Increasing Use of Cardiac and Pulmonary Rehabilitation in Traditional and Community Settings: OPPORTUNITIES TO REDUCE HEALTH CARE DISPARITIES.

Although both cardiac rehabilitation (CR) and pulmonary rehabilitation (PR) are recommended by clinical practice guidelines and covered by most insurers, they remain severely underutilized. To address this problem, the National Heart, Lung, and Blood Institute (NHLBI), in collaboration with the National Institute on Aging (NIA), developed Funding Opportunity Announcements (FOAs) in late 2017 to support phase II clinical trials to increase the uptake of CR and PR in traditional and community settings. The objectives of these FOAs were to (1) test strategies that will lead to increased use of CR and PR in the US population who are eligible based on clinical guidelines; (2) test strategies to reduce disparities in the use of CR and PR based on age, gender, race/ethnicity, and socioeconomic status; and (3) test whether increased use of CR and PR, whether by traditional center-based or new models, is accompanied by improvements in relevant clinical and patient-centered outcomes, including exercise capacity, cardiovascular and pulmonary risk factors, and quality of life. Five NHLBI grants and a single NIA grant were funded in the summer of 2018 for this CR/PR collaborative initiative. A brief description of the research to be developed in each grant is provided.

National Institutes of Health Research Plan on Rehabilitation: NIH Medical Rehabilitation Coordinating Committee.

One in five Americans experiences disability that affects their daily function because of impairments in mobility, cognitive function, sensory impairment, or communication impairment. The need for rehabilitation strategies to optimize function and reduce disability is a clear priority for research to address this public health challenge. The National Institutes of Health (NIH) recently published a Research Plan on Rehabilitation that provides a set of priorities to guide the field over the next 5 years. The plan was developed with input from multiple Institutes and Centers within the NIH, the National Advisory Board for Medical Rehabilitation Research, and the public. This article provides an overview of the need for this research plan, an outline of its development, and a listing of six priority areas for research. The NIH is committed to working with all stakeholder communities engaged in rehabilitation research to track progress made on these priorities and to work to advance the science of medical rehabilitation.This article is being published almost simultaneously in the following six journals: American Journal of Occupational Therapy, American Journal of Physical Medicine and Rehabilitation, Archives of Physical Medicine and Rehabilitation, Neurorehabilitation and Neural Repair, Physical Therapy, and Rehabilitation Psychology. Citation information is as follows: NIH Medical Rehabilitation Coordinating Committee. Am J Phys Med Rehabil. 2017;97(4):404-407.

Understanding the Cellular and Molecular Mechanisms of Physical Activity-Induced Health Benefits.

The beneficial effects of physical activity (PA) are well documented, yet the mechanisms by which PA prevents disease and improves health outcomes are poorly understood. To identify major gaps in knowledge and potential strategies for catalyzing progress in the field, the NIH convened a workshop in late October 2014 entitled "Understanding the Cellular and Molecular Mechanisms of Physical Activity-Induced Health Benefits." Presentations and discussions emphasized the challenges imposed by the integrative and intermittent nature of PA, the tremendous discovery potential of applying "-omics" technologies to understand interorgan crosstalk and biological networking systems during PA, and the need to establish an infrastructure of clinical trial sites with sufficient expertise to incorporate mechanistic outcome measures into adequately sized human PA trials. Identification of the mechanisms that underlie the link between PA and improved health holds extraordinary promise for discovery of novel therapeutic targets and development of personalized exercise medicine.

Workshop on personal motion technologies for healthy independent living: executive summary.

The objective of the June 2010 "Workshop on Personal Motions Technologies for Healthy Independent Living" was to discuss personal motion technologies that might enable older adults and individuals with disability to live independently for longer periods. The 60 participants included clinicians, academic researchers, engineers, patient advocates, caregivers, members of the public, and federal representatives. The workshop was divided into 6 sessions that addressed the following: (1) use of technologies in identifying early indicators of disease or adverse events; (2) monitoring daily activities; (3) coping with impairment; (4) managing mild cognitive impairment; (5) rehabilitation and exercise in the home; and (6) caregiver support. Presentations and discussion focused on clinical needs, the health impact of addressing those needs, state-of-the-art technologies, and challenges to adoption of those technologies. Conclusions included the following: (1) Involvement of end-users in research and development will increase the likelihood that technologies will be adopted. (2) Integration of differing types of technology into a system that includes clinical measures is required for independent living. (3) Seniors are willing to sacrifice some privacy for an effective technology that keeps them in their homes as long as they control who receives their data. (4) Multilevel and multiscale models are needed to understand motion in the context of the environment and to design effective systems.

Weight loss and low-intensity exercise for the treatment of metabolic syndrome in obese postmenopausal women.

