Pre-transplant short physical performance battery: Response to pre-habilitation and relationship to pre- and early post-lung-transplant outcomes.

PURPOSE: To evaluate whether the short physical performance battery (SPPB) pre-lung transplant (LTx) was responsive to pre-habilitation and predicted pre- and early post-transplant outcomes. METHODS: A retrospective study of LTx candidates accepted for transplant between 2016 and 2017. SPPB was categorized as frail/pre-frail (≤9/12) and non-frail (≥10/12). RESULTS: 150 patients had LTx assessment SPPB data (53% male, 61 [52-67] years, 59% had interstitial lung disease (ILD), 26% frail/pre-frail). 131 (87%) underwent transplant by December 31, 2018. Adjusting for age, sex, diagnosis and Canadian transplant listing urgency, and frailty/pre-frailty at LTx assessment was associated with a lower 6MWD pre-transplant [-89 meters 95%CI (-125 to -53), P < .0001]. 62 patients underwent six weeks of pre-habilitation. SPPB increased (11 [10-12) vs. 12 [11-12], P = .01) reflected in the chair stand component (11.4 ± 4.4 vs. 9.8 ± 2.8 seconds, P = .007), with larger improvements in the frail/pre-frail group. A frail/pre-frail SPPB closest to the time of transplant was associated with a lower 6MWD [-77 m 95%CI (-128 to -25), P = .004] but not with hospital length of stay or gait aid use three months post-transplant. CONCLUSIONS: Frailty/pre-frailty was associated with a decreased 6MWD pre- and post-transplant. The SPPB increased following pre-habilitation, which may reflect increased lower extremity strength.

Impaired cardiac autonomic response in lung transplant patients: A retrospective cohort study.

BACKGROUND: Cardiac autonomic dysfunction (AD) is associated with adverse prognosis in lung disease; however, its implications in lung transplantation have not been previously described. This study evaluated the prevalence of AD in lung transplant (LTx) candidates, its determinants, prognostic implications, and prevalence post-transplant. METHODS: Retrospective one-year study of 103 LTx candidates with AD assessed using heart rate (HR) from the six-minute walk test (6MWT). Impaired chronotropic response index (CRI) was defined as <80% age-adjusted HR during 6MWT. Abnormal HR recovery (HRR) was categorized as reduction in HR ≤ 12 beats/minute after the first minute of 6MWT cessation. RESULTS: Abnormal CRI and HRR were observed in 94% and 76% of patients, respectively. A lower CRI was associated with obstructive lung disease and lower estimated aerobic capacity. CRI was independently associated with 6MW distance [12 m per 10% CRI, P = 0.03], but not with post-transplant cardiovascular events, hospital stay, or one-year mortality. At 3 months post-transplant, no improvement was observed in CRI (99%, n = 66/67, P = 0.25) or HRR (88%, n = 36/41, P = 0.12). CONCLUSION: Cardiac AD was prevalent in LTx candidates and recipients, with chronotropic incompetence a modest contributor to exercise intolerance pretransplant. Further study may help determine whether direct autonomic measures such as HR variability may be more prognostic of LTx outcomes.

Pulmonary rehabilitation in lung transplant candidates with pulmonary arterial hypertension.

BACKGROUND: Pulmonary rehabilitation (PR) guidelines support the efficacy and safety of supervised exercise training in mild-moderate pulmonary arterial hypertension (PAH). However, the exercise training response and safety of PR in PAH lung transplant (LTx) candidates has not been described. OBJECTIVES: (1) characterize the clinical characteristics and illness trajectory of adult patients with severe PAH listed for LTx and participating in PR; (2) evaluate the change in exercise capacity, aerobic and resistance training volumes; (3) assess PR safety. METHODS: Single-centre retrospective cohort study of PAH LTx candidates listed January 2014-December 2018 attending a supervised, facility-based outpatient program three times per week. Functional capacity was evaluated using 6-min walk distance (6MWD). Aerobic and muscle training volumes were evaluated with paired comparisons. RESULTS: 40 PAH LTx candidates (age 50 ± 12 years, 73% females, mean pulmonary artery pressure 53 ± 16 mmHg) were included. The median listing duration was 91 [IQR 43-232] days. Sixteen patients (40%) had ≥1 admission pre-transplant. Nine patients (56%) were discharged home and resumed outpatient PR. Baseline 6MWD was 330 ± 119 metres (n = 40) with the final 6MWD pre-LTx increasing by 18 metres 95% CI (-18 to 56), p-value = 0.31, n = 25) over a median duration of 225 [IQR 70-311] days. Modest gains were observed in aerobic and resistance training volumes in PR with no adverse safety events. CONCLUSION: Despite progressive and severe disease in PAH LTx candidates, patients safely participated in PR and maintained exercise capacity. Given frequent admissions, physiotherapy during hospitalization should focus on preserving functional capacity and facilitating re-integration into outpatient PR post-discharge.

A Qualitative Study of the Perspectives of Healthcare Professionals on Features of Digital Health Interventions to Support Physical Activity in Solid Organ Transplant Recipients.

