adults with overweight or obesity. METHODS: This cross-sectional analysis included 72 subjects (27 men) with mean age of 57.9 (SD 6.7) years and mean BMI of 31.6 (SD 4.1) kg/m2. SB and standing time (ST), breaks in sedentary time, light physical activity (LPA) and moderate-to-vigorous physical activity (MVPA) were measured for four consecutive weeks (mean 25 days, SD 4) with a hip-worn triaxial accelerometer. Headache, musculoskeletal pain, back pain, and PRD were assessed by visual analog scales (VAS) and using the Oswestry disability index (ODI). RAND-36 questionnaire was applied to assess health-related quality of life. The associations were studied by linear models. RESULTS: ST was positively and SB proportion was negatively associated with PRD when adjusted for age, sex, BMI, accelerometry duration, MVPA, pain medication use, and general health perceptions assessed by RAND-36. No associations were found between ST and back pain. SB or different PA intensities were not associated with pain experience at specific sites. CONCLUSIONS: Longer daily ST, but not LPA or MVPA is associated with higher level of PRD. Correspondingly, higher proportion of SB is associated with lower level of PRD. This suggests that individuals with PRD prefer to stand, possibly to cope with pain. These results may highlight the importance of habitual standing behaviors in coping with experienced PRD in adults with overweight or obesity.

Cardiopulmonary exercise testing in COVID-19 patients at 3 months follow-up.

BACKGROUND: Long-term effects of Coronavirus Disease of 2019 (COVID-19) are of utmost relevance. We aimed to determine: 1) the functional capacity of COVID-19 survivors by cardiopulmonary exercise testing (CPET); 2) the characteristics associated with cardiopulmonary exercise testing (CPET) performance; 3) the safety and tolerability of CPET. METHODS: We prospectively enrolled consecutive patients with laboratory-confirmed COVID-19 from Azienda Sanitaria Locale 3, Genoa. Three months after hospital discharge a complete clinical evaluation, trans-thoracic echocardiography, CPET, pulmonary function tests, and dominant leg extension (DLE) maximal strength measurement were performed. RESULTS: From the 225 patients discharged alive from March to November 2020, we excluded 12 incomplete/missing cases and 13 unable to perform CPET, leading to a final cohort of 200. Median percent-predicted peak oxygen uptake (%pVO2) was 88% (78.3-103.1). Ninety-nine (49.5%) patients had %pVO2 below, whereas 101 (50.5%) above the 85% predicted value. Among the 99 patients with reduced %pVO2, 61 (61%) had a normal anaerobic threshold: of these, 9(14.8%) had respiratory, 21(34.4%) cardiac, and 31(50.8%) non-cardiopulmonary reasons for exercise limitation. Inerestingly, 80% of patients experienced at least one disabling symtpom, not related to %pVO2 or functional capacity. Multivariate linear regression showed percent-predicted forced expiratory volume in one-second(ß = 5.29,p = 0.023), percent-predicted diffusing capacity of lungs for carbon monoxide(ß = 6.31,p = 0.001), and DLE maximal strength(ß = 14.09,p = 0.008) to be independently associated with pVO2. No adverse event was reported during or after CPET, and no involved health professional developed COVID-19. CONCLUSIONS: At three months after discharge, about 1/3rd of COVID-19 survivors show functional limitations, mainly explained by muscular impairment, calling for future research to identify patients at higher risk of long-term effects that may benefit from careful surveillance and targeted rehabilitation.

Central aortic hemodynamics following acute lower and upper-body exercise in a cold environment among patients with coronary artery disease.