BACKGROUND: The prevalence of the metabolic syndrome (MetSyn) approaches 50% in postmenopausal women. This study examines the efficacy of lifestyle modification for the treatment of MetSyn and its associated risk for cardiovascular disease and diabetes in this population. METHODS: This prospective controlled study examines the effects of a 6-month weight loss and low-intensity exercise program (WL+LEX) on body composition (dual-energy X-ray absorptiometry and abdominal computed tomography scans), fasting glucose and lipid levels, cytokines, and blood pressure in postmenopausal women with and without MetSyn. RESULTS: WL+LEX reduced body weight (MetSyn: -5% vs non-MetSyn: -7%) and fat mass (-11% vs -15%) and increased VO(2max) (+2% vs +3%) in both MetSyn (N = 35) and non-MetSyn (N = 41) groups. Constituents of MetSyn decreased comparably in both groups. Fifteen (45%) MetSyn participants responded (R) by converting to non-MetSyn, 18 remained MetSyn (NR), and 2 had missing data. Reduction in fat mass (-15% vs -8%, p = .02) was greater in R than NR, but there were no between-group differences in changes in VO(2max), cytokines, or other variables. The decrease in the number of MetSyn criteria was greater in R than in NR (-27 vs -13, p < .0001) due to decreases in blood pressure (p < .01), glucose (p = .02), and with a trend for triglyceride (p = .07). Reductions in fat mass best predicted resolution of MetSyn (p = .04). CONCLUSIONS: Women who lose more fat are more likely to lower blood pressure, glucose, and triglyceride levels to resolve MetSyn. Thus, a WL+LEX program effectively treats postmenopausal women with MetSyn.

Plasma adiponectin levels are associated with insulin sensitivity in stroke survivors.

OBJECTIVE: Adiponectin is an anti-inflammatory and insulin-sensitizing adipokine produced by adipose tissue. The purpose of this study was to determine the relationships between adiponectin and glucose metabolism in stroke survivors and to compare adiponectin levels between patients with stroke and nonstroke control subjects similar in age, sex, and body mass index. METHODS: In all, 52 stroke survivors (35 men, 17 women) and 33 nonstroke control subjects (22 men, 11 women) had plasma adiponectin levels measured by RIA, an oral glucose tolerance test, and a peak oxygen consumption-graded treadmill test. Insulin resistance (IR) and insulin sensitivity were assessed using the homeostasis model assessment for IR (HOMA-IR) and insulin sensitivity index (ISI(M)). RESULTS: Adiponectin levels were positively associated with age (r = 0.32, P < .05) and negatively associated with glucose homeostasis (fasting glucose: r = -0.42; insulin: r = -0.36; Glucose at (120 min): r = -0.39; HOMA-IR: r = -0.45; and ISI(M): r = 0.44, all P < .01) in stroke survivors. Adiponectin levels were significantly different among normal glucose-tolerant, impaired glucose-tolerant, and diabetic patients with stroke (11.1 +/- 0.99 v 9.56 +/- 0.99 v 5.75 +/- 1.55 ng/mL, P < .05). Adiponectin levels were 62% higher in patients with stroke than control subjects (9.29 +/- 0.62 v 5.80 +/- 0.40 ng/mL, P < .001) despite greater fasting insulin levels (81%) and 120-minute insulin (70%) in stroke survivors than control subjects (P < .05). HOMA-IR was 78% higher and ISI(M) was 81% lower in stroke survivors than control subjects (P < .05). CONCLUSIONS: Plasma adiponectin levels are associated with age and insulin sensitivity but not adiposity in stroke survivors. The paradoxical finding that the more IR stroke survivors had higher adiponectin levels than more insulin-sensitive control subjects suggests that perhaps anti-inflammatory cytokines increase to counter an inflamed and IR state in stroke survivors.

Reduced skeletal muscle capillarization and glucose intolerance.

OBJECTIVE: Reduced capillarization in hemiparetic skeletal muscle of chronic stroke patients can limit insulin, glucose, and oxygen supply to muscle, thereby contributing to impaired glucose metabolism and cardiovascular deconditioning. We hypothesized that compared to sedentary controls, stroke subjects have reduced skeletal muscle capillarization that is associated with glucose intolerance and reduced peak oxygen consumption (Vo(2peak)). METHODS: Twelve chronic stroke subjects (ages, 62.1+/-2.8 years), and matched sedentary controls with impaired (n=12) or normal (n=12) glucose tolerance underwent oral glucose tolerance tests, exercise tests, and vastus lateralis biopsies. RESULTS: Stroke subjects had lower capillarization in hemiparetic muscle than in nonparetic muscle and normal glucose tolerant controls ( approximately 22 and approximately 28%, respectively; P<0.05) and had similar bilateral capillarization, compared to controls with impaired glucose tolerance. Capillary density in hemiparetic muscle inversely correlated with 120-minute glucose (r=-0.70, P<0.01) and glucose area under the curve (r=-0.78, P<0.01). Vo(2peak) was approximately 40% lower in stroke subjects, compared to controls (P<0.001), but did not correlate with capillarization (P=n.s.). CONCLUSIONS: Hemiparetic muscle capillarization is reduced after stroke, and reduced capillarization is associated with glucose intolerance in stroke and control subjects. Interventions to increase skeletal muscle capillarization may prove beneficial for improving glucose metabolism in chronic stroke patients.