Introduction: Digital health interventions may support physical activity among solid organ transplant recipients. These interventions should be designed with users in mind, including healthcare professionals who counsel transplant recipients on physical activity to ensure acceptance and to promote an optimal user experience. The purpose of this study was to explore the perspectives of health care providers on the features of digital health interventions that would be useful in the promotion, implementation, and maintenance of physical activity among solid organ transplant recipients. Methods: This qualitative, cross-sectional study used semistructured interviews that were conducted remotely, via videoconferencing software, with providers who worked with transplant recipients. Interviews were transcribed, and an iterative-inductive, thematic analysis was used to identify common themes. Data were coded using NVivo software. Findings: Thirteen providers participated in this study. Four main themes were identified: (a) physical activity and exercise features (eg, physical activity guidelines, and exercise instructions); (b) credibility; (c) self-management; and (d) user engagement. Potential barriers to using digital health interventions included staffing requirements, professional regulatory issues, cost, perceived low patient motivation to use, and lack of technological literacy or access. Discussion: Digital health interventions were perceived to be a potential adjunct to current physical activity counseling practices, and part of an innovative strategy to address identified barriers to physical activity participation in solid organ transplant recipients.

Telerehabilitation for Lung Transplant Candidates and Recipients During the COVID-19 Pandemic: Program Evaluation.

BACKGROUND: The COVID-19 pandemic resulted in a rapid shift from center-based rehabilitation to telerehabilitation for chronic respiratory disease and lung transplantation due to infection control precautions. Clinical experience with this delivery model on a large scale has not been described. OBJECTIVE: The aim of this study is to describe usage and satisfaction of providers and lung transplant (LTx) candidates and recipients and functional outcomes following the broad implementation of telerehabilitation with remote patient monitoring during the first wave of the COVID-19 pandemic. METHODS: This study was a program evaluation of providers, LTx candidates, and early LTx recipients who used a web-based, remote monitoring app for at least four weeks between March 16 and September 1, 2020, to participate in telerehabilitation. Within-subjects analysis was performed for physical activity, Self-efficacy For Exercise (SEE) scale score, aerobic and resistance exercise volumes, 6-minute walk test results, and Short Physical Performance Battery (SPPB) results. RESULTS: In total, 78 LTx candidates and 33 recipients were included (57 [51%] males, mean age 58 [SD 12] years, 58 [52%] with interstitial lung disease, 34 [31%] with chronic obstructive pulmonary disease). A total of 50 (64%) LTx candidates and 17 (51%) LTx recipients entered ≥10 prescribed exercise sessions into the app during the study time frame. In addition, 35/42 (83%) candidates agreed the app helped prepare them for surgery and 18/21 (85%) recipients found the app helpful in their self-recovery. The strongest barrier perceived by physiotherapists delivering the telerehabilitation was patient access to home exercise and monitoring equipment. Between the time of app registration and ≥4 weeks on the waiting list, 26 LTx candidates used a treadmill, with sessions increasing in mean duration (from 16 to 22 minutes, P=.002) but not speed (from 1.7 to 1.75 mph, P=.31). Quadriceps weight (pounds) for leg extension did not change (median 3.5, IQR 2.4-5 versus median 4.3, IQR 3-5; P=.08; n=37). On the Rapid Assessment of Physical Activity questionnaire (RAPA), 57% of LTx candidates scored as active, which improved to 87% (P=.02; n=23). There was a decrease in pretransplant 6-minute walk distance (6MWD) from 346 (SD 84) meters to 307 (SD 85) meters (P=.002; n=45) and no change in the SPPB result (12 [IQR 9.5-12] versus 12 [IQR 10-12]; P=.90; n=42). A total of 9 LTx recipients used a treadmill that increased in speed (from 1.9 to 2.7 mph; P=.003) between hospital discharge and three months posttransplant. Quadriceps weight increased (3 [IQR 0-3] pounds versus 5 [IQR 3.8-6.5] pounds; P<.001; n=15). At three months posttransplant, 76% of LTx recipients scored as active (n=17), with a high total SEE score of 74 (SD 11; n=12). In addition, three months posttransplant, 6MWD was 62% (SD 18%) predicted (n=8). CONCLUSIONS: We were able to provide telerehabilitation despite challenges around exercise equipment. This early experience will inform the development of a robust and equitable telerehabilitation model beyond the COVID-19 pandemic.

Physical rehabilitation for lung transplant candidates and recipients: An evidence-informed clinical approach.

Physical rehabilitation of lung transplant candidates and recipients plays an important in optimizing physical function prior to transplant and facilitating recovery of function post-transplant. As medical and surgical interventions in lung transplantation have evolved over time, there has been a demographic shift of individuals undergoing lung transplantation including older individuals, those with multiple co-morbidites, and candidates with respiratory failure requiring bridging to transplantation. These changes have an impact on the rehabilitation needs of lung transplant candidates and recipients. This review provides a practical approach to rehabilitation based on research and clinical practice at our transplant centre. It focuses on functional assessment and exercise prescription during an uncomplicated and complicated clinical course in the pre-transplant, early and late post-transplant periods. The target audience includes clinicians involved in pre- and post-transplant patient care and rehabilitation researchers.