Exercise is beneficial to cardiovascular health, evidenced by reduced post-exercise central aortic blood pressure (BP) and wave reflection. We assessed if post-exercise central hemodynamics are modified due to an altered thermal state related to exercise in the cold in patients with coronary artery disease (CAD). CAD patients (n = 11) performed moderate-intensity lower-body exercise (walking at 65-70% of HRmax) and rested in neutral (+ 22 °C) and cold (- 15 °C) conditions. In another protocol, CAD patients (n = 15) performed static (five 1.5 min work cycles, 10-30% of maximal voluntary contraction) and dynamic (three 5 min workloads, 56-80% of HRmax) upper-body exercise at the same temperatures. Both datasets consisted of four 30-min exposures administered in random order. Central aortic BP and augmentation index (AI) were noninvasively assessed via pulse wave analyses prior to and 25 min after these interventions. Lower-body dynamic exercise decreased post-exercise central systolic BP (6-10 mmHg, p < 0.001) and AI (1-6%, p < 0.001) both after cold and neutral and conditions. Dynamic upper-body exercise lowered central systolic BP (2-4 mmHg, p < 0.001) after exposure to both temperatures. In contrast, static upper-body exercise increased central systolic BP after exposure to cold (7 ± 6 mmHg, p < 0.001). Acute dynamic lower and upper-body exercise mainly lowers post-exercise central BP in CAD patients irrespective of the environmental temperature. In contrast, central systolic BP was elevated after static exercise in cold. CAD patients likely benefit from year-round dynamic exercise, but hemodynamic responses following static exercise in a cold environment should be examined further.Clinical trials.gov: NCT02855905 04/08/2016.

The Effects of an Intensive 2-wk Resistance Training Period on Strength Performance and Nocturnal Heart Rate Variability.

PURPOSE: It is known that modifying the endurance-type training load of athletes may result in altered cardiac autonomic modulation that may be estimated with heart rate variability (HRV). However, the specific effects of intensive resistance-type training remain unclear. The main aim of this study was to find out whether an intensive 2-wk resistance training period affects the nocturnal HRV and strength performance of healthy participants. METHODS: Young healthy men (N = 13, age 24 [2] y) performed 2-wk baseline training, 2-wk intensive training, and a 9-d tapering periods, with 2, 5, and 2 hypertrophic whole-body resistance exercise sessions per week, respectively. Maximal isometric and dynamic strength were tested at the end of these training periods. Nocturnal HRV was also analyzed at the end of these training periods. RESULTS: As a main finding, the nocturnal root mean square of differences of successive R-R intervals decreased (P = .004; from 49 [18] to 43 [15] ms; 95% CI, 2.4-10.4; effect size = 0.97) during the 2-wk intensive resistance training period. In addition, maximal isometric strength improved slightly (P = .045; from 3933 [1362] to 4138 [1540] N; 95% CI, 5.4-404; effect size = 0.60). No changes were found in 1-repetition-maximum leg press or leg press repetitions at 80% 1-repetition maximum. CONCLUSIONS: The present data suggest that increased training load due to a short-term intensive resistance training period can be detected by nocturnal HRV. However, despite short-term accumulated physiological stress, a tendency of improvement in strength performance was detected.

Endothelial function in response to exercise in the cold in patients with coronary artery disease.

BACKGROUND: Regular long-term physical exercise has favourable effects on endothelial function in patients with coronary artery disease (CAD). However, the effects of an acute exercise bout in the cold on endothelial function are not known. METHODS: At first, the effects of moderate-intensity aerobic lower-body exercise were assessed in CAD patients (n = 16) in a neutral [+22°C] and cold [-15°C] environment. Secondly, responses to static and dynamic upper-body exercise in a neutral [+22°C] and cold [-15°C] environment were investigated in CAD patients (n = 15). All experiments were performed in a random order. Endothelial function was measured by flow-mediated dilation (FMD) of the brachial artery in response to reactive hyperaemia, before and after the exposures in a neutral environment. RESULTS: No significant temperature*exercise*condition (pre-post) interaction was observed in FMD% when comparing rest versus aerobic exercise or static versus dynamic upper-body exercise. Relative reactive hyperaemia during FMD protocol, measured by changes in shear rate, was elevated after rest compared to aerobic exercise (p = .001) and after static compared to dynamic upper-body exercise (p < .001). However, no significant temperature*exercise*condition interaction was observed when FMD% was normalized for shear rate. CONCLUSIONS: Endothelial function to an acute bout of exercise among CAD patients was not modified by the environmental temperature where the exercise was performed. The present findings argue against the hypothesis that exercise in cold environmental conditions impairs endothelial function in patients with CAD.