Reduction in midthigh low-density muscle with aerobic exercise training and weight loss impacts glucose tolerance in older men.

CONTEXT: Intramuscular lipid content increases with aging and obesity and is directly related to impaired glucose tolerance and insulin resistance. OBJECTIVE: Our purpose was to determine the effects of aerobic exercise training (AEX) with and without weight loss (WL) on midthigh low-density muscle (LDM; a measure of im lipid) and whether changes in LDM impact glucose tolerance in sedentary older men. DESIGN: Forty-six men (60.4 +/- 1.1 yr) completed 6 months of AEX (n = 34) or AEX + WL (n = 12) and had oral glucose tolerance tests (OGTTs) and computed tomography measures of LDM and regional abdominal and thigh fat depot areas. RESULTS: At baseline, LDM area directly correlated with fasting plasma glucose (FPG), 120-min glucose (G(120)), and glucose area under the curve (G(AUC)) during an OGTT (r = 0.44, r = 0.51, and r = 0.54, respectively, P < 0.01). After the interventions, the AEX + WL group had greater decreases in LDM (-13.5 vs. +1.3%, respectively), FPG (-8.3 vs. +2.1%, respectively), G(120) (-22.5 vs. -3.6%, respectively), and G(AUC) (-17.3 vs. - 3.1%, respectively) than the AEX group. In the entire sample, the decreases in LDM correlated with reductions in FPG, G(120), and G(AUC) during an OGTT (r = 0.31, r = 0.34, and r = 0.41, P < 0.05). Changes in other regional fat depots did not independently correlate with glucose tolerance or insulin responses. CONCLUSION: AEX + WL is more efficacious than AEX for reducing LDM and glucose tolerance. The improvement in glucose tolerance may be partially mediated by decreases in LDM in older men.

Resistive training and chromium picolinate: effects on inositols and liver and kidney functions in older adults.

This study assessed the effects of resistive training (RT) with or without chromium picolinate (Cr-pic) supplementation on the 24-h urinary excretions of myo-inositol, D-chiro-inositol, and pinitol, as well as clinical indices of kidney and liver functions. Thirty-two nondiabetic subjects, age 62 +/- 4 y, performed RT twice weekly for 12 wk and consumed either 924 ug Cr/d as Cr-pic (n = 17) or a placebo (n = 15). Whole-body strength increased in all subjects by 20 % and urinary chromium excretion increased 47-fold in the Cr-pic group. Urinary myo-inositol, D-chiro-inositol, and pinitol were not changed with RT or influenced by Cr-pic. Serum indices of kidney and liver functions were within clinically normal ranges at baseline and the end of the study. These results suggest that RT did not influence the urinary excretions of inositols. High dose Cr-pic did not influence the urinary excretion of inositols and the selected indices of kidney and liver functions in conjunction with RT.

Effects of resistive training and chromium picolinate on body composition and skeletal muscle size in older women.

This study assessed the effect of resistive training (RT), with or without highdose chromium picolinate (Cr-pic) supplementation, on body composition and skeletal muscle size of older women. Seventeen sedentary women, age range 54-71 years, BMI 28.8 +/- 2.4 kg/m2, were randomly assigned (double-blind) to groups (Cr-pic, n = 9; Placebo, n = 8) that consumed either 924 micrograms Cr/d as Cr-pic or a low-Cr placebo (< 0.2 microgram Cr/d) during a 12-week RT program (2 day/week, 3 sets.exercise-1.d-1, 80% of 1 repetition maximum). Urinary chromium excretion was 60-fold higher in the Cr-pic group, compared to the Placebo group (p < .001), during the intervention. Resistive training increased maximal strength of the muscle groups trained by 8 to 34% (p < .001), and these responses were not influenced by Cr-pic supplementation. Percent body fat and fat-free mass were unchanged with RT in these weight-stable women, independent of Cr-pic supplementation. Type I and type II muscle fiber areas of the m. vastus lateralis were not changed over time and were not influenced by Cr-pic supplementation. These data demonstrate that high-dose Cr-pic supplementation did not increase maximal strength above that of resistive training alone in older women. Further, these data show that, under these experimental conditions, whole body composition and skeletal muscle size were not significantly changed due to resistive training and were not influenced by supplemental chromium picolinate.