Nature of Cardiac Rehabilitation Around the Globe.

BACKGROUND: Cardiac rehabilitation (CR) is a clinically-effective but complex model of care. The purpose of this study was to characterize the nature of CR programs around the world, in relation to guideline recommendations, and compare this by World Health Organization (WHO) region. METHODS: In this cross-sectional study, a piloted survey was administered online to CR programs globally. Cardiac associations and local champions facilitated program identification. Quality (benchmark of ≥ 75% of programs in a given country meeting each of 20 indicators) was ranked. Results were compared by WHO region using generalized linear mixed models. FINDINGS: 111/203 (54.7%) countries in the world offer CR; data were collected in 93 (83.8%; N = 1082 surveys, 32.1% program response rate). The most commonly-accepted indications were: myocardial infarction (n = 832, 97.4%), percutaneous coronary intervention (n = 820, 96.1%; 0.10), and coronary artery bypass surgery (n = 817, 95.8%). Most programs were led by physicians (n = 680; 69.1%). The most common CR providers (mean = 5.9 ±â€¯2.8/program) were: nurses (n = 816, 88.1%; low in Africa, p < 0.001), dietitians (n = 739, 80.2%), and physiotherapists (n = 733, 79.3%). The most commonly-offered core components (mean = 8.7 ±â€¯1.9 program) were: initial assessment (n = 939, 98.8%; most commonly for hypertension, tobacco, and physical inactivity), risk factor management (n = 928, 98.2%), patient education (n = 895, 96.9%), and exercise (n = 898, 94.3%; lower in Western Pacific, p < 0.01). All regions met ≥ 16/20 quality indicators, but quality was < 75% for tobacco cessation and return-to-work counseling (lower in Americas, p = < 0.05). INTERPRETATION: This first-ever survey of CR around the globe suggests CR quality is high. However, there is significant regional variation, which could impact patient outcomes.

Cardiac Rehabilitation Availability and Density around the Globe.

BACKGROUND: Despite the epidemic of cardiovascular disease and the benefits of cardiac rehabilitation (CR), availability is known to be insufficient, although this is not quantified. This study ascertained CR availability, volumes and its drivers, and density. METHODS: A survey was administered to CR programs globally. Cardiac associations and local champions facilitated program identification. Factors associated with volumes were assessed using generalized linear mixed models, and compared by World Health Organization region. Density (i.e. annual ischemic heart disease [IHD] incidence estimate from Global Burden of Disease study divided by national CR capacity) was computed. FINDINGS: CR was available in 111/203 (54.7%) countries; data were collected in 93 (83.8% country response; N = 1082 surveys, 32.1% program response rate). Availability by region ranged from 80.7% of countries in Europe, to 17.0% in Africa (p < .001). There were 5753 programs globally that could serve 1,655,083 patients/year, despite an estimated 20,279,651 incident IHD cases globally/year. Volume was significantly greater where patients were systematically referred (odds ratio [OR] = 1.36, 95% confidence interval [CI] = 1.35-1.38) and programs offered alternative models (OR = 1.05, 95%CI = 1.04-1.06), and significantly lower with private (OR = .92, 95%CI = .91-.93) or public (OR = .83, 95%CI = .82-84) funding compared to hybrid sources.Median capacity (i.e., number of patients a program could serve annually) was 246/program (Q25-Q75 = 150-390). The absolute density was one CR spot per 11 IHD cases in countries with CR, and 12 globally. INTERPRETATION: CR is available in only half of countries globally. Where offered, capacity is grossly insufficient, such that most patients will not derive the benefits associated with participation.

Physical activity is associated with cardiac autonomic function in adolescent men.

INTRODUCTION: Moderate to vigorous physical activity (MVPA) has been shown to be associated with autonomic regulation of the heart measured with heart rate variability (HRV). Only a limited amount of studies have examined this relationship among adolescents, and the effects of increasing PA on HRV is not well established. The aim of this study was to investigate how overall self-reported PA associates with HRV in a large population of adolescent men. METHODS: The study was part of the Finnish MOPO study consisting of 3629 young men (mean age 18, SD 1 years) enrolled for military call-ups in 2009-2013. Overall PA, including both the intensity and frequency of habitual exercise, was assessed by a questionnaire and the respondents categorized into four groups of PA (low, moderate, high and top). Short-term HRV, physical performance and body composition were measured. RESULTS: HRV, as indicated by mean ln rMSSD, increased according the PA categories as follows: low (3.65 ms (SD 0.7), p<0.001 vs. other groups), moderate (3.78 ms (0.6) p<0.001), high (3.85 ms (0.6) p<0.001) and top activity (3.93 ms (0.6) p<0.001) According to the multivariable linear regression analysis, a significant positive relationship (ß = 0.129, p<0.05) was observed between self-reported PA and ln rMSSD independent of body mass index, waist circumference and fat percentage. CONCLUSIONS: Physical activity was positively associated with cardiac autonomic regulation, in adolescent men. A linear increase in HRV according to PA was observed, suggesting that even slight increments in PA might be beneficial for cardiac autonomic regulation The results emphasize the importance of physical activity in improving cardiac health in young people.

Are 15-Year Trajectories of Low Back Pain and Sciatica Associated With Cardiovascular Autonomic Function in the General Population?: The Northern Finland Birth Cohort 1966 Study.

STUDY DESIGN: A population-based cohort study. OBJECTIVE: The aim of this study was to examine whether 15-year trajectories of low back pain (LBP) and sciatica are associated with cardiovascular autonomic function in a large general population sample. SUMMARY OF BACKGROUND DATA: Previous studies using mainly small patient samples have suggested that LBP and sciatica are associated with abnormal cardiovascular autonomic function, namely altered heart rate variability (HRV) and baroreflex sensitivity (BRS). We examined this association in a large general population sample. METHODS: The data collections of the Northern Finland Birth Cohort 1966 consisted of pain questionnaires at 31 and 46 years (history of LBP, sciatica, and other musculoskeletal pains during the previous year; yes/no for each) and measurements of HRV and BRS at 46 years (heart rate, HR; root mean square of successive differences in beat-to-beat intervals, rMSSD; low-frequency systolic blood pressure variability, SBPV; cross-spectral BRS, BRS; each while seated and standing). The data collections also comprised several confounders. Trajectories for LBP, sciatica, and both together ("no pain," "decreasing," "increasing," "long-term pain") were constructed and general linear models were used to perform comparisons between trajectories (for HR/rMSSD, n = 3398; for SBPV/BRS, n = 1667). RESULTS: In the crude models, LBP and sciatica were associated with higher HR, lower rMSSD, higher SBPV, and lower BRS, but these associations were mostly attenuated by adjustments. Regarding both LBP and sciatica, only the "increasing" trajectory was associated with two of the eight outcomes (standing SBPV, seated BRS) after adjustments. Regarding LBP, the "increasing" trajectory was associated with three (standing SBPV, seated BRS, standing BRS), the "long-term pain" trajectory with one (standing BRS), and the "decreasing" trajectory with one outcome (seated SBPV) after adjustments. Sciatica showed no association with the outcomes after adjustments. CONCLUSION: We conclude that the 15-year trajectories of LBP and sciatica do not have a consistent independent association with cardiovascular autonomic function among the general population. LEVEL OF EVIDENCE: 3.